Nursing Fundamentals Practice Actual
Final Exam EXTRA STUDY 2025 Updated
with 100% Correct and Verified
Answers.
.5.What intervention should the nurse include in the plan of care for a client who is being treated with
an Unna's paste boot for leg ulcers due to chronic venous insufficiency?
A. Check capillary refill of toes on lower extremity with Unna's paste boot.
B. Apply dressing to wound area before applying the Unna's paste boot.
C. Wrap the leg from the knee down towards the foot.
D. Remove the Unna's paste boot q8h to assess wound healing.
The Unna's paste boot becomes rigid after it dries, so it is important to check distally for adequate
circulation (A). Kerlix is often wrapped around the outside of the boot and an ace bandage may be used
to cover both, but no bandage should be put under it (B). The Unna's paste boot should be applied from
the foot and wrapped towards the knee (C). The Unna's paste boot acts as a sterile dressing, and should
not be removed q8h. Weekly removal is reasonable (D).
Correct Answer: A
...A .5-year-old client who has a history of end stage renal failure and advanced lung cancer, recently had
a stroke. Two days ago the healthcare provider discontinued the client's dialysis treatments, stating that
death is inevitable, but the client is disoriented and will not sign a DNR directive. What is the priority
nursing intervention?
A. Review the client's most recent laboratory reports.
B. Refer the client and family members for hospice care.
C. Notify the hospital ethics committee of the client situation.
D. Determine who is legally empowered to make decisions.
When death is impending, it is essential for the nurse to determine who is legally empowered to make
decisions regarding the use of life-saving measures for the client (D). (A) will be abnormal and will
worsen without dialysis, so are not of immediate concern. (B) may help improve the client's quality of
life prior to death, but is of less immediacy than determining whether actions should be taken to save a
,client's life. If the nurse remains unable to determine who is empowered to make decisions in this
situation, the nurse may choose to contact the ethics committee (C) for a resolution.
Correct Answer: D
...The charge nurse assigns a nursing procedure to a new staff nurse who has not previously performed
the procedure. What action is most important for the new staff nurse to take?
A. Review the steps in the procedure manual.
B. Ask another nurse to assist while implementing the procedure.
C. Follow the agency's policy and procedure.
D. Refuse to perform the task that is beyond the nurse's experience.
According to states' nurse practice acts, it is the responsibility of the nurse to function within the scope
of competency (D), and in this case safe nursing practice constitutes refusal to perform the procedure
because of a lack of experience. Although state mandates, agency policies, and continued education and
experience identify tasks that are within the scope of nursing practice, nurses should first refuse to
perform tasks that are beyond their proficiency, and then pursue opportunities to enhance their
competency (A, B, and C).
Correct Answer: D
.8.Before administering a client's medication, the nurse assesses a change in the client's condition and
decides to withhold the medication until consulting with the healthcare provider. After consultation
with the healthcare provider, the dose of the medication is changed and the nurse administers the
newly prescribed dose an hour later than the originally scheduled time. What action should the nurse
implement in response to this situation?
A. Notify the charge nurse that a medication error occurred.
B. Submit a medication variance report to the supervisor.
C. Document the events that occurred in the nurses' notes.
D. Discard the original medication administration record.
The nurse took the correct action and should document the events that occurred in the nurses' notes
(C). (A) did not occur and (B) is not indicated. The medication administration record is part of the client's
medical record and should be placed in the chart, (D) when no longer current.
Correct Answer: C
,.9.On the third postoperative day following thoracic surgery, a client reports feeling constipated. Which
intervention should the nurse implement to promote bowel elimination?
A. Remind the client to turn every two hours while lying in bed.
B. Provide warm prune juice before the client goes to bed at night.
C. Teach the client to splint the incision while walking to the bathroom.
D. Administer an analgesic before the client attempts to defecate.
Prune juice is a natural laxative that stimulates peristalsis, and warming the prune juice (B) facilitates
peristalsis. (A) is also helpful in promoting peristalsis but is less likely to relieve the client's constipation.
(C) reduces discomfort during ambulation, but will not help relieve the client's constipation. Defecation
is not painful following most surgeries, and many analgesics used postoperatively cause constipation, so
(D) is contraindicated.
Correct Answer: B
.0.The home health nurse visits an elderly client who lives at home with her husband. The client is
experiencing frequent episodes of diarrhea and bowel incontinence. Which problem, for which the
client is at risk, has the greatest priority when planning the client's care?
A. Disturbed sleep pattern.
B. Caregiver role strain.
C. Impaired skin integrity.
D. Fluid volume imbalance.
Diarrhea can lead to fluid volume loss, which is potentially life-threatening, so the highest priority is to
prevent a fluid volume imbalance (D). Diarrhea and bowel incontinence can also lead to (A, B, and C),
but these are of less potential harm than a fluid volume deficit.
Correct Answer: D
.1.After a client has been premedicated for surgery with an opioid analgesic, the nurse discovers that
the operative permit has not been signed. What action should the nurse implement?
A. Notify the surgeon that the consent form has not been signed.
, B. Read the consent form to the client before witnessing the client's signature.
C. Determine if the client's spouse is willing to sign the consent form.
D. Administer an opioid antagonist prior to obtaining the client's signature.
Once a client has been premedicated for surgery with any type of sedative, legal informed consent is not
possible, so the nurse must notify the surgeon (A). (B, C, and D) are not legally viable options for
ensuring informed consent.
Correct Answer: A
.2.A client who has been on bedrest for several days now has a prescription to progress activity as
tolerated. When the nurse assists the client out of bed for the first time, the client becomes dizzy. What
action should the nurse implement?
A. Encourage the client to take several slow, deep breaths while ambulating.
B. Help the client to remain standing by the bedside until the dizziness is relieved.
C. Instruct the client to remain on bedrest until the healthcare provider is contacted.
D. Advise the client to sit on the side of the bed for a few minutes before standing again.
The nurse should implement (D), because orthostatic hypotension is a common result of immobilization,
causing the client to feel dizzy when first getting out of bed following a period of bedrest. To prevent
this problem, it is helpful to have the body acclimate to a standing position by sitting upright for a short
period (D) before rising to a standing position. (A) is unlikely to alleviate the dizziness. (B) may result in a
loss of consciousness. (C) is not indicated and will increase the potential for complications associated
with prolonged immobility.
Correct Answer: D
.3.The charge nurse observes an unlicensed assistive personnel (UAP) bending at the waist to lift a 20-
pound box of medical supplies off the treatment room floor. What instruction should the charge nurse
provide to the UAP?
A. Ask another staff member for assistance.
B. Request that supplies are delivered in smaller containers.
C. Push the box against the wall to provide support while lifting.
D. Bend at the knees when lifting heavy objects.
Final Exam EXTRA STUDY 2025 Updated
with 100% Correct and Verified
Answers.
.5.What intervention should the nurse include in the plan of care for a client who is being treated with
an Unna's paste boot for leg ulcers due to chronic venous insufficiency?
A. Check capillary refill of toes on lower extremity with Unna's paste boot.
B. Apply dressing to wound area before applying the Unna's paste boot.
C. Wrap the leg from the knee down towards the foot.
D. Remove the Unna's paste boot q8h to assess wound healing.
The Unna's paste boot becomes rigid after it dries, so it is important to check distally for adequate
circulation (A). Kerlix is often wrapped around the outside of the boot and an ace bandage may be used
to cover both, but no bandage should be put under it (B). The Unna's paste boot should be applied from
the foot and wrapped towards the knee (C). The Unna's paste boot acts as a sterile dressing, and should
not be removed q8h. Weekly removal is reasonable (D).
Correct Answer: A
...A .5-year-old client who has a history of end stage renal failure and advanced lung cancer, recently had
a stroke. Two days ago the healthcare provider discontinued the client's dialysis treatments, stating that
death is inevitable, but the client is disoriented and will not sign a DNR directive. What is the priority
nursing intervention?
A. Review the client's most recent laboratory reports.
B. Refer the client and family members for hospice care.
C. Notify the hospital ethics committee of the client situation.
D. Determine who is legally empowered to make decisions.
When death is impending, it is essential for the nurse to determine who is legally empowered to make
decisions regarding the use of life-saving measures for the client (D). (A) will be abnormal and will
worsen without dialysis, so are not of immediate concern. (B) may help improve the client's quality of
life prior to death, but is of less immediacy than determining whether actions should be taken to save a
,client's life. If the nurse remains unable to determine who is empowered to make decisions in this
situation, the nurse may choose to contact the ethics committee (C) for a resolution.
Correct Answer: D
...The charge nurse assigns a nursing procedure to a new staff nurse who has not previously performed
the procedure. What action is most important for the new staff nurse to take?
A. Review the steps in the procedure manual.
B. Ask another nurse to assist while implementing the procedure.
C. Follow the agency's policy and procedure.
D. Refuse to perform the task that is beyond the nurse's experience.
According to states' nurse practice acts, it is the responsibility of the nurse to function within the scope
of competency (D), and in this case safe nursing practice constitutes refusal to perform the procedure
because of a lack of experience. Although state mandates, agency policies, and continued education and
experience identify tasks that are within the scope of nursing practice, nurses should first refuse to
perform tasks that are beyond their proficiency, and then pursue opportunities to enhance their
competency (A, B, and C).
Correct Answer: D
.8.Before administering a client's medication, the nurse assesses a change in the client's condition and
decides to withhold the medication until consulting with the healthcare provider. After consultation
with the healthcare provider, the dose of the medication is changed and the nurse administers the
newly prescribed dose an hour later than the originally scheduled time. What action should the nurse
implement in response to this situation?
A. Notify the charge nurse that a medication error occurred.
B. Submit a medication variance report to the supervisor.
C. Document the events that occurred in the nurses' notes.
D. Discard the original medication administration record.
The nurse took the correct action and should document the events that occurred in the nurses' notes
(C). (A) did not occur and (B) is not indicated. The medication administration record is part of the client's
medical record and should be placed in the chart, (D) when no longer current.
Correct Answer: C
,.9.On the third postoperative day following thoracic surgery, a client reports feeling constipated. Which
intervention should the nurse implement to promote bowel elimination?
A. Remind the client to turn every two hours while lying in bed.
B. Provide warm prune juice before the client goes to bed at night.
C. Teach the client to splint the incision while walking to the bathroom.
D. Administer an analgesic before the client attempts to defecate.
Prune juice is a natural laxative that stimulates peristalsis, and warming the prune juice (B) facilitates
peristalsis. (A) is also helpful in promoting peristalsis but is less likely to relieve the client's constipation.
(C) reduces discomfort during ambulation, but will not help relieve the client's constipation. Defecation
is not painful following most surgeries, and many analgesics used postoperatively cause constipation, so
(D) is contraindicated.
Correct Answer: B
.0.The home health nurse visits an elderly client who lives at home with her husband. The client is
experiencing frequent episodes of diarrhea and bowel incontinence. Which problem, for which the
client is at risk, has the greatest priority when planning the client's care?
A. Disturbed sleep pattern.
B. Caregiver role strain.
C. Impaired skin integrity.
D. Fluid volume imbalance.
Diarrhea can lead to fluid volume loss, which is potentially life-threatening, so the highest priority is to
prevent a fluid volume imbalance (D). Diarrhea and bowel incontinence can also lead to (A, B, and C),
but these are of less potential harm than a fluid volume deficit.
Correct Answer: D
.1.After a client has been premedicated for surgery with an opioid analgesic, the nurse discovers that
the operative permit has not been signed. What action should the nurse implement?
A. Notify the surgeon that the consent form has not been signed.
, B. Read the consent form to the client before witnessing the client's signature.
C. Determine if the client's spouse is willing to sign the consent form.
D. Administer an opioid antagonist prior to obtaining the client's signature.
Once a client has been premedicated for surgery with any type of sedative, legal informed consent is not
possible, so the nurse must notify the surgeon (A). (B, C, and D) are not legally viable options for
ensuring informed consent.
Correct Answer: A
.2.A client who has been on bedrest for several days now has a prescription to progress activity as
tolerated. When the nurse assists the client out of bed for the first time, the client becomes dizzy. What
action should the nurse implement?
A. Encourage the client to take several slow, deep breaths while ambulating.
B. Help the client to remain standing by the bedside until the dizziness is relieved.
C. Instruct the client to remain on bedrest until the healthcare provider is contacted.
D. Advise the client to sit on the side of the bed for a few minutes before standing again.
The nurse should implement (D), because orthostatic hypotension is a common result of immobilization,
causing the client to feel dizzy when first getting out of bed following a period of bedrest. To prevent
this problem, it is helpful to have the body acclimate to a standing position by sitting upright for a short
period (D) before rising to a standing position. (A) is unlikely to alleviate the dizziness. (B) may result in a
loss of consciousness. (C) is not indicated and will increase the potential for complications associated
with prolonged immobility.
Correct Answer: D
.3.The charge nurse observes an unlicensed assistive personnel (UAP) bending at the waist to lift a 20-
pound box of medical supplies off the treatment room floor. What instruction should the charge nurse
provide to the UAP?
A. Ask another staff member for assistance.
B. Request that supplies are delivered in smaller containers.
C. Push the box against the wall to provide support while lifting.
D. Bend at the knees when lifting heavy objects.
