Practice Questions & Verified Answers | Nursing
Fundamentals Review
1. A 35-year-old client with cancer refuses to allow an IV for chemotherapy
and says she wants to go home to die. What is the priority nursing action?
A. Evaluate the client’s mental status for competence
B. Notify the healthcare provider for discharge orders
C. Initiate a DNR
D. Document refusal
Answer: A
Rationale: Competent clients may refuse treatment. Assessment of decision-
making capacity is first. Other actions follow based on competence.
2. Which lab test best reflects a client’s long-term protein status?
A. Serum albumin
B. Prealbumin
C. BUN
D. Creatinine
Answer: A
Rationale: Albumin’s long half-life (~20 days) reflects long-term protein
levels.
3. Which client statement indicates need for assistance with bathing?
A. “I don’t understand why I’m so weak and tired.”
B. “I prefer to bathe myself but need encouragement.”
C. “I can dress myself but need help with washing my back.”
D. “I enjoy bathing independently.”
,Answer: A
Rationale: Fatigue and weakness indicate functional limitation.
4. How should the nurse handle soiled linens with feces?
A. Shake outside the room
B. Place directly in laundry chute
C. Place in a pillowcase and deposit in dirty linen hamper
D. Rinse at sink
Answer: C
Rationale: Containment prevents contamination. Shaking or rinsing spreads
infection.
5. For an immobile client, which nursing diagnosis has highest priority?
A. Impaired gas exchange
B. Risk for impaired skin integrity
C. Risk for constipation
D. Activity intolerance
Answer: A
Rationale: Oxygenation is always the first priority.
6. An immobile elderly male has wet-sounding lungs, concentrated urine,
temp 95.8°F. What nursing action is most important?
A. Turn client q2h
B. Increase fluids
C. Administer diuretics
D. Encourage coughing
,Answer: A
Rationale: Turning promotes drainage and prevents pneumonia.
7. A post-stroke client ambulates with a quad cane. Which assessment poses
the greatest risk?
A. Numerous scatter rugs
B. Non-slip socks
C. Walker for stairs
D. Handrails in bathroom
Answer: A
Rationale: Scatter rugs are fall hazards for mobility-impaired clients.
8. The nurse removes a dressing from a 1-inch heel pressure ulcer and sees
straw-colored drainage. How should this be documented?
A. One-inch pressure sore with serous drainage
B. Stage II ulcer with purulent drainage
C. Necrotic tissue with exudate
D. One-inch abrasion with serosanguinous drainage
Answer: A
Rationale: Serous drainage is straw-colored, normal for healing.
9. Medication prescribed QID. Which schedule is correct?
A. 0800, 1200, 1600, 2000
B. 0600, 1200, 1800, 2400
C. 0700, 1300, 1900, 2300
, D. 0800, 1400, 2000, 0200
Answer: A
Rationale: QID = four evenly spaced doses during waking hours.
10. Which client is likely to tolerate higher pain?
A. 55y/o woman with moderate low back pain for 3 months
B. 30y/o man with first-time appendicitis
C. 50y/o woman with new migraine
D. 20y/o athlete with ankle sprain
Answer: A
Rationale: Previous successful pain management increases tolerance.
11. A 4-year-old asks, “Will it hurt?” before tonsillectomy. Best response:
A. “It may hurt, but we’ll give medicine to help.”
B. “No, you won’t feel anything.”
C. “Yes, it will hurt a lot.”
D. “I don’t know.”
Answer: A
Rationale: Honest, reassuring, age-appropriate response.
12. A 45-year-old with renal insufficiency and hypertension is on a low-
sodium, low-protein diet. Which 24-hour diet recalls indicate noncompliance?
(Select all that apply)