Fundamentals

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Sample questions from Fundamentals

This material has 90 questions with answers and rationales. Here are the first 5.

1. 1.A 72-year-old client on a medical-surgical unit suddenly becomes short of breath while lying flat. Respirations are 30/min, oxygen saturation is 86% on room air, and the client is using accessory muscles. Which action should the nurse take first?

   • A.Obtain a complete respiratory history.
   • B.Raise the head of the bed and apply oxygen per emergency protocol.
   • C.Notify the provider and wait for additional prescriptions.
   • D.Assist the client to walk to improve lung expansion.

   Rationale: Positioning upright and applying oxygen immediately address impaired oxygenation. A complete history delays stabilization, and notifying the provider without intervening leaves an urgent problem untreated. Walking increases oxygen demand and is unsafe during acute respiratory distress. The exam takeaway is to address breathing with available emergency interventions before gathering nonessential data.

2. 2.An 81-year-old client admitted to a rehabilitation unit after a hip fracture becomes dizzy when standing. Blood pressure changes from 138/76 mm Hg supine to 108/62 mm Hg standing. Which intervention best reduces the client's immediate fall risk?

   • A.Keep all four side rails raised while the client is in bed.
   • B.Restrict oral fluids to decrease bathroom trips.
   • C.Have the client change positions slowly and assist with transfers.
   • D.Encourage independent walking to restore confidence.

   Rationale: Slow position changes and assisted transfers reduce injury risk from orthostatic hypotension. Raising all four rails can function as a restraint and may encourage unsafe climbing. Fluid restriction can worsen volume depletion, while independent walking is unsafe during symptomatic hypotension. Match fall precautions to the client's specific risk rather than relying on a single universal measure.

3. 3.A 46-year-old client on an orthopedic unit requires routine morning care after an uncomplicated knee replacement. The client is alert, has stable vital signs, and walked with staff yesterday. Which task may the RN delegate to trained assistive personnel?

   • A.Assist the client to a chair using the established transfer plan.
   • B.Evaluate whether the prescribed analgesic relieved pain.
   • C.Teach the client how to use an incentive spirometer.
   • D.Assess the incision for signs of infection.

   Rationale: Assisting a stable client with an established transfer plan is a routine task appropriate for trained assistive personnel. Evaluating pain relief and assessing an incision require nursing judgment. Initial teaching about an incentive spirometer also requires a licensed nurse. Delegate predictable tasks while retaining assessment, teaching, and evaluation responsibilities.

4. 4.A 64-year-old client on a medical unit has frequent watery stools and a positive test for Clostridioides difficile. After providing perineal care, which action is most appropriate?

   • A.Keep the gloves on while documenting at the hallway computer.
   • B.Use alcohol-based hand rub instead of handwashing because the hands look clean.
   • C.Remove the gloves and rinse the hands briefly with water alone.
   • D.Remove protective equipment appropriately and wash the hands with soap and water.

   Answer and rationale are in the full material.

5. 5.A 39-year-old client arrives at an outpatient clinic with a persistent cough, night sweats, weight loss, and suspected pulmonary tuberculosis. Which placement and protective equipment should the nurse arrange?

   • A.A positive-pressure room and a surgical mask for staff.
   • B.An airborne infection isolation room and a fit-tested N95 respirator for staff.
   • C.A shared room with another coughing client and gloves for staff.
   • D.A private room with the door open and eye protection alone.

   Answer and rationale are in the full material.