Fundamentals Assessment for Mental Health
1. A nurse is preparing to mix short-acting and intermediate-acting insulin in one syringe to
administer to a client who has type 1 diabetes mellitus. Identify the sequence the nurse should
follow.
Answer:
1: Draw up the volume of insulin from the intermediate-acting insulin vial.
2: Inject the volume of air equal to the amount of insulin to withdraw from the intermediateacting insulin vial.
3: Inject the volume of air equal to the insulin dose form the short-acting insulin vial
4: Withdraw the prescribed amount of insulin form the short-acting insulin vial.
5: Withdraw the prescribed amount of insulin form the intermediate-acting insulin vial.
Rationale:
a. To mix insulin from two vials in the same syringe, the nurse should first draw up a volume of
air equal to the volume of insulin from the intermediate-acting insulin vial.
b. The nurse should then inject the volume of air equal to the amount of insulin to withdraw from
the intermediate-acting insulin vial, making sure the needle does not touch the insulin.
c. Next, the nurse should inject the volume of air equal to the insulin dose from the short-acting
insulin vial.
d. Then, the nurse should withdraw the prescribed amount of insulin from the short-acting insulin
vial.
e. Lastly, the nurse should withdraw the prescribed amount of insulin from the intermediateacting insulin vial. The insulins are now mixed and ready to administer.
2. A nurse is assessing a client who wears partial dentures and reports mouth pain. Which of the
following actions should the nurse take?
Answer: Advise the client to rinse their mouth and dentures after each meal.
Rationale:
The nurse should advise the client to rinse their mouth and dentures after each meal to remove
food and particles and to promote healing of gums and oral mucosa.
3. A nurse is planning care for a client who has dysphagia and is at risk for aspiration.
Which of the following referrals should the nurse make?
Answer: Speech-language pathologist
Rationale:
The nurse should recommend a referral for a client who has dysphagia to a speech language
pathologist. Clients who have dysphagia have difficulty swallowing and are at risk for aspiration.
The speech-language pathologist can perform a swallow study to determine the extent of the
client's dysphagia and work with the client to develop new swallowing techniques.
4. A nurse is planning teaching for a client who has a new diagnosis of type 2 diabetes mellitus.
Which of the following actions should the nurse take prior to performing the teaching? (select all
that apply)
Answer:
a. Establish the client's learning needs
b. determine the client's literacy level
c. Evaluate the client's readiness for learning
d. Identify the client's learning style
Rationale:
a. Establish the client's learning needs is correct. Prior to planning any teaching session, the
nurse should perform a comprehensive assessment of the client's learning needs. This assessment
incorporates information from the client's history and physical assessment, current health
problems, understanding of and adherence to the prescribed treatment plan, and support system.
b. Determine the client's literacy level is correct. Knowing the client's literacy level is an
important factor in communicating with the client and in delivering audiovisual presentations
and written materials. If the client cannot understand the information the nurse presents, they will
not learn.
c. Evaluate the client's readiness for learning is correct. The nurse should determine the client's
physical readiness (pain control), emotional readiness (acceptance of diagnosis), and cognitive
readiness (appropriate level of consciousness).
d. Identify the client's learning style is correct. The best way to learn varies from client to client.
Some people learn best by watching a demonstration, while others thrive in a group setting, and
others prefer to read information on their own. In a group setting, the nurse should use a variety
of styles to accommodate most learners.
5. A nurse is preparing to notify the provider about a change in a client's status. Which of the
following information should the nurse plan to include in the "background" portion of the SBAR
communication tool?
Answer: Previous treatments
Rationale:
The nurse should include previous treatments in the "background" portion of the SBAR
communication tool. Other information the nurse should include in the "background" portion is
the client's admission history, diagnosis, pertinent medical history, and code status.
6. A nurse is providing discharge teaching to a client who has a new prescription for home
oxygen therapy utilizing a compressed oxygen system. Which of the following statements by the
client indicates an understanding of the teaching?
Answer: "I will store oxygen tanks in an upright position"
Rationale:
This statement by the client indicates an understanding of the teaching. The nurse should instruct
the client to store oxygen tanks in an upright position in a holder to prevent damage to the tank
and injury to the client and the client's family.
7. A nurse is caring for a client who has terminal cancer. The client begins to cry and says, "I am
afraid of dying." Which of the following responses should the nurse make?
Answer: "It must me a very difficult time for you."
Rationale:
The nurse is using the therapeutic communication technique of verbalizing the implied. This
technique puts into words what the client has said indirectly and creates a more positive nurseclient relationship.
8. A nurse is assessing a client's coping skills. Which of the following should the nurse identify
as an internal stressor?
Answer: Fear of medical test results
Rationale:
Fear of medical test results is an internal stressor that originates within the body and mind of a
client. Internal stressors are pressures that the client places upon themselves and are often the
most common causes of stress. These stressors often force clients to deal with conflicting inner
values and interactions with others. When a client manages internal stressors, it enhances their
ability to deal with external stressors.
9. A nurse is performing postmortem care for an older client who had just died. Which of the
following actions should the nurse take?
Answer: Identify the client using two identifiers
Rationale:
The nurse should identify the deceased client using two identifiers, such as name and birth date,
or name and account number, and then compare the identifiers to the information in the client's
medical records
10. A nurse has administered 5 mL of medication to a client via NG tube. Then used 30 mL of
water to flush the tube both before and after the instillation. the nurse should document which of
the following amounts as liquid intake for the client?
Answer: 65 mL
Rationale:
A client who has an NG tube can receive numerous liquid medications, plus water to flush the
tube before and after medications. Over a 24-hr period, these liquids can amount to a significant
intake. The nurse should document them on the intake and output record. A value of 65 mL
accounts for 5 mL of medication and two 30-mL flushes.
11. A nurse is performing a family assessment for a client who has recently developed paraplegia
following a stroke. Which of the following actions should the nurse take first?
Answer: Determine how the client views the concept of family
Rationale:
According to evidence-based practice, the nurse should first determine how the client views the
concept of a family. This will influence the nurse's decision on how or whether to move forward
in including the family into the client's plan of care.
12. A nurse is caring for a client who reports having insomnia due to increased stress. Which of
the following actions should the nurse take first?
Answer: Determine the source of the client's stress
Rationale:
The first action the nurse should take when using the nursing process is to assess or determine
what is causing the client to experience increased stress.
13. A nurse is caring for a client who had a stroke and is immobile. Which of the following
actions should the nurse take to maintain the client's skin integrity?
Answer: Use an alcohol-free barrier product
Rationale:
The nurse should apply an alcohol-free barrier film to keep the client's skin dry and protect it
from the collection of moisture. This action will help to maintain the integrity of the client's skin.
14. A nurse receives a telephone prescription form the provider, who states, "four milligrams of
morphine diluted with 5 milliliters of sterile water intravenous each morning at nine o'clock
before client dressing changes." Which of the following entries by the nurse indicates correct
transcription of the prescription?
Answer: Morphine 4 mg IV bolus daily at 0900 before dressing change, dilute medication with 5
mL of sterile water
Rationale:
This entry by the nurse indicates correct transcription of the prescription. This transcription
contains acceptable abbreviations according to The Joint Commission and includes complete
information from the provider.
15. A nurse in a long-term care facility is planning to use therapeutic tough for a group of
selected clients who have chronic pain. The nurse should identify that the use of therapeutic
touch is contraindicated for which of the following patients?
Answer: A client who has chronic back pain and a history of physical maltreatment
Rationale:
Therapeutic touch consists of using the nurse's hands to harmonize energy fields and to facilitate
relief of pain or anxiety, such as for a client who has chronic back pain. The nurse can touch the
client with their palms or move the palms near, but not touching the client's body. Prior physical
maltreatment and some mental health disorders are contraindications for therapeutic touch,
because touch or near touch could cause severe anxiety.
16. A nurse is preparing to delegate task for multiple clients at the beginning of the shift. Which
of the following tasks should the nurse delegate to an assistive personnel (AP)?
Answer: Assist a client with ambulation
Rationale:
When delegating client care activities to an AP, the delegating nurse should follow the five rights
of delegation, which include right task, right circumstance, right person, right direction, and right
evaluation. Assisting a client with ambulation is within the range of function of an AP.
17. A home health nurse is making an initial assessment visit to an older client who has type 1
diabetes mellitus. Which of the following statements should the nurse make to evaluate the
clients ability to measure blood glucose accurately?
Answer: "Please use your glucometer and show me the results."
Rationale:
Asking for a return demonstration is an effective way to assess a client's ability to complete a
psychomotor activity. The nurse should carefully observe the client using the glucometer to
validate the client's understanding of the procedure and evaluate whether or not the method is
accurate.
18. A nurse is caring for a client who has an ankle sprain and a prescription for an aquathermia
pad. Which of the following actions should the nurse take?
Answer: Cover the pad with a pillowcase before application.
Rationale:
The nurse should cover the aquathermia pad with a thin towel or pillowcase before use because
applying the pad directly to the skin could cause a burn injury.
19. A nurse is preparing to administer drops to a client. Which of the following actions should
the nurse take?
Answer: Rest the non-dominant hand on the clients forehead while instilling the drops.
Rationale:
The nurse should rest the dominant hand on the client's forehead while instilling the drops. This
action stabilizes the nurse's hand and ensures that the hand will move with the client if they move
suddenly. This simple precaution reduces the risk of striking the client's eye with the dropper and
injuring it.
20. ...using progressive relaxation techniques. Which of the following statements by the client
indicates an understanding of the teaching?
Answer: "I'll compare the sensations I feel when I tense my muscles to what I feel when I relax
them."
Rationale:
Progressive relaxation involves tensing and relaxing specific muscles, moving progressively
through the body's muscle groups. The key is to distinguish sensations during tension from those
during relaxation.
21. A home health nurse is teaching about oral care to the family of a client who is in a coma.
Which of the following task should the nurse instruct the family to perform first?
Answer: Place the client in a side-lying position
Rationale:
The greatest risk to this client is injury from aspiration. Therefore, the first action the nurse
should instruct the family to perform is to place the client in a side-lying position. If the client
should not be placed in a side-lying position, then the nurse should instruct the family to turn the
client's head to the side to allow fluid to run out of the client's mouth.
22. A nurse is creating a plan of care for a client who requires suture removal. Which of the
following actions should the nurse plan to take?
Answer: Cut the sutures as close to the skin as possible.
Rationale:
The nurse should cut the sutures as close to the skin as possible. The exposed part of the suture
contains bacteria, so cutting close to the skin prevents bacteria from entering the clean wound,
decreasing the risk for infection.
23. A nurse is evaluating preoperative teaching with a client who is to undergo surgery with
general anesthesia. Which of the following statements by the client indicates an understanding of
the teaching?
Answer: "I should remove nail polish form my fingers before surgery."
Rationale:
The nurse should instruct the client to remove nail polish for accurate pulse oximetry monitoring
and for a clear view of the nail beds when assessing capillary refill.
24. A nurse is moving a client up in bed with assistance of another nurse. Which of the following
actions should the nurse take?
Answer: Positions the client's arms across their chest.
Rationale:
The nurse should position the client's arms across their chest to minimize friction during
movement and prevent injury.
25. RN in a rehab unit is assessing a group of clients who have a TBI. The RN should identify
that which of the following clients requires a priority referral?
Answer: A client who consistently coughs after drinking liquids
Rationale:
The greatest risk to this client is injury from aspiration. Therefore, this is the client the nurse
should address first. The priority referral the nurse should make is to a speech language
pathologist because a client who coughs after drinking liquids is at risk for aspiration.
Manifestations of dysphagia include changes in voice tone, coughing, delayed swallowing,
pocketing of food, and occasional silent aspiration, which can occur if a client is experiencing a
decrease in sensation.
26. A RN is assessing a client who has hypokalemia. Which of the following findings should the
NR expect?
Answer: Decreased bowel sounds
Rationale:
Decreased bowel sounds are an indication of hypokalemia because of decreased excitability of
cells, resulting in less responsiveness to normal stimuli in nerves and muscles.
27. RN is preparing to assess a client's cardiac function by auscultating heart sounds at the
pulmonic landmarks. Which of the following areas should the RN identify as the pulmonic area?
(hotspot question)
Answer: C (left sternal border, second intercostal space)
Rationale:
The nurse should identify that this is the pulmonic area of the cardiac landmarks, which is
located at the left second intercostal space, near the sternum.
28. RN is assessing a client who has an NG tube and is receiving continuous enteral feedings.
The nurse auscultates coarse crackles in the client's lungs. After discontinuing the feeding, which
actions should the RN take next?
Answer: Position the client on their side
Rationale:
The greatest risk to this client is aspiration from possible dislodgment of the NG tube and
aspirated stomach contents into the respiratory tract. Therefore, the priority nursing action to
decrease exacerbation of the condition is to position the client on their side.
29. A RN is applying a new transdermal patch to a client. Which of the following actions should
the RN take?
Answer: Wear gloves when applying the patch
Rationale:
The nurse should apply the patch while wearing clean gloves to prevent transfer of the
medication through the skin.
30. A RN is reviewing the medical record of a client is postoperative. Based on the info in the
medical record, which of the following actions should the RN take first?
Answer: Obtain a RX for IV fluids
Rationale:
The greatest risk to this client is injury from fluid volume deficit. Therefore, the first action the
nurse should take is to contact the provider for a prescription to initiate IV fluid infusion. The
client has assessment findings that indicate fluid volume deficit, such as an increased urine
specific gravity, a decreased blood pressure, an increased temperature, and a weak pulse. The
client also has increased fluid output with decreased intake as well as concentrated urine. To
prevent further fluid volume deficit, the nurse's priority action is to administer IV fluids to the
client.
31. A RN is assessing an older adult client who has become increasingly confused and agitated in
the last 48 hrs. Which of the following conditions should the nurse expect?
Answer: UTI
Rationale:
According to evidence-based practice, the nurse should expect the client who has a urinary tract
infection to become increasingly confused and agitated. Confusion and agitation in older adult
clients often result from a systemic infection, such as a urinary tract infection or pneumonia.
32. A home health RN is teaching a client who has a latex allergy about items typically found in
the home that can trigger an allergic reaction. Which of the following items should the RN
instruct the client to avoid? (Select all that apply)
Answer:
a. Dishwashing gloves
b. Adhesive tape
c. Bananas
d. Rubber bands
Rationale:
a. Dishwashing gloves is correct. Many kinds of dishwashing gloves contain latex.
Therefore, it places the client at risk for an allergic reaction.
b. Adhesive tape is correct. Adhesive tape contains latex. Therefore, it places the client at risk for
an allergic reaction. Bananas is correct. Certain foods such as kiwi, avocados, and bananas can
trigger latex allergies.
c. Rubber bands is correct. Rubber bands contain latex. Therefore, they place the client at risk for
an allergic reaction.
33. A charge RN is providing an in-service about client advocacy to a group of newly licensed
RN. Which of the following examples should the RN include?
Answer: Providing information about advance directives to a client
34. A RN is reviewing data in a client's medical record. Which of the following info should the
RN expect to find in the discharge summary section?
Answer: List of community resources
Rationale:
The nurse should expect to find a list of community resources provided to the client in the
discharge summary section. Other information the nurse should expect to find in the discharge
summary section includes unresolved problems, a list of complications to report to the provider,
the mode of transportation used, and who accompanied the client at discharge.
35. A nurse is providing teaching to a client who has a new dx of type 1 DM. The client
expresses feelings of hopelessness about managing the disease. Which of the following actions
should the RN take first?
Answer: Explore the client's past coping mechanisms
Rationale:
The first action the nurse should take when using the nursing process is to assess the methods
that the client used to successfully cope with other issues in the past and then reinforce them.
This will help encourage the client to begin to learn self-care.
36. A RN manager is teaching a group of newly licensed RN's about procedures are within their
scope of practice. Which if the following examples should the RN include in the teaching?
Answer: Monitoring a continuous intra-arterial infusion of a thrombolytic medication
Rationale:
Monitoring the infusion of a clot-dissolving agent is within a nurse's scope of practice. In
addition, the nurse should inspect the IV line for a disconnection, check the infusion site for
bleeding, and maintain site integrity.
37. A RN is completing a preadmission interview for a client who is it undergo surgery the
following day. The client reports a latex allergy. Which of the following interventions should the
RN include when planning care for the client's surgery?
Answer:
a. Notify ancillary dept. of the client's allergy
b. Label the surgical suite as latex-free
c. Ensure a latex allergy care is available
Rationale:
a. Notify ancillary departments of the client's allergy is correct. Notifying ancillary departments
of the client's sensitivity to latex allows the staff to take appropriate measures to ensure that
medications and surgical items are not contaminated by latex.
b. Label the surgical suite as latex-free is correct. This helps keep personnel from bringing rubber
products into the room.
c. Ensure a latex allergy cart is available is correct. A latex allergy cart should be kept in the
operating room at all times. All of the contents must be latex-free.
38. A school RN is teaching a group of parents about measures to prevent firearm injuries in the
home. Which of the following instructions should the nurse include in the teaching?
Answer: "Keep ammunition and guns in separate, locked locations."
Rationale:
The nurse should instruct the parents to keep ammunition in a locked cabinet separate from the
firearms to reduce the risk for injury. This action will prevent access to the firearm and also
prevents injury from accidental discharge because the firearm does not contain ammunition.
Also, the keys to the cabinet should not be accessible to children.
39. A RN is caring for a client who has terminal illness. The client request a DNR order, but their
family opposes the decision. Which of the following actions should the nurse take first.
Answer: Gather information to support the client's request for a DNR order
Rationale:
Using the nursing process, the first action the nurse should take is to assess the situation by
gathering information to support the client's request for a DNR order. This information should
include the client's current clinical status, factors such as the client's spirituality, culture, and
family dynamics, and evidence from literature about the client's condition.
40. A home health nurse is performing a home assessment for an older adult client. which of the
following statements by the client should alert the nurse to suggest additional safety measures?
Answer: "I use space heaters to keep warm in the winter."
Rationale:
A common environmental hazard in the home is the use of space heaters, which can increase the
risk of fire. a nurse is preparing to administer an intramuscular injection to a client. at which of
the following angles should the nurse plan to insert the needle 90
The nurse should plan to insert the needle at a 90° angle when administering medication via the
intramuscular route. The intramuscular route promotes quicker medication absorption into the
muscle than the other routes of medication administration.
41. A nurse is preparing to mix short-acting and intermediate-acting insulin in one syringe to
administer to a client who has type 1 diabetes mellitus. Identify the sequence the nurse should
follow.
Answer:
1: Draw up the volume of insulin from the intermediate-acting insulin vial.
2: Inject the volume of air equal to the amount of insulin to withdraw from the intermediateacting insulin vial.
3: Inject the volume of air equal to the insulin dose form the short-acting insulin vial
4: Withdraw the prescribed amount of insulin form the short-acting insulin vial.
5: Withdraw the prescribed amount of insulin form the intermediate-acting insulin vial.
42. A nurse is assessing a client who wears partial dentures and reports mouth pain. Which of the
following actions should the nurse take?
Answer: Advise the client to rinse their mouth and dentures after each meal.
43. A nurse is planning care for a client who has dysphagia and is at risk for aspiration. Which of
the following referrals should the nurse make?
Answer: Speech-language pathologist
44. Thoracentesis post procedure?
Answer: Position the client on the unaffected side.
45. The nurse should position the client on the unaffected side to help facilitate expansion of the
affected lung. Maintain the head of the bed at 45°.
Answer: Some facility protocols recommend that the nurse should raise the head of the bed to
30° for at least 30 min to facilitate expansion of the affected lung and ease of breathing.
Rationale:
Measure the client's abdominal girth at the level of the umbilicus. The nurse should measure the
client's abdominal girth following an abdominal paracentesis, rather than a thoracentesis.
Leave the puncture site open to air. The nurse should apply a small, sterile dressing over the
puncture site.
46. A nurse is planning teaching for a client who has a new diagnosis of type 2 diabetes mellitus.
Which of the following actions should the nurse take prior to performing the teaching? (select all
that apply)
Answer:
a. Establish the client's learning needs
b. Determine the client's literacy level
c. Evaluate the client's readiness for learning
d. Identify the client's learning style
47. A nurse is preparing to notify the provider about a change in a client's status. Which of the
following information should the nurse plan to include in the "background" portion of the SBAR
communication tool?
Answer: Previous treatments
48. A nurse is providing discharge teaching to a client who has a new prescription for home
oxygen therapy utilizing a compressed oxygen system. Which of the following statements by the
client indicates an understanding of the teaching?
Answer: "I will store oxygen tanks in an upright position"
49. A nurse is caring for a client who has terminal cancer. The client begins to cry and says, "I
am afraid of dying." Which of the following responses should the nurse make?
Answer: "It must me a very difficult time for you."
50. A nurse is assessing a client's coping skills. Which of the following should the nurse identify
as an internal stressor?
Answer: Fear of medical test results
51. A nurse is performing postmortem care for an older client who had just died. Which of the
following actions should the nurse take?
Answer: Identify the client using two identifiers
52. A nurse has administered 5 mL of medication to a client via NG tube. Then used 30 mL of
water to flush the tube both before and after the instillation. the nurse should document which of
the following amounts as liquid intake for the client?
Answer: 65 mL
53. A nurse is performing a family assessment for a client who has recently developed paraplegia
following a stroke. Which of the following actions should the nurse take first?
Answer: Determine how the client views the concept of family
54. A nurse is caring for a client who reports having insomnia due to increased stress. Which of
the following actions should the nurse take first?
Answer: Determine the source of the client's stress
55. A nurse is caring for a client who had a stroke and is immobile. Which of the following
actions should the nurse take to maintain the client's skin integrity?
Answer: Use an alcohol-free barrier product
56. A nurse receives a telephone prescription form the provider, who states, "four milligrams of
morphine diluted with 5 milliliters of sterile water intravenous each morning at nine o'clock
before client dressing changes." Which of the following entries by the nurse indicates correct
transcription of the prescription?
Answer: Morphine 4 mg IV bolus daily at 0900 before dressing change, dilute medication with 5
mL of sterile water
57. how to assess for clonus?
Answer: Use a reflex hammer.
Rationale:
The nurse should use a reflex hammer to assess the client for clonus. The reflex hammer causes
the muscle to immediately contract due to a two-neuron reflex arc involving the spinal or
brainstem segment that innervates the muscle.
Administer magnesium sulfate. Administering magnesium sulfate is not a test for clonus.
Magnesium sulfate is administered for convulsions, hypomagnesemia, and hypertension.
Perform a Romberg test. A Romberg test assesses balance, gross-motor function, and
equilibrium.
Test the gait for symmetry. Testing the client's gait gives the nurse information about symmetry,
walking ability, posture, and balance.
58. A nurse in a long-term care facility is planning to use therapeutic tough for a group of
selected clients who have chronic pain. The nurse should identify that the use of therapeutic
touch is contraindicated for which of the following patients?
Answer: A client who has chronic back pain and a history of physical maltreatment
59. A nurse is preparing to delegate task for multiple clients at the beginning of the shift. Which
of the following tasks should the nurse delegate to an assistive personnel (AP)?
Answer: Assist a client with ambulation
60. A home health nurse is making an initial assessment visit to an older client who has type 1
diabetes mellitus. Which of the following statements should the nurse make to evaluate the
clients ability to measure blood glucose accurately?
Answer: "Please use your glucometer and show me the results."
61. A nurse is caring for a client who has an ankle sprain and a prescription for an aquathermia
pad. Which of the following actions should the nurse take?
Answer: Cover the pad with a pillowcase before application. over the pad with a pillowcase
before application.
Rationale:
The nurse should cover the aquathermia pad with a thin towel or pillowcase before use because
applying the pad directly to the skin could cause a burn injury.
Apply the pad for 45 min per application. An application of the aquathermia pad usually lasts 30
min. Prolonged application of the pad places the client at risk for a burn injury. Set the
temperature of the aquathermia pad to 50° C (122° F).The nurse should set the temperature of the
aquathermia pad to 40° C (104° F).
Use safety pins to hold the pad in place. The nurse should not use pins to hold the aquathermia
pad in place because they can cause a leak. The nurse should use tape or gauze ties to hold the
pad in place.
62. A nurse is preparing to administer drops to a client. Which of the following actions should
the nurse take?
Answer: Rest the non-dominant hand on the clients forehead while instilling the drops.
Rationale:
Tilt the client's head away from the side receiving the drops. The nurse should help the client
assume a comfortable position, either sitting or lying, with their head tilted backward and
looking up at the ceiling.
Instil the drops directly onto the cornea of the eye receiving the drops. The nurse should never
instil an eye medication directly onto the cornea due to the high risk for injury. Instead, the nurse
should expose the lower conjunctival sac by drawing down the skin over the client's cheekbone.
The nurse should then instil the prescribed number of drops onto the lower conjunctival sac.
Rest the dominant hand on the client's forehead while instilling the drops. The nurse should rest
the dominant hand on the client's forehead while instilling the drops. This action stabilizes the
nurse's hand and ensures that the hand will move with the client if they move suddenly. This
simple precaution reduces the risk of striking the client's eye with the dropper and injuring it.
Hold the medication dropper 0.5 cm (0.2 in) above the conjunctival sac.
The nurse should hold the medication dropper 1 to 2 cm (0.4 to 0.8 in) above the conjunctival
sac. With this distance, the client is less likely to blink. Therefore, the eye drop is instilled more
efficiently. It is also important to not touch the conjunctival sac or cornea.
63. ...using progressive relaxation techniques. Which of the following statements by the client
indicates an understanding of the teaching?
Answer: "I'll compare the sensations I feel when I tense my muscles to what I feel when I relax
them."
64. A home health nurse is teaching about oral care to the family of a client who is in a coma.
Which of the following task should the nurse instruct the family to perform first?
Answer: Place the client in a side-lying position
65. A nurse is creating a plan of care for a client who requires suture removal. Which of the
following actions should the nurse plan to take?
Answer: Cut the sutures as close to the skin as possible.
Rationale:
Pull the visible part of the suture through the underlying tissue. The nurse should identify that
pulling the visible part of the suture through underlying tissue increases the client's risk for
infection.
Cleanse the wound with sterile water prior to removing the sutures. The nurse should cleanse the
wound with an antimicrobial solution prior to removing the sutures. This decreases the client's
risk of infection.
Cut the sutures as close to the skin as possible.
The nurse should cut the sutures as close to the skin as possible. The exposed part of the suture
contains bacteria, so cutting close to the skin prevents bacteria from entering the clean wound,
decreasing the risk for infection.
Remove the sutures in a consecutive order. The nurse should remove every other suture in an
alternating pattern. Removing the sutures in a consecutive order is not recommended because
this could increase the risk for wound dehiscence.
66. A nurse is evaluating preoperative teaching with a client who is to undergo surgery with
general anesthesia. Which of the following statements by the client indicates an understanding of
the teaching?
Answer: "I should remove nail polish form my fingers before surgery."
67. A nurse is moving a client up in bed with assistance of another nurse. Which of the following
actions should the nurse take?
Answer: Positions the client's arms across their chest.
68. RN in a rehab unit is assessing a group of clients who have a TBI. The RN should identify
that which of the following clients requires a priority referral?
Answer: A client who consistently coughs after drinking liquids
69. A RN is assessing a client who has hypokalemia. Which of the following findings should the
NR expect?
Answer: Decreased bowel sounds
Rationale:
Strong, bounding pulse A weak, irregular pulse is an expected finding of hypokalemia. Positive
Chvostek's sign A positive Chvostek's sign is an indication of hypocalcemia or hypomagnesemia.
Chvostek's sign occurs when the nurse taps the client's facial nerve, resulting in contraction of
the facial muscle.
Hyperactive reflexes Hypoactive, or diminished, reflexes are an expected finding of hypokalemia
or hypocalcemia.
Decreased bowel sounds Decreased bowel sounds are an indication of hypokalemia because of
decreased excitability of cells, resulting in less responsiveness to normal stimuli in nerves and
muscles.
70. RN is preparing to assess a client's cardiac function by auscultating heart sounds at the
cardiac landmarks. Which of the following areas should the RN identify as the pulmonic area?
(hotspot question)
Answer: D (right sternal border, second intercostal space)
Rationale:
A is incorrect. The nurse should identify that this area is the mitral area of the cardiac
landmarks, which is considered the point of maximal impulse. This is also the area in which the
apical heart rate is best auscultated. This area is located at the fifth intercostal space, to the left of
the sternum, at the left midclavicular line.
B is incorrect. The nurse should identify that this area is the tricuspid area of the cardiac
landmarks, which is located at the left fourth or fifth intercostal space, near the sternum.
C is correct. The nurse should identify that this is the pulmonic area of the cardiac landmarks,
which is located at the left second intercostal space, near the sternum.
D is incorrect. The nurse should identify that this is the aortic area of the cardiac landmarks,
which is located at the right second intercostal space, near the sternum.
71. RN is assessing a client who has an NG tube and is receiving continuous enteral feedings.
The nurse auscultates coarse crackles in the client's lungs. After discontinuing the feeding, which
actions should the RN take next?
Answer: Position the client on their side.
Rationale:
Prepare to initiate antibiotic therapy. The nurse should prepare to initiate antibiotic therapy
because stomach contents in the respiratory tract will likely lead to pneumonia.
However, there is another action the nurse should take first.
Obtain a prescription for a chest x-ray. The nurse should obtain a prescription for a chest x-ray to
determine if the client aspirated stomach contents into the respiratory tract.
However, there is another action the nurse should take first.
Position the client on their side.
The greatest risk to this client is aspiration from possible dislodgment of the NG tube and
aspirated stomach contents into the respiratory tract. Therefore, the priority nursing action to
decrease exacerbation of the condition is to position the client on their side.
Suction the client's orotracheal airway. The nurse should suction the client's orotracheal airway to
prevent further aspiration of stomach contents into the respiratory tract.
However, there is another action the nurse should take first.
72. A RN is applying a new transdermal patch to a client. Which of the following actions should
the RN take?
Answer: Wear gloves when applying the patch
73. A RN is reviewing the medical record of a client is postoperative. Based on the info in the
medical record, which of the following actions should the RN take first?
Answer: Obtain a RX for IV fluids
74. A RN is assessing an older adult client who has become increasingly confused and agitated in
the last 48 hrs. Which of the following conditions should the nurse expect?
Answer: UTI
75. A home health RN is teaching a client who has a latex allergy about items typically found in
the home that can trigger an allergic reaction. Which of the following items should the RN
instruct the client to avoid? (Select all that apply)
Answer:
a. Dishwashing gloves
b. Adhesive tape
c. Bananas
d. Rubber bands
76. A charge RN is providing an in-service about client advocacy to a group of newly licensed
RN. Which of the following examples should the RN include?
Answer: Providing information about advance directives to a client
77. A RN is reviewing data in a client's medical record. Which of the following info should the
RN expect to find in the discharge summary section?
Answer: List of community resources
78. A nurse is providing teaching to a client who has a new dx of type 1 DM. The client
expresses feelings of hopelessness about managing the disease. Which of the following actions
should the RN take first?
Answer: Explore the client's past coping mechanisms
79. A RN manager is teaching a group of newly licensed RN's about procedures are within their
scope of practice. Which if the following examples should the RN include in the teaching?
Answer: Monitoring a continuous intra-arterial infusion of a thrombolytic medication
80. A RN is completing a preadmission interview for a client who is it undergo surgery the
following day. The client reports a latex allergy. Which of the following interventions should the
RN include when planning care for the client's surgery?
Answer:
a. Notify ancillary dept. of the client's allergy
b. Label the surgical suite as latex-free
c. Ensure a latex allergy care is available
81. A school RN is teaching a group of parents about measures to prevent firearm injuries in the
home. Which of the following instructions should the nurse include in the teaching?
Answer: "Keep ammunition and guns in separate, locked locations."
82. A RN is caring for a client who has terminal illness. The client request a DNR order, but their
family opposes the decision. Which of the following actions should the nurse take first. Gather
information to support the client's request for a DNR order Rinne test?
Answer: Place a vibrating tuning fork on the top of the client's head. The nurse should place a
vibrating tuning fork on the top of the client's head when performing the Weber's test.
Rationale:
The Rinne test assesses the transmission of sound through bone conduction.
Move a vibrating tuning fork's prongs in front of the client's left or right ear canal. The nurse
should perform the Rinne test by placing the handle of a vibrating tuning fork on the client's
mastoid process and then moving the vibrating prongs 1 to 2 cm (0.4 to 0.8 in) in front of the
client's left or right ear canal. The Rinne test compares bone conduction with air conduction.
The client is expected to hear sound conduction by air for twice as long as bone conduction.
Activate a tuning fork and place the prongs on the client's occipital area.
When performing the Rinne test, the nurse should activate the tuning fork and place the handle
on the mastoid process near one ear until the client no longer hears the sound created by the
vibration.
Instruct the client to occlude one ear and repeat a softly spoken phrase by the nurse. The nurse
should perform the whisper test by whispering a phrase and then have the client repeat the phrase
to assess for high-frequency hearing.
Sets found in the same folder
1. A nurse is planning care for a client who is receiving an IV fluid infusion. Which of the
following interventions should the nurse implement to maintain asepsis?
a. change secondary IV infusion twice weekly
b. change a continuously infusing IV bag after 48 hr.
c. change primary IV infusion set every 96 hr
d. change extension tubing once per week
Answer: c. change primary IV infusion set every 96 hr
2. The nurse should change primary iv infusion set every 96 hr to minimize risk of infection A
nurse is performing a family assessment for a client who has recently developed paraplegia
following a stroke. Which of the following actions should the nurse take first?
a. determine how the client views the concept of family
b. identify how culture influences family functioning
c. determine if the client has an external support system
d. identify how the family deals with unexpected health changes
Answer: a. determine how the client views the concept of family
3. The nurse should first determine how the client views the concept of family. this will influence
the nurse's decision on how or whether to move forward in including the family into the client's
plan of care. A nurse is caring for a client who has suspected clonus. Which of the following
actions should the nurse take to assess for this condition?
a. use a reflex hammer
b. administer magnesium sulfate
c. perform a Romberg test
d. test the gait for symmetry
Answer: a. use a reflex hammer
4. the reflex hammer causes the muscles to immediately contract due to a two-neuron reflex arc
involving the spinal or brainstem segment that innervates the muscle. A nurse is preparing to mix
short-acting and intermediate acting insulin in one syringe to administer to a client with type 1
diabetes. Put the steps in order.
a. withdraw the prescribed amount of insulin from the short-acting insulin vial.
b. inject the volume of air equal to the amount of insulin to withdraw from the intermediateacting insulin vial.
c. withdraw the prescribed amount of insulin from the intermediate-acting insulin vial.
d. inject the volume of air equal to the insulin dose from the short-acting insulin vial.
e. draw up a volume of air equal to the volume of insulin from the intermediate-acting insulin
vial.
Answer:
e. draw up a volume of air equal to the volume of insulin from the intermediate-acting insulin
vial.
b. inject the volume of air equal to the amount of insulin to withdraw from the intermediateacting insulin vial.
d. inject the volume of air equal to the insulin dose from the short-acting insulin vial.
a. withdraw the prescribed amount of insulin from the short-acting insulin vial.
c. withdraw the prescribed amount of insulin from the intermediate-acting insulin vial.
5. A nurse is assessing a client who has hypokalemia. Which of the following findings should the
nurse expect?
a. strong, bounding pulse
b. positive chvostek's sign
c. hyperactive reflexes
d. decreased bowel sounds
Answer: d. decreased bowel sounds
Rationale:
decreased bowel sounds are an indication of hypokalemia because of decreased excitability of
cells, resulting in less responsiveness to normal stimuli in nerves and muscles.
6. A nurse is assessing a client who has an NG tube and is receiving continuous enteral feedings.
The nurse auscultates coarse crackles in the client's lungs. After discontinuing the feeding, which
of the following actions should the nurse take next?
a. prepare to initiate antibiotic therapy
b. obtain a prescription for a chest x-ray
c. position the client on their side
d. suction the client's orotracheal airway
Answer: c. position the client on their side
Rationale:
The greatest risk to this client is aspiration from possible dislodgment of NG tube and aspirated
stomach contents into the respiratory tract. Decrease exacerbation of the condition is to position
the client on their side.
7. A nurse is providing teaching about cough etiquette to a client who has influenza. Which of the
following instructions should the nurse include in the teaching?
a. "cover your nose and mouth with a tissue when coughing"
b. "where gloves when preparing meals if coughing a lot"
c. "stay 2 feet away from others when coughing"
d. "turning your head away when coughing can transmit micro-organisms into the air"
Answer: a. the nurse should instruct the client to cover their nose and mouth with a tissue when
coughing and discard the tissue in the nearest trash
8. A nurse is completing a preadmission interview for a client who is to undergo surgery the
following day. The client reports a latex allergy. Which of the following interventions should the
nurse include when planning care? (select all that apply)
a. schedule the client as last surgery of the day
b. notify ancillary departments of the client's allergy
c. label surgical suite as latex free
d. provide powdered gloves
e. ensure latex allergy cart is available.
Answer:
b. notify ancillary departments of the client's allergy
c. label surgical suite as latex free
e. ensure latex allergy cart is available.
9. A home health nurse is teaching a client who has a latex allergy about items typically found in
the home that triggers reactions. Which of the following items should the nurse instruct the client
to avoid? (select all that apply)
a. dishwashing gloves
b. adhesive tape
c. macadamia nuts
d. bananas
e. rubber bands
Answer:
a. dishwashing gloves
b. adhesive tape
d. bananas
e. rubber bands
10. A nurse is assessing a client who wears partial dentures and reports mouth pain. Which of the
following actions should the nurse take?
a. provide client with alcohol based mouthwash
b. instruct client to brush their teeth with firm toothbrush
c. advise the client to rinse their mouth and dentures after each meal
d. swab the clients mouth with lemon glycerin sponges at bedtime
Answer: c. advise the client to rinse their mouth and dentures after each meal
Rationale:
The nurse should do this to allow the client to remove food and other particles and to promote
healing of gums and oral mucosa.
11. A nurse is creating a care plan for a client who requires suture removal. Which of the
following actions should the nurse plan to take?
a. pull visible part of suture through the underlying tissue
b. cleanse the wound with sterile water prior to removing the sutures
c. cut the sutures as close to the skin as possible
d. remove the sutures in a consecutive order
Answer: c. cut the sutures as close to the skin as possible
Rationale:
The exposed part of the suture contains bacteria, so cutting close to the skin prevents bacteria
from entering the clean wound, decreasing the risk for infection.
12. A nurse in an operating room is performing surgical hand hygiene. Which of the following
actions should the nurse take?
a. scrub with soap 15 cm above the elbows
b. use a nail pick to clean fingernails under running water
c. keep hands below elbows when rinsing
d. scrub each finger using five stroke with a hand brush
Answer: b. use a nail pick to clean fingernails under running water
Rationale:
lots of germs under nails
13. Which of the following is a vector that can transmit and spread an infection?
a. infectious person
b. mosquito
c. contaminated ball
d. contaminated door knob
Answer: b. mosquito
Rationale:
a vector is an organism that takes up a pathogenic organism and transmits the infection to
another person or animal by regurgitating the organism or by injecting it.
14. Which nutritional assessment data should the nurse collect during the health history and
physical assessment portions of the nursing assessment?
a. dentition
b. parathyroid functioning
c. adrenal gland functioning
d. the Babinski reflex for swallowing
Answer: a. poor dentition places clients at risk for impaired nutrition
15. Following a spinal cord injury, the nurse instructs the client to drink fluids primarily to:
a. maintain fluid and electrolyte balance
b. prevent dehydration
c. prevent skin breakdown
d. prevent infection of the urinary tract
Answer: d. prevent infection of the urinary tract
Rationale:
atonic bladder is a complication of spinal cord injury which leads to urinary stasis and infection.
16. A nurse is caring for a client who is receiving TPN. Which of the following nursing
interventions should be performed during the TPN administration? (select all that apply)
a. assess skin turgor daily
b. monitor blood glucose levels
c. assess insertion site and condition of dressing
d. ambulate client daily
e. provide medications for sedation
Answer:
a. assess skin turgor daily
b. monitor blood glucose levels
c. assess insertion site and condition of dressing
17. The nurse is caring for an unresponsive client suspected of having uncal herniation after
traumatic brain injury. Which of the following does the nurse understand is an early sign of uncal
herniation?
a. respiratory depression
b. ipsilateral pupillary dilation
c. flapping tremors
d. ecchymosis of the extremities
Answer: b. ipsilateral pupillary dilation
Rationale:
Brain herniation is characterized by displacement of the brain structures due to increased ICP.
This is an early sign of uncal herniation that occurs as a result of compression of the third cranial
nerve.
18. A client has just returned from surgery after below-the-knee amputation. The client has an
immediate postoperative prothesis in place. What is the purpose of an IPOP?
a. prevents development of blood clot in leg
b. increases the adjustment period so the client is not rushed
c. prevents infection in the stump incision
d. promotes body image after surgery
Answer: d. also facilitates early ambulation and prevents swelling of stump
19. A client has a prescription for "Medication X" 2 grams po. The tablets are supplied in 500-mg
doses. How many tabs?
Answer: 4
1000 mg = 1 gram
20. A nurse is caring for an adult client who got injured in a car accident and suffered a spinal
cord injury 3 days ago. He is paralyzed below the level T5 on the spinal cord. Based on the
information provided, which of the following nursing interventions is most important?
a. increase the client's activity level as quickly as possible
b. teach the client to promote circulation through ankle rotation and foot pumping
c. administer vasodilator medications as ordered
d. place an abdominal binder on the client and remove it every 24 hours
Answer: a. increase the client's activity level as quickly as possible
21. The client is at high risk for immobility. Although he may not be able to walk or move legs
below the waist, the nurse can help the client to increase levels by assisting with getting out of
bed. Movement can reduce the complications associated with immobility. Which of the
following clients should not be considered to use anti-embolism stockings? (select all that apply)
a. a client with pulmonary edema due to heart failure
b. a client with necrotic limb tissue in the lower leg
c. a client with a deformity of the lower leg
d. a post operative hip replacement client
e. a client with diabetes
Answer:
a. a client with pulmonary edema due to heart failure
b. a client with necrotic limb tissue in the lower leg
c. a client with a deformity of the lower leg
22. A nurse is giving an intramuscular injection to a client. Which of the following steps can the
nurse perform that would best prevent a needlestick injury? (select all that apply)
a. use a syringe and needle with a built in safety design
b. keep a sharps container near where the injection is being given
c. ask the patient to hold the syringe until the nurse can get the appropriate disposal unit
d. recap the needle after use
e. ask if the medication can be administered subq instead
Answer:
a. use a syringe and needle with a built in safety design
b. keep a sharps container near where the injection is being given
23. List the correct order of steps in assisting a client who is having a seizure.
a. protect the clients head and loosen restrictive clothing
b. document the seizure and clients condition
c. administer anti-seizure meds
d. stay with the client and call for help
e. note the length of seizure and any factors that may have caused it
Answer:
d. stay with the client and call for help
a. protect the clients head and loosen restrictive clothing
c. administer anti-seizure meds
e. note the length of seizure and any factors that may have caused it
b. document the seizure and clients condition
24. A nurse in the ER is accosted by a client's angry family member who knocks a telephone to
the floor and throws gloves at the nurse. Which of the following should the nurse do first?
a. convey understanding that the family member is upset
b. call hospital administrator
c. ask others to move patients and visitors and leave the area
d. inform the individual that this behavior is not tolerated
Answer: c. ask others to move patients and visitors and leave the area
Rationale:
the immediate priority for the nurse is to ensure safety for everyone in the area. The nurse should
leave and security should be called
25. A nurse is caring for a client who is postoperative Roux-en-Y gastric bypass surgery for
management of obesity. The client will most likely require a multivitamin with additional
supplementation of which of the following to avoid a frequent complication of the procedure?
a. vitamin C
b. vitamin D
c. vitamin B12
d. intrinsic factor
Answer: c. vitamin B12
Rationale:
bypassing parts of the GI tract causes malabsorption of vitamin A, vitamin B1, folate, vitamin
B12, vitamin E, and vitamin K.
26. Which of the following factors contributes to the increased incidence of pinworm infestation
among small children?
a. milk and yogurt drinks
b. one-piece uniforms
c. cloth diapers
d. shoes and socks
Answer: c. cloth diapers
Rationale:
cloth diapers on a toddler leaking the stools may increase the risk of transmission in the
classroom by children transmitting it to their mouths from hands or fingers that have been
exposed.
27. A nurse is teaching a client who has heart failure about increasing dietary potassium. The
nurse should instruct the client that which of the following food selections contains the highest
amount of potassium?
a. 1 medium apple
b. 1 medium baked potato
c. 1 cup raw green grapes
d. 1 large scrambled eggs
Answer: b. 1 medium baked potato baked potato contains 941 mg of potassium per serving
apple- 195 mg raw green beans- 288 mg large egg scrambled- 81 mg
28. A nurse is providing nutrition teaching to a group of clients who are at risk for developing
type 2 diabetes mellitus. Which of the following statements should the nurse make?
(select all that apply)
a. eat less meat and processed foods
b. decrease intake of saturated fats
c. increase daily fiber intake
d. limit carbs to 25% of your daily caloric intake
e. include foods that are high in omega-3 fatty acids in your diet
Answer:
a. eat less meat and processed foods
b. decrease intake of saturated fats
c. increase daily fiber intake
e. include foods that are high in omega-3 fatty acids in your diet
Rationale:
carbs should be limited to 45%
29. A home health nurse is planning care for a client who has a small bowel obstruction and is
receiving parenteral nutrition (PN) through a PICC line in their rt arm. Which of the following
interventions should the nurse include in the plan of care? (select all that apply)
a. use a 10 ml syringe to flush PICC line
b. apply gentle force if resistance is met during injection
c. cleanse ports according to agency policy prior to use
d. maintain a transparent dressing over insertion site
e. flush with 5 ml heparin before and after each infusion
Answer:
a. use a 10 ml syringe to flush PICC line
c. cleanse ports according to agency policy prior to use
d. maintain a transparent dressing over insertion site
Rationale:
the nurse should avoid applying force, instead gently aspirate to restore patency. the nurse should
flush PICC with 0.9% sodium chloride before and after infusions. heparin in recommended when
PICC isn't actively in use.
30. A school nurse is providing teaching to a guardian whose school-age child has pediculosis
capitis. Which of the following statements by the guardian indicates an understanding of the
teaching?
a. i should seal non-washable items in airtight plastic bags
b. my child must be free of nits before returning to school
c. i will treat all members of our family
d. bedding, clothing, and towels should be soaked in cold water
Answer: a. i should seal non-washable items in airtight plastic bags seal for 14 days to kill any
lice return to school after initial treatment only members of family who have lice too should
receive treatment wash all recently used stuff in HOT water
31. A nurse is leading an in-service for clients who are receiving peripheral parenteral nutrition
(PPN). Which of the following actions should the nurse include when providing information
about care for clients receiving PPN? (select all that apply)
a. examine trends in weight loss
b. review pre albumin finding
c. administer an IV solution of 20% dextrose in 0.9% sodium chloride
d. do not refrigerate the PPN solution after it is prepared
e. use an IV infusion pump
Answer:
a. examine trends in weight loss
b. review pre albumin finding
e. use an IV infusion pump
Rationale:
a. examining trends in weight loss will help evaluate the outcome of PPN
b. reviewing prealbumin finding will determine if the client has a nutritional deficiency
e. an iv infusion pump is used to regulate the flow and provide accurate delivery of the PPN
solution
Rationale:
An IV solution of 20% dextrose is administered only as total parenteral nutrition (TPN) using a
central vein
PPN solutions, once prepared, should be used immediately or refrigerated. solutions should be
removed from refrigerator 1 hr before infusing to reach room temp.
32. A nurse is assessing a newly admitted client who reports numbness in the distal extremities
and ataxia for the past 3 weeks. Which nutritional deficiency could be the cause of the client's
symptoms?
a. vitamin D
b. potassium
c. vitamin B12
d. magnesium
Answer: c. vitamin B12
Rationale:
numbness and tingling of hands and feet are neurological manifestations associated with vitamin
B12 vitamin D- bone pain, muscle weakness, rickets low potassium- irritability, decreased
respirations, muscle weakness, GI distress low magnesium- twitching of muscles, muscle
weakness
33. A nurse is preparing to teach an in-service for a nursing assistant about importance of
nutrition for clients who have cancer. Which of the following recommendations should the nurse
make to increase calorie and protein intake? (select all that apply)
a. use peanut butter as a spread on crackers
b. ass water in place of milk in soups
c. spread cream cheese and butter on hot bread
d. dip chicken in eggs before cooking
e. sprinkle cheese on a baked potato
Answer:
a. use peanut butter as a spread on crackers
c. spread cream cheese and butter on hot bread
d. dip chicken in eggs before cooking
e. sprinkle cheese on a baked potato
Rationale:
the client should substitute whole milk, cream, or hard-boiled eggs to soups and sauces to
increase protein and calories
34. A nurse is positioning a client to promote drainage from the lower lung lobes. Which of the
following bed positions is the most appropriate?
a. flat
b. knees up and head elevated
c. feet lowered
d. feet raised
Answer: d. feet raised
Rationale:
feet raised-Trendelenburg position to promote gravity drainage of basal lung lobes.
35. A nurse is caring for a client who requires knee-high antiembolic stockings to help prevent
venous stasis. Which of the following actions should the nurse take when measuring the client
for the stockings?
a. measure from heel to gluteal fold
b. measure circumference of both thighs at widest point
c. measure from heel to popliteal space
d. measure distance from buttock to heel
Answer: c. measure from heel to popliteal space
