Nursing Fundamentals
This position is used to prevent aspiration during oral medication administration.
What is High-fowlers?
How many nurses are needed to waste a controlled substance?
What is 2 nurses?
This sound heard during lung auscultation may indicate fluid in the lungs.
What are crackles?
A nurse is assessing a pregnant client during a routine prenatal visit. Which fetal heart rate is within the expected range?
A. 90 bpm
B. 105 bpm
C. 140 bpm
D. 170 bpm
What is C — 140 bpm?
You catch a patient trying to hide snacks under the hospital pillow, claiming “they are for later, I swear.” What’s your first action?
A. Confiscate the snacks immediately
B. Ask why they are hiding the snacks and assess dietary restrictions
C. Laugh and let them keep the snacks
D. Document it as “patient stealing food”
What is B — Ask why they are hiding the snacks and assess dietary restrictions?
The nurse is caring for four patients. Which patient should the nurse assess first?
A. Patient with pain rated 6/10
B. Patient with oxygen saturation of 88%
C. Patient requesting assistance to the bathroom
D. Patient asking for water
What is B — Oxygen saturation 88%?
A patient taking warfarin should have which lab monitored?
A. Hemoglobin
B. INR
C. Potassium
D. Sodium
What is B — INR?
This assessment technique should NOT be performed before auscultating the abdomen.
What is Palpation?
Which finding indicates moderate dehydration in a child?
A. Sunken fontanelle
B. Moist mucous membranes
C. Capillary refill <2 seconds
D. Strong peripheral pulses
What is A — Sunken fontanelle?
Which charting entry is considered ethically and legally appropriate?
A. “Patient acting weird today”
B. “Patient crying and pacing in room”
C. “Patient probably upset”
D. “Patient rude to staff”
What is B — “Patient crying and pacing in room”?
A nurse is repositioning a patient who has been on bedrest for several days. Which intervention is most effective in preventing pressure injuries?
A. Repositioning the patient every 4 hours
B. Applying lotion to the skin once daily
C. Repositioning the patient every 2 hours
D. Elevating the head of the bed to 60°
What is C — Reposition every 2 hours?
A patient taking Metformin is scheduled for a CT scan with contrast dye. What should the nurse anticipate?
A. Administer extra metformin
B. Hold metformin for 24–48 hours
C. Increase insulin dose
D. Give potassium supplement
What is B — Hold Metformin?
(This prevents lactic acidosis)
Which diagnostic test will be most useful to the nurse in determining whether a patient admitted with acute shortness of breath has heart failure?
A. serum troponin
B. arterial blood gases
C. B-type natriuretic peptide
D. 12-lead electrocardiogram
What is C — B-type natriuretic peptide?
Why is vitamin K administered to newborns shortly after birth?
A. Prevent infection
B. Prevent bleeding
C. Improve lung function
D. Prevent jaundice
What is B — Prevent bleeding?
A terminally ill patient asks the nurse not to tell their family about their prognosis. The family insists they have a right to know. What is the best nursing action?
A. Tell the family immediately because they have a right to know
B. Respect the patient’s wishes and keep the information confidential
C. Assess the patient’s understanding, clarify their wishes, and discuss ethical and legal obligations with the patient and family
D. Avoid the situation and document only the patient’s request
What is C — Assess the patient’s understanding, clarify their wishes, and discuss ethical and legal obligations with the patient and family?
A nurse is caring for a patient who is on fall precautions. Which intervention should the nurse implement?
A. Raise all four side rails
B. Place the call light within reach
C. Keep the room dark to promote sleep
D. Encourage the patient to ambulate alone
What is B — Place the call light within reach?
Which medication requires the nurse to monitor apical pulse before administration and for you to hold the medication if the HR is <60?
A. Digoxin
B. Acetaminophen
C. Amoxicillin
D. Ibuprofen
What is A — Digoxin?
A patient has the following vital signs:
BP: 88/54, HR: 120, RR: 26
What condition might this indicate?
A. Hypertension
B. Shock
C. Dehydration
D. Fever
What is B — Shock?
During labor, the fetal monitor shows late decelerations. What is the nurse’s priority action?
A. Increase oxytocin infusion
B. Reposition the mother to her side
C. Encourage pushing
D. Prepare for discharge
What is B — Reposition the mother to her side?
A nurse administers medication to a patient without obtaining consent. Which legal/ethical issue does this represent?
A. Negligence
B. Assault
C. Battery
D. Malpractice
What is C — Battery?
Which findings increase a patient’s risk for pressure injuries? Select all that apply.
A. Immobility
B. Malnutrition
C. Moisture from incontinence
D. Adequate protein intake
E. Decreased sensation
What is A, B, C, E?
A. Immobility
B. Malnutrition
C. Moisture from incontinence
E. Decreased sensation
Which medication requires monitoring for ototoxicity?
A. Furosemide
B. Amoxicillin
C. Aspirin
D. Acetaminophen
What is A — Furosemide?
A nurse is caring for a patient with DVT. The patient reports a sudden shortness of breath. Which complication is the patient likely experiencing?
A. Pulmonary embolism
B. Pneumonia
C. Myocardial infarction
D. Atelectasis
What is A — Pulmonary embolism?
A nurse is assessing a client 2 hours postpartum. Which finding requires immediate intervention?
A. Fundus firm and midline
B. Saturating one pad every 15 minutes
C. Small amount of lochia rubra
D. Mild uterine cramping
What is B — Saturating one pad every 15 minutes?
A patient has a handwritten DNR from a previous admission. The current chart does not include a signed DNR. The patient experiences cardiac arrest. What should the nurse do?
A. Follow the handwritten note and do not initiate CPR
B. Initiate CPR until a verified DNR order is obtained
C. Call the family to decide
D. Wait for the provider to arrive before acting
What is B — Initiate CPR until a verified DNR order is obtained?