FUNDAMENTALS FINAL (CORRECT)
QUESTIONS AND ANSWERS
A0nurse0is0teaching0a0client0how0to0self-
administer0insulin.0Which0of0the0following0actions0should0the0nurse0take0to0evaluate0th
e0client's0understanding0of0the0process0within0the0psychomotor0domain0of0learning0-
0ans✔Have0the0client0demonstrate0the0procedure.
A0nurse0is0preparing0to0administer0a0cleansing0enema0to0a0client.0Which0of0the0followi
ng0actions0should0the0nurse0plan0to0take?0-0ans✔position0to0the0left0side
A0client0who0reports0shortness0of0breath0requests0her0nurse's0help0in0changing0positio
ns.0After0repositioning0the0client,0which0of0the0following0actions0should0the0nurse0take0
next?0-0ans✔Observe0the0rate,0depth,0and0character0of0respirations.
The0nurse0should0apply0the0nursing0process0priority-
setting0framework0when0caring0for0this0client.0The0nurse0can0use0the0nursing0process0
to0plan0client0care0and0prioritize0nursing0actions.0Each0step0of0the0nursing0process0bui
lds0on0the0previous0step,0beginning0with0assessment0or0data0collection.0Before0the0nu
rse0can0formulate0a0plan0of0action,0implement0a0nursing0intervention,0or0notify0a0provi
der0of0a0change0in0the0client's0status,0the0nurse0must0first0collect0adequate0data0from0
the0client.0Assessing0or0collecting0additional0data0will0provide0the0nurse0with0knowledg
e0to0make0an0appropriate0decision;0therefore,0the0first0action0the0nurse0should0take0is0
to0assess0the0client's0respiratory0status.
A0nurse0is0caring0for0a0client0who0has0bilateral0casts0on0her0hands.0Which0of0the0follo
wing0actions0should0the0nurse0take0when0assisting0the0client0with0feeding?0-
0ans✔sit0at0bedside0when0feeding0client
A0nurse0is0caring0for0a0client,0who0while0sitting0in0a0chair,0starts0to0experience0a0seizu
re.0Which0of0the0following0actions0should0the0nurse0take?0-
0ans✔Lower0the0client0to0the0floor0and0place0a0pad0under0the0client's0head.
To0reduce0the0risk0of0injury0to0the0client,0the0nurse0should0lower0the0client0to0the0floor
0and0place0a0pillow0or0other0soft0object0under0the0client's0head.
, A0home0health0nurse0is0planning0to0provide0health0promotion0activities0for0a0group0of0
clients0in0the0community.0Which0of0the0following0activities0is0an0example0of0the0nurse0
promoting0primary0prevention?0-
0ans✔Educating0clients0about0the0recommended0immunization0schedule0for0adults
An0assistive0personnel0(AP)0is0assisting0a0nurse0with0the0care0of0a0female0client0who0
has0an0indwelling0urinary0catheter.0Which0of0the0following0actions0by0the0AP0indicates
0a0need0for0further0teaching?0-
0ans✔Hangs0the0collection0bag0at0the0level0of0the0bladder.
A0nurse0is0performing0a0neurological0assessment0for0a0client.0Which0of0the0following0e
xaminations0should0the0nurse0use0to0check0the0client's0balance?0-0ans✔Romberg
A0nurse0is0providing0discharge0teaching0to0a0client0who0is0recovering0from0lung0cance
r.0The0provider0instructed0the0client0that0he0could0resume0lower-
intensity0activities0of0daily0living.0Which0of0the0following0activities0should0the0nurse0rec
ommend0to0the0client?0-0ans✔Washing0dishes
A0nurse0is0planning0to0perform0passive0range-of-
motion0exercises0for0a0client.0Which0of0the0following0actions0should0the0nurse0take0-
0ans✔Repeat0each0joint050times0during0each0session.
A0nurse0is0planning0care0for0a0client0who0has0a0single-
lumen0nasogastric0(NG)0tube0for0gastric0decompression.0Which0of0the0following0action
s0should0the0nurse0include0in0the0plan0of0care?0(Select0all0that0apply.)0-0ans✔-
Provide0oral0hygiene0frequently.
-Measure0the0amount0of0drainage0from0the0NG0tube0every0shift.0
-Secure0the0NG0tube0to0the0client's0gown.
A0nurse0is0reviewing0the0laboratory0values0for0a0client0who0has0a0positive0Chvostek's0
sign.0Which0of0the0following0laboratory0findings0should0the0nurse0expect?0-
0ans✔decreased0Calcium
Calcium0is0necessary0for0nerve0conduction0and0muscle0contractions.0When0the0client'
s0total0calcium0level0is0below08.40mg/
dL,0tetany0and0muscle0spasms0may0occur.0The0nurse0should0tap0the0facial0nerve0in0fr
ont0of0the0client's0ear.0If0facial0muscle0twitching0follows0this0stimulus,0it0is0a0positive0C
hvostek's0sign0and0an0indication0of0hypocalcemia.
A0nurse0is0caring0for0a0client0who0has0a0prescription0for0a0vest0restraint.0Which0of0the0
following0actions0should0the0nurse0take?0-0ans✔Tie0the0restraint0with0a0quick-
release0knot
A0nurse0is0reviewing0the0correct0use0of0a0fire0extinguisher0with0a0client.0Which0of0the0f
ollowing0actions0should0the0nurse0direct0the0client0to0take0first?0-
0ans✔Remove0the0safety0pin0from0the0extinguisher.
QUESTIONS AND ANSWERS
A0nurse0is0teaching0a0client0how0to0self-
administer0insulin.0Which0of0the0following0actions0should0the0nurse0take0to0evaluate0th
e0client's0understanding0of0the0process0within0the0psychomotor0domain0of0learning0-
0ans✔Have0the0client0demonstrate0the0procedure.
A0nurse0is0preparing0to0administer0a0cleansing0enema0to0a0client.0Which0of0the0followi
ng0actions0should0the0nurse0plan0to0take?0-0ans✔position0to0the0left0side
A0client0who0reports0shortness0of0breath0requests0her0nurse's0help0in0changing0positio
ns.0After0repositioning0the0client,0which0of0the0following0actions0should0the0nurse0take0
next?0-0ans✔Observe0the0rate,0depth,0and0character0of0respirations.
The0nurse0should0apply0the0nursing0process0priority-
setting0framework0when0caring0for0this0client.0The0nurse0can0use0the0nursing0process0
to0plan0client0care0and0prioritize0nursing0actions.0Each0step0of0the0nursing0process0bui
lds0on0the0previous0step,0beginning0with0assessment0or0data0collection.0Before0the0nu
rse0can0formulate0a0plan0of0action,0implement0a0nursing0intervention,0or0notify0a0provi
der0of0a0change0in0the0client's0status,0the0nurse0must0first0collect0adequate0data0from0
the0client.0Assessing0or0collecting0additional0data0will0provide0the0nurse0with0knowledg
e0to0make0an0appropriate0decision;0therefore,0the0first0action0the0nurse0should0take0is0
to0assess0the0client's0respiratory0status.
A0nurse0is0caring0for0a0client0who0has0bilateral0casts0on0her0hands.0Which0of0the0follo
wing0actions0should0the0nurse0take0when0assisting0the0client0with0feeding?0-
0ans✔sit0at0bedside0when0feeding0client
A0nurse0is0caring0for0a0client,0who0while0sitting0in0a0chair,0starts0to0experience0a0seizu
re.0Which0of0the0following0actions0should0the0nurse0take?0-
0ans✔Lower0the0client0to0the0floor0and0place0a0pad0under0the0client's0head.
To0reduce0the0risk0of0injury0to0the0client,0the0nurse0should0lower0the0client0to0the0floor
0and0place0a0pillow0or0other0soft0object0under0the0client's0head.
, A0home0health0nurse0is0planning0to0provide0health0promotion0activities0for0a0group0of0
clients0in0the0community.0Which0of0the0following0activities0is0an0example0of0the0nurse0
promoting0primary0prevention?0-
0ans✔Educating0clients0about0the0recommended0immunization0schedule0for0adults
An0assistive0personnel0(AP)0is0assisting0a0nurse0with0the0care0of0a0female0client0who0
has0an0indwelling0urinary0catheter.0Which0of0the0following0actions0by0the0AP0indicates
0a0need0for0further0teaching?0-
0ans✔Hangs0the0collection0bag0at0the0level0of0the0bladder.
A0nurse0is0performing0a0neurological0assessment0for0a0client.0Which0of0the0following0e
xaminations0should0the0nurse0use0to0check0the0client's0balance?0-0ans✔Romberg
A0nurse0is0providing0discharge0teaching0to0a0client0who0is0recovering0from0lung0cance
r.0The0provider0instructed0the0client0that0he0could0resume0lower-
intensity0activities0of0daily0living.0Which0of0the0following0activities0should0the0nurse0rec
ommend0to0the0client?0-0ans✔Washing0dishes
A0nurse0is0planning0to0perform0passive0range-of-
motion0exercises0for0a0client.0Which0of0the0following0actions0should0the0nurse0take0-
0ans✔Repeat0each0joint050times0during0each0session.
A0nurse0is0planning0care0for0a0client0who0has0a0single-
lumen0nasogastric0(NG)0tube0for0gastric0decompression.0Which0of0the0following0action
s0should0the0nurse0include0in0the0plan0of0care?0(Select0all0that0apply.)0-0ans✔-
Provide0oral0hygiene0frequently.
-Measure0the0amount0of0drainage0from0the0NG0tube0every0shift.0
-Secure0the0NG0tube0to0the0client's0gown.
A0nurse0is0reviewing0the0laboratory0values0for0a0client0who0has0a0positive0Chvostek's0
sign.0Which0of0the0following0laboratory0findings0should0the0nurse0expect?0-
0ans✔decreased0Calcium
Calcium0is0necessary0for0nerve0conduction0and0muscle0contractions.0When0the0client'
s0total0calcium0level0is0below08.40mg/
dL,0tetany0and0muscle0spasms0may0occur.0The0nurse0should0tap0the0facial0nerve0in0fr
ont0of0the0client's0ear.0If0facial0muscle0twitching0follows0this0stimulus,0it0is0a0positive0C
hvostek's0sign0and0an0indication0of0hypocalcemia.
A0nurse0is0caring0for0a0client0who0has0a0prescription0for0a0vest0restraint.0Which0of0the0
following0actions0should0the0nurse0take?0-0ans✔Tie0the0restraint0with0a0quick-
release0knot
A0nurse0is0reviewing0the0correct0use0of0a0fire0extinguisher0with0a0client.0Which0of0the0f
ollowing0actions0should0the0nurse0direct0the0client0to0take0first?0-
0ans✔Remove0the0safety0pin0from0the0extinguisher.
