RN Fundamentals Online Practice 2019 B

1. A charge nurse is discussing the responsibility of nurses caring for clients who have a

Clostridium difficile infection. Which of the following information should the nurse include in

the teaching? Answer: Have family members wear a gown and gloves when visiting.

Rationale:

Nurses are responsible for ensuring that family members wear a gown and gloves to prevent the

transmission of Clostridium difficile spores. Staff must also wear gowns and gloves.

2. A nurse is giving change-of-shift report about a client they admitted earlier that day who has

pneumonia. Which of the following pieces of information is the priority for the nurse to

provide? Answer: Breath sounds

Rationale: When using the airway, breathing, circulation approach to client care, the nurse

should determine that the priority information to provide is the current status of the client's

breath sounds.

3. A nurse is preparing to delegate client care tasks to an assistive personnel (AP). Which of

the following tasks should the nurse delegate?

Answer: Ambulating a client who is postoperative

Rationale: Ambulating a client is within the range of function of an AP. The nurse can delegate

tasks to the AP that do not require special skills, assessment, or teaching.

4. A nurse enters a client’s room and finds her on the floor. The client’s roommate reports that

the client was trying to get out of bed and fell over the side rail onto the floor. Which of the

following statements should the nurse document about this incident?

My answer: “Client was trying to get out of

bed.” Answer: "Client found lying on floor."

Rationale: The nurse should include documentation of information that is descriptive

and objective concerning what the nurse actually observed, without including any

opinions or judgments about motives or cause.

5. A nurse is caring for a client who has a prescription for wound irrigation. Which of the

following actions should the nurse take?

Answer: Cleanse the wound from the center outward.

Rationale: The nurse should clean the wound from the center outward to prevent introduction

of micro-organisms from the outer skin surface. The nurse should wear clean gloves to remove

the old dressing, not sterile gloves. The nurse should warm the irrigation solution to body

temperature.

The nurse should use a 35-mL syringe to irrigate the wound. Syringes that hold 30 to 60 mL of

fluid create a safe but effective amount of pressure for wound irrigation.

6. A nurse is admitting a client who has rubella. Which of the following types of transmissionbased precautions should the nurse initiate?

My answer: Airborne

Answer: Droplet

Rationale: Droplet precautions are a requirement for clients who have infections that spread via

droplet nuclei that are larger than 5 microns in diameter, including influenza, rubella,

meningococcal pneumonia, and streptococcal pharyngitis. Airborne precautions are a

requirement for clients who have infections that spread via droplet nuclei that are smaller than

5 microns in diameter, including varicella, tuberculosis, and measles.

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7. A nurse is providing discharge teaching for a client who has a new prescription for a home

oxygen concentrator. Which of the following instructions should the nurse provide to the

client and his family? (Select all that apply.)

Answer: Check the cord routinely for frays or tearing; consider purchasing a generator for power

backup; observe for signs of hypoxia

Rationale: Oxygen concentrators require electrical power. Safe use of this delivery system

includes assessing the electrical function of the device; therefore, the nurse should instruct the

client to routinely check the condition of the cord. Loss of electricity prevents the oxygen

concentrator from functioning and could deprive the client of necessary oxygen. The nurse

should also instruct the family to have the client placed on their municipality's priority list for

restoring power after an outage occurs. The nurse should instruct the family to observe for and

report signs of hypoxia, such as anxiety, worsening fatigue, dizziness, rapid pulse and

respirations, pallor, and cyanosis. Even with supplemental oxygen, the client's status can worsen,

resulting in the development of hypoxia.

8. A nurse is calculating a client’s fluid intake over the past 8 hr. which of the following items

should the nurse plan to document on the client’s intake and output record as 120 mL of fluid?

Answer: 8 oz of ice chips

Rationale: The nurse should document half of the volume of ice chips when calculating

fluid intake to account for the air in between the chips. The nurse should understand that 4

oz of liquid water is equal to 120 mL of fluid.

9. A nurse is caring for a client who has tuberculosis. Which of the following actions should

the nurse take? (Select all that apply.)

Answer: Place the client in a room with negative-pressure airflow; wear gloves when assisting

the client with oral care; use antimicrobial sanitizer for hand hygiene

Rationale: The nurse should place the client in a room with negative-pressure airflow to meet

the requirements of airborne precautions. The nurse should wear gloves when assisting the

client with oral care to meet the requirements of standard precautions, which the nurse must

adhere to for all clients regardless of their diagnosis. The nurse should wear gloves whenever

their hands might come in contact with a client's bodily fluids, such as saliva, and the mucous

membranes in the mouth. The nurse should use antimicrobial sanitizer for routine hand

hygiene when caring for a client who has tuberculosis. Nurses should also wash their hands

with soap and water when their hands are visibly soiled. The nurse should wear an N95

respirator during client care to meet the requirements of airborne precautions.

10. A nurse is caring for a client who is refusing a blood transfusion for religious reasons. The

client’s partner wants the client to have the blood transfusion. Which of the following actions

should the nurse take?

Answer: Withhold the blood transfusion.

Rationale: The principle of autonomy ensures that a client who is competent has the right

to refuse treatment.

11. A nurse is teaching a client whose left leg is in a cast about using crutches. Which of the

following statements should the nurse identify as an indication that the client understands

the teaching?

My answer: "I will make sure the shoulder rests are snug against my armpits."

Answer: "When descending stairs, I will first shift my weight to my right leg."

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