NURSING FOUNDATIONS REVIEW || VERIFIED QUESTIONS
& ANSWERS || HIGH-YIELD STUDY GUIDE || COMPLETE
EXAM PREP || GRADED A+
(The answer appears before the question)
A) Second intercostal space at the left sternal border
B) Fourth intercostal space at the right sternal border
C) Fourth intercostal space at the left sternal border
D) Second intercostal space at the right sternal border
A nurse is caring for a client who has a heart murmur. The nurse is preparing to
auscultate the pulmonary valve. Over which of the following locations should
the nurse place the bell of the stethoscope?
a. Number of staff induced injury
b. Client satisfaction survey
c. Health care-associated infection rate.
d. Rate of needle-stick injuries by nurse.
A policy requiring the removal of acrylic nails by all nursing personnel was
implemented 6 months ago. Which assessment measure best determines if the
intended outcome of the policy is being achieved.
A. Offer smalls sips of water through a straw
B. Place tongue blade on back half of tongue
C. Use a penlight to observe back of oral cavity
D. Auscultate breath sounds after client swallows
The nurse is preparing to assist a newly admitted client with personal hygiene
measures. The client...the client's gag reflex. Which action should the nurse
include?
A. Assess the client for confusion and reteach the procedure
B. Check the urine for color and texture
C. Empty the urinal contents into the 24-hour collection container
D. Discard the contents of the urinal
,The nurse explains to an older adult male the procedure for collecting a 24-hour
urine specimen for creatinine clearance.
A. Ask her how she would like to participate in the client’s care
B. Provide the wife with information about hospice
C. Encourage the wife to visit after painful treatments are completed
D. Refer her to support group for family members of those dying of cancer
A 54-year-old male client and his wife were informed this morning that he has
terminal cancer. Which nursing intervention is likely to be most
A. Plan low carbohydrate and high protein meals
B. Engage in strenuous activity for an hour daily
C. Keep a record of food and drinks consumed daily
D. Participated in a group exercise class 3 times a week
A client who has a body mass index (BMI) of 30 is requesting information on
the initial approach to a weight loss plan. Which action should the nurse
recommend?
A. Tops of the ear
B. Bridge of the nose
C. Around the nostrils
D. Over the cheeks
E. Across the forehead
The nurse assesses a client who has a nasal cannula delivering oxygen at 2
L/min. To assess for skin damage related to the cannula, which areas should the
nurse observe?
a. Remove the basin of water from the client’s bed immediately
b. Remind the UAP to dry between the client’s toes completely
c. Advise the UAP that this procedure is damaging to the skin
d. Add skin cream to the basin of water while the foot is soaking
The nurse observes an unlicensed assistive personnel (UAP) who is providing a
total bed bath for a confused and lethargic client. The UAP is soaking the
,client's foot in a basin of warm water placed on the bed. What action should the
nurse take?
a. Communicate the colleague’s actions to the unit charge nurse
b. Send an email to facility administration reporting the action
c. Write an anonymous complaint to a professional website
d. Post a comment about the action on a staff discussion board
The nurse in the emergency department observes a colleague viewing the
electronic health record (EHR) of a client who holds an elected position in the
community. The client is not a part of the colleague's assignment. Which action
should the nurse implement?
a. Leave the room and close the door to the client’s room
b. Assess the appearance of the client’s surgical dressing
c. Bring the client a prescribed PRN sedative-hypnotic
d. Discuss symptoms of sleep deprivation with the client
At 0100 on a male client's second postoperative night, the client states he is
unstable to sleep and plans to read until feeling sleepy. What action should the
nurse implement?
a. Remove identifying information of the clients who participated
b. Recall that authored content may be legally discoverable
c. Share material from credible, peer reviewed sources only
d. Respect all copyright laws when adding website content
The nursing staff in the cardiovascular intensive care unit are creating a
continuous quality improvement project on social media that addresses coronary
artery disease (CAD). Which action should the nurse implement to protect client
privacy?
a. Answer the client’s specific questions with a short understandable
explanation
b. Postpone the procedure until the client understands the risks and
benefits c. Call the client’s next of kin and ask them to provide verbal consent
d. Page the healthcare provider to return and provide additional explanation
, A male client with unstable angina needs a cardiac catheterization, so the
healthcare provider explains the risks and benefits of the procedure, and then
leaves to set up for the procedure. When the nurse presents the consent form for
signature, the client hesitates and asks how the wires will keep his heart going.
Which action should the nurse take?
b. bend the arm by flexing the ulnar to the humerus
c. Turn the head to the right and left
d. Extend the arm at the ide and rotate in circles
The nurse is teaching a client how to do active range of motion (ROM)
exercises. To exercise the hinge joints, which action should the nurse instruct
the client to perform?
a. Access for side effects of the medication.
b. Document the client’s responses.
c. complete a medication error report.
d. Determine if the pain was relieved.
A postoperative client has three different PRN analgesics prescribed for
different levels of pain. The nurse inadvertently administers a dose that is not
within the prescribed parameters. What actions should the nurse take first?
a. Hyperphosphatemia
b. Hypocalcemia
c. Hypermagnesemia
d. Hypokalemia
When assessing a male client, the nurse finds that he is fatigue, and is
experiencing muscle weakness, leg cramps, and cardiac dysrhythmias. Based on
these findings, the nurse plans to check the client's laboratory values to validate
the existence of which?
a. Obtain a perception from the healthcare provider regarding visitation
privileges
b. Request a consultation with the ethics committee for resolution of the
situation
c. Encourage the client to speak with her husband regarding his disruptive
behavior