Fundamentals nursing Exam 2 LATEST 2026-2027 300
QUESTIONS AND 100% Verified ANSWERS
A nurse is caring for a client who reports onset of abdominal pain. the nurse should assign the client's condition to
which of the following categories when prioritizing care?
- chronic
-minimal
-urgent
- expectant - answer>>urgent
urgent category have a greater probability of poor outcomes if prompt actions are not taken, abdominal pain can
be caused by non lifetreatening problems such as gas and constipation but can also be a manifestation of more
significant illness such as bowel obstruction or appendicitis's, the nurse should assess further to determine the
cause of abdominal pain
A nurse is caring for a client who is confused and trying to remove their peripheral IV. Using the least
restrictive/least invasive priority setting framework, which of the following actions should the nurse take 1st?
- apply soft limb restraints to the client's wrists
-admin an anti anxiety med to the client intramuscularly (IM)
- cover the IV site with an elastic bandage
- request a prescription for a central venous catheter - answer>>cover the IV site with an elastic band
will hide the IV from the clients vision while at the same time allowing the nurse easy access to the site
A nurse at a provider's office is reviewing the records of several clients. which of the following clients should the
nurse recommend as the priority for treatment?
- a client who has a history of hypertension and requires a yearly checkup
- a client who reports new chest pain
- a client who reports increased joint stiffness due to arthritis
- a client who has diabetes mellitus and needs dietary instruction - answer>>a client who reports of new chest pain
,a nurse is assessing a client using the ABCDE approach. the nurse has already assessed the client's airway and
breathing status. which of the following assessments should the nurse perform next?
- body temperature
- abdominal contour
-skin integrity
- blood pressure - answer>>blood pressure
next is circulatory system, can include BP, checking peripheral pulses and measuring capillary refill time
A nurse is providing education on priority setting framework to a group of newly licensed nurses. which of the
following statements should the nurse make regarding the safety and risk reduction priority setting framework?
- when using this framework, clients are prioritized using a color coded system
- this framework uses the least restrictive measures first as long as the clients safety is maintained
- when using this framework, the nurse will encourage the client to have social relationships through group
interactions
- this framework assigns the highest priority to the situation that poses a threat to the client's physical well being -
answer>>this framework assigns the highest priority to the situation that poses a threat to the client's physical
well being
A nurse is reviewing the medical records of 4 clients. which of the following clients should the nurse identify as the
priority for care?
- a client who received digoxin and has a HR of 48/min
- a client who received pain medication and has a respiratory rate of 14/min
- a client who has a UTI and temp of 37.9 C (100.2 F)
- a client who has anemia and a BP of 118/78 mm HG - answer>>a client who received digoxin and has a HR of
48/min
unstable, the HR is below the expected range and check for manifestations of decreased cardiac output
A nurse is caring for a client who is experiencing unexpected manifestations with several body systems. which of
the following priority setting frameworks should the nurse use to prioritize client assessment?
,acute vs chronic
ABBCDE
least restrictive/least invasice
survival potential - answer>>ABCDE
A nurse is assessing an olde adult client's risk for falls. which of the following assessment should the nurse use to
identify the client's safety needs (SALTA)
- lacrimal appartus
- pupil clarity
-appearance of bulbar conjunctivae
-visual fields
-visual acuity - answer>>visual fields
-visual acuity
pupil clarity
A nurse is responding to a call light and finds a client lying on the bathroom floor. which of the following actions
should the nurse take first?
- check the client for injuries
- move hazardous objects away from the client
-notify the provider
-ask the client to describer how she felt prior to the fall - answer>>check the client for injury
assess the client for injuries
A nurse is initiating a protective environment for a client who has\d an allofernic stem cell transplant. which of the
following precautions should the nurse plan for this client?
- make sure the client's room has at least 6 air exchanges per hour
- make sure the client wears a mask when outside her room if there is constructive in the area.
- place the client in a private room w the negative-pressure airflow
, - wear a N95 respirator when giving the client direct care - answer>>make sure the client wears a mask when
outside her room if there is constructive in the area.
compromises clients immune system, greatly increasing the risk for infection. the client will need protection from
breathing in any pathogens in the environment
has at least 12 air cexhanges
- should be in positive pressure room
- N 95 only for airborne precautions
A nurse on a med-surg unit is caring for a client who has a new prescription for wrist restraints. which of the
following actions should the nurse take?
- pad the client's wrist before applying restraints.
- evaluate the client's circulation every 8 hr after application
- remove the restorations every 4 hours to evaluate the client status
secure the restrain to the beds side rails - answer>>pad the client's wrist before applying restraints.
without can abrade the client's skin resulting in injury
A nurse is caring for a client who is post operative and is exhibiting signs of hemorrhagic shock. the nurse notifies
the surgeon, who tells the nurse to continue to measure the client''s vital signs every 15 min and to report back in
1 hr. which of the following actions should the nurse take 1st?
- document the provider's statement in the med record
- complete an incident report
- consult the facilitys risk manager
- notify the nurse manager - answer>>notify the nurse manager
the greatest risk to the client is not receiving timely intervention for a deterioration in physiological status therefor
the next action the nurse should take is to activate the chain of command to ensure that the client receives the
necessary cary
QUESTIONS AND 100% Verified ANSWERS
A nurse is caring for a client who reports onset of abdominal pain. the nurse should assign the client's condition to
which of the following categories when prioritizing care?
- chronic
-minimal
-urgent
- expectant - answer>>urgent
urgent category have a greater probability of poor outcomes if prompt actions are not taken, abdominal pain can
be caused by non lifetreatening problems such as gas and constipation but can also be a manifestation of more
significant illness such as bowel obstruction or appendicitis's, the nurse should assess further to determine the
cause of abdominal pain
A nurse is caring for a client who is confused and trying to remove their peripheral IV. Using the least
restrictive/least invasive priority setting framework, which of the following actions should the nurse take 1st?
- apply soft limb restraints to the client's wrists
-admin an anti anxiety med to the client intramuscularly (IM)
- cover the IV site with an elastic bandage
- request a prescription for a central venous catheter - answer>>cover the IV site with an elastic band
will hide the IV from the clients vision while at the same time allowing the nurse easy access to the site
A nurse at a provider's office is reviewing the records of several clients. which of the following clients should the
nurse recommend as the priority for treatment?
- a client who has a history of hypertension and requires a yearly checkup
- a client who reports new chest pain
- a client who reports increased joint stiffness due to arthritis
- a client who has diabetes mellitus and needs dietary instruction - answer>>a client who reports of new chest pain
,a nurse is assessing a client using the ABCDE approach. the nurse has already assessed the client's airway and
breathing status. which of the following assessments should the nurse perform next?
- body temperature
- abdominal contour
-skin integrity
- blood pressure - answer>>blood pressure
next is circulatory system, can include BP, checking peripheral pulses and measuring capillary refill time
A nurse is providing education on priority setting framework to a group of newly licensed nurses. which of the
following statements should the nurse make regarding the safety and risk reduction priority setting framework?
- when using this framework, clients are prioritized using a color coded system
- this framework uses the least restrictive measures first as long as the clients safety is maintained
- when using this framework, the nurse will encourage the client to have social relationships through group
interactions
- this framework assigns the highest priority to the situation that poses a threat to the client's physical well being -
answer>>this framework assigns the highest priority to the situation that poses a threat to the client's physical
well being
A nurse is reviewing the medical records of 4 clients. which of the following clients should the nurse identify as the
priority for care?
- a client who received digoxin and has a HR of 48/min
- a client who received pain medication and has a respiratory rate of 14/min
- a client who has a UTI and temp of 37.9 C (100.2 F)
- a client who has anemia and a BP of 118/78 mm HG - answer>>a client who received digoxin and has a HR of
48/min
unstable, the HR is below the expected range and check for manifestations of decreased cardiac output
A nurse is caring for a client who is experiencing unexpected manifestations with several body systems. which of
the following priority setting frameworks should the nurse use to prioritize client assessment?
,acute vs chronic
ABBCDE
least restrictive/least invasice
survival potential - answer>>ABCDE
A nurse is assessing an olde adult client's risk for falls. which of the following assessment should the nurse use to
identify the client's safety needs (SALTA)
- lacrimal appartus
- pupil clarity
-appearance of bulbar conjunctivae
-visual fields
-visual acuity - answer>>visual fields
-visual acuity
pupil clarity
A nurse is responding to a call light and finds a client lying on the bathroom floor. which of the following actions
should the nurse take first?
- check the client for injuries
- move hazardous objects away from the client
-notify the provider
-ask the client to describer how she felt prior to the fall - answer>>check the client for injury
assess the client for injuries
A nurse is initiating a protective environment for a client who has\d an allofernic stem cell transplant. which of the
following precautions should the nurse plan for this client?
- make sure the client's room has at least 6 air exchanges per hour
- make sure the client wears a mask when outside her room if there is constructive in the area.
- place the client in a private room w the negative-pressure airflow
, - wear a N95 respirator when giving the client direct care - answer>>make sure the client wears a mask when
outside her room if there is constructive in the area.
compromises clients immune system, greatly increasing the risk for infection. the client will need protection from
breathing in any pathogens in the environment
has at least 12 air cexhanges
- should be in positive pressure room
- N 95 only for airborne precautions
A nurse on a med-surg unit is caring for a client who has a new prescription for wrist restraints. which of the
following actions should the nurse take?
- pad the client's wrist before applying restraints.
- evaluate the client's circulation every 8 hr after application
- remove the restorations every 4 hours to evaluate the client status
secure the restrain to the beds side rails - answer>>pad the client's wrist before applying restraints.
without can abrade the client's skin resulting in injury
A nurse is caring for a client who is post operative and is exhibiting signs of hemorrhagic shock. the nurse notifies
the surgeon, who tells the nurse to continue to measure the client''s vital signs every 15 min and to report back in
1 hr. which of the following actions should the nurse take 1st?
- document the provider's statement in the med record
- complete an incident report
- consult the facilitys risk manager
- notify the nurse manager - answer>>notify the nurse manager
the greatest risk to the client is not receiving timely intervention for a deterioration in physiological status therefor
the next action the nurse should take is to activate the chain of command to ensure that the client receives the
necessary cary
