NURSING FUNDAMENTALS HE SI PREP 2023/2024 CORRECT AND VERIFIED ANSWERS 1.The nurse plans to obtain health assessment information from a primary source. Which option is a primary source for the completion of the health assessment? A) Client. B) Healthcare provider. C) A family member. D) Previous medical records Correct Answer: A 2. After completing an assessment and determining that a client has a problem, which action should the nurse perform next? A) Determine the etiology of the problem. B) Prioritize nursing care interventions. C) Plan appropriate interventions. D) Collaborate with the client to set goals. Correct Answer: A 3.A resident in a skilled nursing facility for short -term rehabilitation after a hip replacement tells the nurse, "I don't want any more blood taken for those useless tests." Which narrative documentation should the nurse enter in the client's medical record ? A) Healthcare provider notified of failure to collect specimens for prescribed blood studies. B) Blood specimens not collected because client no longer wants blood tests performed. C) Healthcare provider notified of client's refusal to have blood spe cimens collected for testing. D) Client irritable, uncooperative, and refuses to have blood collected. Healthcare provider notified Correct Answer: C 4.The nurse is using a genogram while conducting a client ’s health assessment and past medical history. What information should the genogram provide? A) Genetic and familial health disorders. B) Chronic health problems. C) Reason for seeking health care. D) Undetected disorders. Correct Answer: A 5.At the beginning of the shift, the nurse assesses a client who is admitted from the post -
anesthesia care unit (PACU). When should the nurse document the client's findings? A) At the beginning, middle, and end of the shift. B) After client priorities are identified for the development of the nursing care plan. C) At the end of the shift so full attention can be given to the client's needs. D) Immediately after the assessments are completed Correct Answer: D 6.A client who has been NPO for 3 days is receiving an infusion of D5W 0.45 normal saline (NS) with potassium chloride (KCl) 20 mEq at 83 ml/hour. The client's eight -hour urine output is 400 ml, blood urea nitrogen (BUN) is 15 mg/dl, lungs are clear bilatera lly, serum glucose is 120 mg/dl, and the serum potassium is 3.7 mEq/L. Which action is most important for the nurse to implement? A) Notify healthcare provider and request to change the IV infusion to hypertonic D10W. B) Decrease in the infusion rate of the current IV and report to the healthcare provider. C) Document in the medical record that these normal findings are expected outcomes. D) Obtain potassium chloride 20 mEq in anticipation of a prescription to add to present IV . Correct Answer: C 7.On admission, a client presents a signed living will that includes a Do Not Resuscitate (DNR) prescription. When the client stops breathing, the nurse performs cardiopulmonary resuscitation (CPR) and successfully revives the client. What legal issues could be brought against the nurse? A) Assault. B) Battery. C) Malpractice. D) False imprisonment. Correct Answer: B 8.During the daily nursing assessment, a client begins to cry and states that the majority of family and friends have stopped calling and visiting. What action should the nurse take? A) Listen and show interest as the client expresses these feelings. B) Reinforce that this behavior means they were not true friends. C) Ask the healthcare provider for a psychiatric consult. D) Continue with the assessment and tell the client not to worry. Correct Answer: A 9.An older client who is a resident in a long term care facility has been bedridden for a week. Which finding should the nurse identify as a client risk factor for pressure ulcers? A) Generalized dry skin. B) Localized dry skin on lower extremities. C) Red flush over entire skin surface. D) Rashes in the axillary, groin, and skin fold regions Correct Answer: D 10.An Arab -American woman, who is a devout traditional Muslim, lives with her married son's family, which includes several adult children and their children. What is the best plan to obtain consent for surgery for this client? A) Obtain an interpreter to explain the procedure to the client. B) Encourage the client to make her own decision regarding surgery. C) Ask the family members to provide an interpretation of the surgeon's explanation to the client. D) Tell the surgeon that the son will decide after explanation of the proposed surgery is provided. Correct Answer: D 11.Which response by a client with a nursing diagnosis of Spiritual distress, indicates to the nurse that a desired outcome measure has been met? A) Expresses concern about the meaning and importance of life B) Remains angry at God for the continuation of the illness. C) Accepts that punishment from God is not related to illness. D) Refuses to participate in religious rituals that have no meaning. Correct Answer: C 12.The nurse is caring for a client with diabetes insipidus. The nurse should anticipate the administration of: Desmopressin
anesthesia care unit (PACU). When should the nurse document the client's findings? A) At the beginning, middle, and end of the shift. B) After client priorities are identified for the development of the nursing care plan. C) At the end of the shift so full attention can be given to the client's needs. D) Immediately after the assessments are completed Correct Answer: D 6.A client who has been NPO for 3 days is receiving an infusion of D5W 0.45 normal saline (NS) with potassium chloride (KCl) 20 mEq at 83 ml/hour. The client's eight -hour urine output is 400 ml, blood urea nitrogen (BUN) is 15 mg/dl, lungs are clear bilatera lly, serum glucose is 120 mg/dl, and the serum potassium is 3.7 mEq/L. Which action is most important for the nurse to implement? A) Notify healthcare provider and request to change the IV infusion to hypertonic D10W. B) Decrease in the infusion rate of the current IV and report to the healthcare provider. C) Document in the medical record that these normal findings are expected outcomes. D) Obtain potassium chloride 20 mEq in anticipation of a prescription to add to present IV . Correct Answer: C 7.On admission, a client presents a signed living will that includes a Do Not Resuscitate (DNR) prescription. When the client stops breathing, the nurse performs cardiopulmonary resuscitation (CPR) and successfully revives the client. What legal issues could be brought against the nurse? A) Assault. B) Battery. C) Malpractice. D) False imprisonment. Correct Answer: B 8.During the daily nursing assessment, a client begins to cry and states that the majority of family and friends have stopped calling and visiting. What action should the nurse take? A) Listen and show interest as the client expresses these feelings. B) Reinforce that this behavior means they were not true friends. C) Ask the healthcare provider for a psychiatric consult. D) Continue with the assessment and tell the client not to worry. Correct Answer: A 9.An older client who is a resident in a long term care facility has been bedridden for a week. Which finding should the nurse identify as a client risk factor for pressure ulcers? A) Generalized dry skin. B) Localized dry skin on lower extremities. C) Red flush over entire skin surface. D) Rashes in the axillary, groin, and skin fold regions Correct Answer: D 10.An Arab -American woman, who is a devout traditional Muslim, lives with her married son's family, which includes several adult children and their children. What is the best plan to obtain consent for surgery for this client? A) Obtain an interpreter to explain the procedure to the client. B) Encourage the client to make her own decision regarding surgery. C) Ask the family members to provide an interpretation of the surgeon's explanation to the client. D) Tell the surgeon that the son will decide after explanation of the proposed surgery is provided. Correct Answer: D 11.Which response by a client with a nursing diagnosis of Spiritual distress, indicates to the nurse that a desired outcome measure has been met? A) Expresses concern about the meaning and importance of life B) Remains angry at God for the continuation of the illness. C) Accepts that punishment from God is not related to illness. D) Refuses to participate in religious rituals that have no meaning. Correct Answer: C 12.The nurse is caring for a client with diabetes insipidus. The nurse should anticipate the administration of: Desmopressin
