HURST Fundamental QBank –
Fundamental Questions with Complete
Solutions
A nurse is assessing a client with abdominal surgery 24 hours postop. Which assessment finding would
require an immediate intervention?
1. The nasogastric (NG) tube contents are pale green.
2. An abdominal dressing with the tape on 3 sides of the dressing.
3. Abdominal pain of 5 on 10 point pain scale when client coughs.
4. A bulb-shaped Jackson-Pratt (JP) drain with 25 mL of sanguineous drainage.
4. Correct: The JP drain should be addressed first. The purpose of the JP drain is to remove fluids adjunct
to the surgical site by suction. The JP bulb should be continually compressed to create suction in the
tube which will remove fluid. The compression of the bulb is released when the fluid in the bulb is
emptied and then recompressed.
The nurse is reviewing discharge instructions with the spouse of client following a laminectomy. When
the nurse explains the need to log roll the client, the spouse expresses doubt about the ability to do so
independently. What statement by the nurse is appropriate?
1. "Many spouses have been able to learn this procedure."
2. "Which part of this procedure has you most concerned?"
,3. "Don't you have any family to help you with this procedure?"
4. "Are you worried about caring for your spouse?"
2. CORRECT. The nurse's question is open-ended since it allows the spouse to elaborate on any specific
areas of concern or doubt. This approach encourages the spouse to express feelings with any care after
discharge, and not just the log rolling technique.
A client scheduled for electroshock therapy becomes anxious prior to the initial treatment and refuses
the procedure. What is the nurse's priority at this time?
1. Administer pre-op sedation to help the client relax.
2. Notify the primary healthcare provider of the client's refusal.
3. Remind the client that the consent is already signed.
4. Ask the family to help convince the client to re-consider.
2. Correct. The client has withdrawn consent for the procedure; therefore, the primary healthcare
provider should be informed immediately to cancel the treatment. The primary healthcare provider may
wish to speak with the client, but the client can legally refuse any procedure at any time.
What action by the nurse is most helpful when responding to a bomb threat phone call?
1. Ask where and when the bomb is going to explode.
2. Quickly terminate the conversation and call in the bomb threat.
3. Document on the hospital Bomb Threat Checklist.
4. Immediately seek cover and warn others.
1. CORRECT. The nurse should keep the caller on the phone for as long as possible and try to obtain
information, while being alert for voice characteristics and background noises. While keeping the caller
on the line, the nurse should motion to another employee to call in the bomb threat.
, The nurse provides instructions on the proper use of crutches to a client. Which comment by the client
indicates a need for additional instructions?
1. "I move the crutches 6 to 12 inches ahead prior to moving foot forward."
2. "To descend stairs I will move crutches and my unaffected leg first, followed by the affected leg."
3. "When rising from a chair, I will place crutches on my affected side, lean forward, and push off from
the chair with one hand."
4. "To climb stairs I will advance my unaffected leg past crutches, then place weight on unaffected leg,
and advance affected leg and the crutches to the step."
2. Correct: This client will need additional instruction. The client should place their crutches on the step
below first. Then move the affected leg down to the next step. The client should follow with the
unaffected leg.
A client shares with the nurse that they are having difficulty staying asleep. Which sleep hygiene
intervention would the nurse share with the client to promote falling asleep?
1. Take a cool bath.
2. Include a daytime exercise plan.
3. Take an antihistamine at bedtime.
4. Scan the news feeds on the computer.
2. Correct: Including a daytime exercise program is a sleep hygiene recommendation that will increase
the quality of sleep. The exercise program increases metabolism and reduces stress. Activities after 1700
should be avoided if they a strenuous.
What action should the nurse take when testing a client's near vision?
1. Have client read a Snellen chart from 20 feet away.
Fundamental Questions with Complete
Solutions
A nurse is assessing a client with abdominal surgery 24 hours postop. Which assessment finding would
require an immediate intervention?
1. The nasogastric (NG) tube contents are pale green.
2. An abdominal dressing with the tape on 3 sides of the dressing.
3. Abdominal pain of 5 on 10 point pain scale when client coughs.
4. A bulb-shaped Jackson-Pratt (JP) drain with 25 mL of sanguineous drainage.
4. Correct: The JP drain should be addressed first. The purpose of the JP drain is to remove fluids adjunct
to the surgical site by suction. The JP bulb should be continually compressed to create suction in the
tube which will remove fluid. The compression of the bulb is released when the fluid in the bulb is
emptied and then recompressed.
The nurse is reviewing discharge instructions with the spouse of client following a laminectomy. When
the nurse explains the need to log roll the client, the spouse expresses doubt about the ability to do so
independently. What statement by the nurse is appropriate?
1. "Many spouses have been able to learn this procedure."
2. "Which part of this procedure has you most concerned?"
,3. "Don't you have any family to help you with this procedure?"
4. "Are you worried about caring for your spouse?"
2. CORRECT. The nurse's question is open-ended since it allows the spouse to elaborate on any specific
areas of concern or doubt. This approach encourages the spouse to express feelings with any care after
discharge, and not just the log rolling technique.
A client scheduled for electroshock therapy becomes anxious prior to the initial treatment and refuses
the procedure. What is the nurse's priority at this time?
1. Administer pre-op sedation to help the client relax.
2. Notify the primary healthcare provider of the client's refusal.
3. Remind the client that the consent is already signed.
4. Ask the family to help convince the client to re-consider.
2. Correct. The client has withdrawn consent for the procedure; therefore, the primary healthcare
provider should be informed immediately to cancel the treatment. The primary healthcare provider may
wish to speak with the client, but the client can legally refuse any procedure at any time.
What action by the nurse is most helpful when responding to a bomb threat phone call?
1. Ask where and when the bomb is going to explode.
2. Quickly terminate the conversation and call in the bomb threat.
3. Document on the hospital Bomb Threat Checklist.
4. Immediately seek cover and warn others.
1. CORRECT. The nurse should keep the caller on the phone for as long as possible and try to obtain
information, while being alert for voice characteristics and background noises. While keeping the caller
on the line, the nurse should motion to another employee to call in the bomb threat.
, The nurse provides instructions on the proper use of crutches to a client. Which comment by the client
indicates a need for additional instructions?
1. "I move the crutches 6 to 12 inches ahead prior to moving foot forward."
2. "To descend stairs I will move crutches and my unaffected leg first, followed by the affected leg."
3. "When rising from a chair, I will place crutches on my affected side, lean forward, and push off from
the chair with one hand."
4. "To climb stairs I will advance my unaffected leg past crutches, then place weight on unaffected leg,
and advance affected leg and the crutches to the step."
2. Correct: This client will need additional instruction. The client should place their crutches on the step
below first. Then move the affected leg down to the next step. The client should follow with the
unaffected leg.
A client shares with the nurse that they are having difficulty staying asleep. Which sleep hygiene
intervention would the nurse share with the client to promote falling asleep?
1. Take a cool bath.
2. Include a daytime exercise plan.
3. Take an antihistamine at bedtime.
4. Scan the news feeds on the computer.
2. Correct: Including a daytime exercise program is a sleep hygiene recommendation that will increase
the quality of sleep. The exercise program increases metabolism and reduces stress. Activities after 1700
should be avoided if they a strenuous.
What action should the nurse take when testing a client's near vision?
1. Have client read a Snellen chart from 20 feet away.
