Fundamentals Proctor Exam
A nurse is using the I-SBAR communication tool to provide the client's provider with
information about the client. The nurse should convey the client's pain status in which
portion of the report? - *answers *Assessment
Rationale:
The nurse provides information about assessment findings in this portion of the report.
This includes vital signs, pain assessment, and changes in assessment findings.
A nurse is providing discharge teaching to a client who is recovering from lung cancer.
The provider instructed the client that he could resume lower-intensity activities of daily
living. Which of the following activities should the nurse recommend to the client? -
*answers *Washing dishes
Rationale:
Washing dishes requires a low level of activity and is appropriate for this client.
A nurse in the emergency department is caring for a client who has abdominal trauma.
Which of the following assessment findings should the nurse identify as an indication of
hypovolemic shock? - *answers *Tachycardia
Rationale:
Due to the decrease in circulating blood volume that occurs with internal bleeding, the
oxygen-carrying capacity of the blood is reduced. The body attempts to relieve the
hypoxia by increasing the heart rate and cardiac output, along with increasing the
respiratory rate.
A nurse is planning to assess the abdomen of a client who reports feeling bloated for
several weeks. Which of the following methods of assessment should the nurse use
first? - *answers *Inspection
Rationale:
According to evidence-based practice, the nurse should inspect the abdomen first by
observing the contour of the abdomen, the condition of the skin, and the position of the
umbilicus. Findings from this step of assessment are used by the nurse in the
subsequent steps.
A nurse is responding to a parent's question about his infant's expected physical
development during the first year of life. Which of the following information should the
nurse include? - *answers *A 10-month-old infant can pull up to a standing position.
Rationale:
An 8 to 10-month-old infant can pull himself to a standing position.
A client who reports shortness of breath requests her nurse's help in changing positions.
After repositioning the client, which of the following actions should the nurse take next?
- *answers *Observe the rate, depth, and character of the client's respirations.
, Fundamentals Proctor Exam
Rationale:
The nurse should apply the nursing process priority-setting framework when caring for
this client. The nurse can use the nursing process to plan client care and prioritize
nursing actions. Each step of the nursing process builds on the previous step, beginning
with assessment or data collection. Before the nurse can formulate a plan of action,
implement a nursing intervention, or notify a provider of a change in the client's status,
the nurse must first collect adequate data from the client. Assessing or collecting
additional data will provide the nurse with knowledge to make an appropriate decision;
therefore, the first action the nurse should take is to assess the client's respiratory
status.
A nurse is planning to insert a nasogastric tube for a client after explaining the
procedure. The client states, "You are not putting that hose down my throat." Which of
the following statements should the nurse make? - *answers *"I can see that this is
upsetting you."
Rationale:
The nurse is using the therapeutic communication techniques of reflecting and restating,
which encourages communication by the client.
An assistive personnel (AP) is assisting a nurse with the care of a female client who has
an indwelling urinary catheter. Which of the following actions by the AP indicates a need
for further teaching? - *answers *The AP hangs the collection bag at the level of the
bladder.
Rationale:
The AP should place the drainage bag below the level of the bladder to ensure proper
drainage by gravity.
A nurse is explaining the use of written consent forms to a newly-licensed nurse. The
nurse should ensure that a written consent form has been signed by which of the
following clients? - *answers *A client who has a prescription for a transfusion of
packed red blood cells
Rationale:
Administration of blood is a procedure that carries risk; therefore, the client must sign a
consent form prior to the procedure.
A nurse is planning care for a client who is postoperative and has a history of poor
nutritional intake. Which of the following actions should the nurse include in the plan of
care to promote wound healing? - *answers *Provide a protein intake of 1.5 g/kg of
body weight per day.
Rationale:
A nurse is using the I-SBAR communication tool to provide the client's provider with
information about the client. The nurse should convey the client's pain status in which
portion of the report? - *answers *Assessment
Rationale:
The nurse provides information about assessment findings in this portion of the report.
This includes vital signs, pain assessment, and changes in assessment findings.
A nurse is providing discharge teaching to a client who is recovering from lung cancer.
The provider instructed the client that he could resume lower-intensity activities of daily
living. Which of the following activities should the nurse recommend to the client? -
*answers *Washing dishes
Rationale:
Washing dishes requires a low level of activity and is appropriate for this client.
A nurse in the emergency department is caring for a client who has abdominal trauma.
Which of the following assessment findings should the nurse identify as an indication of
hypovolemic shock? - *answers *Tachycardia
Rationale:
Due to the decrease in circulating blood volume that occurs with internal bleeding, the
oxygen-carrying capacity of the blood is reduced. The body attempts to relieve the
hypoxia by increasing the heart rate and cardiac output, along with increasing the
respiratory rate.
A nurse is planning to assess the abdomen of a client who reports feeling bloated for
several weeks. Which of the following methods of assessment should the nurse use
first? - *answers *Inspection
Rationale:
According to evidence-based practice, the nurse should inspect the abdomen first by
observing the contour of the abdomen, the condition of the skin, and the position of the
umbilicus. Findings from this step of assessment are used by the nurse in the
subsequent steps.
A nurse is responding to a parent's question about his infant's expected physical
development during the first year of life. Which of the following information should the
nurse include? - *answers *A 10-month-old infant can pull up to a standing position.
Rationale:
An 8 to 10-month-old infant can pull himself to a standing position.
A client who reports shortness of breath requests her nurse's help in changing positions.
After repositioning the client, which of the following actions should the nurse take next?
- *answers *Observe the rate, depth, and character of the client's respirations.
, Fundamentals Proctor Exam
Rationale:
The nurse should apply the nursing process priority-setting framework when caring for
this client. The nurse can use the nursing process to plan client care and prioritize
nursing actions. Each step of the nursing process builds on the previous step, beginning
with assessment or data collection. Before the nurse can formulate a plan of action,
implement a nursing intervention, or notify a provider of a change in the client's status,
the nurse must first collect adequate data from the client. Assessing or collecting
additional data will provide the nurse with knowledge to make an appropriate decision;
therefore, the first action the nurse should take is to assess the client's respiratory
status.
A nurse is planning to insert a nasogastric tube for a client after explaining the
procedure. The client states, "You are not putting that hose down my throat." Which of
the following statements should the nurse make? - *answers *"I can see that this is
upsetting you."
Rationale:
The nurse is using the therapeutic communication techniques of reflecting and restating,
which encourages communication by the client.
An assistive personnel (AP) is assisting a nurse with the care of a female client who has
an indwelling urinary catheter. Which of the following actions by the AP indicates a need
for further teaching? - *answers *The AP hangs the collection bag at the level of the
bladder.
Rationale:
The AP should place the drainage bag below the level of the bladder to ensure proper
drainage by gravity.
A nurse is explaining the use of written consent forms to a newly-licensed nurse. The
nurse should ensure that a written consent form has been signed by which of the
following clients? - *answers *A client who has a prescription for a transfusion of
packed red blood cells
Rationale:
Administration of blood is a procedure that carries risk; therefore, the client must sign a
consent form prior to the procedure.
A nurse is planning care for a client who is postoperative and has a history of poor
nutritional intake. Which of the following actions should the nurse include in the plan of
care to promote wound healing? - *answers *Provide a protein intake of 1.5 g/kg of
body weight per day.
Rationale:
