RN Fundamentals Online Practice 2019 B
1. A charge nurse is discussing the responsibility of nurses caring for clients who have a Clostridium
difficile infection. Which of the following information should the nurse include in the teaching?
Answer: Have family members wear a gown and gloves when visiting.
Rationale:
Nurses are responsible for ensuring that family members wear a gown and gloves to prevent the
transmission of Clostridium difficile spores. Staff must also wear gowns and gloves.
2. A nurse is giving change-of-shift report about a client they admitted earlier that day who has
pneumonia. Which of the following pieces of information is the priority for the nurse to provide?
Answer: Breath sounds
Rationale: When using the airway, breathing, circulation approach to client care, the nurse
should determine that the priority information to provide is the current status of the client's
breath sounds.
3. A nurse is preparing to delegate client care tasks to an assistive personnel (AP). Which of the
following tasks should the nurse delegate?
Answer: Ambulating a client who is postoperative
Rationale: Ambulating a client is within the range of function of an AP. The nurse can delegate
tasks to the AP that do not require special skills, assessment, or teaching.
4. A nurse enters a client’s room and finds her on the floor. The client’s roommate reports that the
client was trying to get out of bed and fell over the side rail onto the floor. Which of the
following statements should the nurse document about this incident?
My answer: “Client was trying to get out of bed.”
Answer: "Client found lying on floor."
Rationale: The nurse should include documentation of information that is descriptive and
objective concerning what the nurse actually observed, without including any opinions or
judgments about motives or cause.
5. A nurse is caring for a client who has a prescription for wound irrigation. Which of the following
actions should the nurse take?
Answer: Cleanse the wound from the center outward.
Rationale: The nurse should clean the wound from the center outward to prevent introduction
of micro-organisms from the outer skin surface. The nurse should wear clean gloves to remove
the old dressing, not sterile gloves. The nurse should warm the irrigation solution to body
temperature.
The nurse should use a 35-mL syringe to irrigate the wound. Syringes that hold 30 to 60 mL of
fluid create a safe but effective amount of pressure for wound irrigation.
6. A nurse is admitting a client who has rubella. Which of the following types of transmission-based
precautions should the nurse initiate?
My answer: Airborne
Answer: Droplet
Rationale: Droplet precautions are a requirement for clients who have infections that spread via
droplet nuclei that are larger than 5 microns in diameter, including influenza, rubella,
meningococcal pneumonia, and streptococcal pharyngitis. Airborne precautions are a
requirement for clients who have infections that spread via droplet nuclei that are smaller than 5
microns in diameter, including varicella, tuberculosis, and measles.
, 7. A nurse is providing discharge teaching for a client who has a new prescription for a home
oxygen concentrator. Which of the following instructions should the nurse provide to the client
and his family? (Select all that apply.)
Answer: Check the cord routinely for frays or tearing; consider purchasing a generator for power
backup; observe for signs of hypoxia
Rationale: Oxygen concentrators require electrical power. Safe use of this delivery system
includes assessing the electrical function of the device; therefore, the nurse should instruct the
client to routinely check the condition of the cord. Loss of electricity prevents the oxygen
concentrator from functioning and could deprive the client of necessary oxygen. The nurse
should also instruct the family to have the client placed on their municipality's priority list for
restoring power after an outage occurs. The nurse should instruct the family to observe for and
report signs of hypoxia, such as anxiety, worsening fatigue, dizziness, rapid pulse and
respirations, pallor, and cyanosis. Even with supplemental oxygen, the client's status can worsen,
resulting in the development of hypoxia.
8. A nurse is calculating a client’s fluid intake over the past 8 hr. which of the following items should
the nurse plan to document on the client’s intake and output record as 120 mL of fluid?
Answer: 8 oz of ice chips
Rationale: The nurse should document half of the volume of ice chips when calculating fluid
intake to account for the air in between the chips. The nurse should understand that 4 oz of
liquid water is equal to 120 mL of fluid.
9. A nurse is caring for a client who has tuberculosis. Which of the following actions should the
nurse take? (Select all that apply.)
Answer: Place the client in a room with negative-pressure airflow; wear gloves when assisting
the client with oral care; use antimicrobial sanitizer for hand hygiene
Rationale: The nurse should place the client in a room with negative -pressure airflow to meet
the requirements of airborne precautions. The nurse should wear gloves when assisting the
client with oral care to meet the requirements of standard precautions, which the nurse must
adhere to for all clients regardless of their diagnosis. The nurse should wear gloves whenever
their hands might come in contact with a client's bodily fluids, such as saliva, and the mucous
membranes in the mouth. The nurse should use antimicrobial sanitizer for routine hand hygiene
when caring for a client who has tuberculosis. Nurses should also wash their hands with soap
and water when their hands are visibly soiled. The nurse should wear an N95 respirator during
client care to meet the requirements of airborne precautions.
10. A nurse is caring for a client who is refusing a blood transfusion for religious reasons. The client’s
partner wants the client to have the blood transfusion. Which of the following actions should the
nurse take?
Answer: Withhold the blood transfusion.
Rationale: The principle of autonomy ensures that a client who is competent has the right to
refuse treatment.
11. A nurse is teaching a client whose left leg is in a cast about using crutches. Which of the
following statements should the nurse identify as an indication that the client understands the
teaching?
My answer: "I will make sure the shoulder rests are snug against my armpits."
Answer: "When descending stairs, I will first shift my weight to my right leg."
1. A charge nurse is discussing the responsibility of nurses caring for clients who have a Clostridium
difficile infection. Which of the following information should the nurse include in the teaching?
Answer: Have family members wear a gown and gloves when visiting.
Rationale:
Nurses are responsible for ensuring that family members wear a gown and gloves to prevent the
transmission of Clostridium difficile spores. Staff must also wear gowns and gloves.
2. A nurse is giving change-of-shift report about a client they admitted earlier that day who has
pneumonia. Which of the following pieces of information is the priority for the nurse to provide?
Answer: Breath sounds
Rationale: When using the airway, breathing, circulation approach to client care, the nurse
should determine that the priority information to provide is the current status of the client's
breath sounds.
3. A nurse is preparing to delegate client care tasks to an assistive personnel (AP). Which of the
following tasks should the nurse delegate?
Answer: Ambulating a client who is postoperative
Rationale: Ambulating a client is within the range of function of an AP. The nurse can delegate
tasks to the AP that do not require special skills, assessment, or teaching.
4. A nurse enters a client’s room and finds her on the floor. The client’s roommate reports that the
client was trying to get out of bed and fell over the side rail onto the floor. Which of the
following statements should the nurse document about this incident?
My answer: “Client was trying to get out of bed.”
Answer: "Client found lying on floor."
Rationale: The nurse should include documentation of information that is descriptive and
objective concerning what the nurse actually observed, without including any opinions or
judgments about motives or cause.
5. A nurse is caring for a client who has a prescription for wound irrigation. Which of the following
actions should the nurse take?
Answer: Cleanse the wound from the center outward.
Rationale: The nurse should clean the wound from the center outward to prevent introduction
of micro-organisms from the outer skin surface. The nurse should wear clean gloves to remove
the old dressing, not sterile gloves. The nurse should warm the irrigation solution to body
temperature.
The nurse should use a 35-mL syringe to irrigate the wound. Syringes that hold 30 to 60 mL of
fluid create a safe but effective amount of pressure for wound irrigation.
6. A nurse is admitting a client who has rubella. Which of the following types of transmission-based
precautions should the nurse initiate?
My answer: Airborne
Answer: Droplet
Rationale: Droplet precautions are a requirement for clients who have infections that spread via
droplet nuclei that are larger than 5 microns in diameter, including influenza, rubella,
meningococcal pneumonia, and streptococcal pharyngitis. Airborne precautions are a
requirement for clients who have infections that spread via droplet nuclei that are smaller than 5
microns in diameter, including varicella, tuberculosis, and measles.
, 7. A nurse is providing discharge teaching for a client who has a new prescription for a home
oxygen concentrator. Which of the following instructions should the nurse provide to the client
and his family? (Select all that apply.)
Answer: Check the cord routinely for frays or tearing; consider purchasing a generator for power
backup; observe for signs of hypoxia
Rationale: Oxygen concentrators require electrical power. Safe use of this delivery system
includes assessing the electrical function of the device; therefore, the nurse should instruct the
client to routinely check the condition of the cord. Loss of electricity prevents the oxygen
concentrator from functioning and could deprive the client of necessary oxygen. The nurse
should also instruct the family to have the client placed on their municipality's priority list for
restoring power after an outage occurs. The nurse should instruct the family to observe for and
report signs of hypoxia, such as anxiety, worsening fatigue, dizziness, rapid pulse and
respirations, pallor, and cyanosis. Even with supplemental oxygen, the client's status can worsen,
resulting in the development of hypoxia.
8. A nurse is calculating a client’s fluid intake over the past 8 hr. which of the following items should
the nurse plan to document on the client’s intake and output record as 120 mL of fluid?
Answer: 8 oz of ice chips
Rationale: The nurse should document half of the volume of ice chips when calculating fluid
intake to account for the air in between the chips. The nurse should understand that 4 oz of
liquid water is equal to 120 mL of fluid.
9. A nurse is caring for a client who has tuberculosis. Which of the following actions should the
nurse take? (Select all that apply.)
Answer: Place the client in a room with negative-pressure airflow; wear gloves when assisting
the client with oral care; use antimicrobial sanitizer for hand hygiene
Rationale: The nurse should place the client in a room with negative -pressure airflow to meet
the requirements of airborne precautions. The nurse should wear gloves when assisting the
client with oral care to meet the requirements of standard precautions, which the nurse must
adhere to for all clients regardless of their diagnosis. The nurse should wear gloves whenever
their hands might come in contact with a client's bodily fluids, such as saliva, and the mucous
membranes in the mouth. The nurse should use antimicrobial sanitizer for routine hand hygiene
when caring for a client who has tuberculosis. Nurses should also wash their hands with soap
and water when their hands are visibly soiled. The nurse should wear an N95 respirator during
client care to meet the requirements of airborne precautions.
10. A nurse is caring for a client who is refusing a blood transfusion for religious reasons. The client’s
partner wants the client to have the blood transfusion. Which of the following actions should the
nurse take?
Answer: Withhold the blood transfusion.
Rationale: The principle of autonomy ensures that a client who is competent has the right to
refuse treatment.
11. A nurse is teaching a client whose left leg is in a cast about using crutches. Which of the
following statements should the nurse identify as an indication that the client understands the
teaching?
My answer: "I will make sure the shoulder rests are snug against my armpits."
Answer: "When descending stairs, I will first shift my weight to my right leg."
