NCLEX Practice Questions with Answers and Sources
NCLEX-style practice questions for independent study: review 89 original nursing fundamentals questions, each answered from and quoted from the Open RN Nursing Fundamentals textbook (2nd edition) hosted on the National Library of Medicine's NCBI Bookshelf. Not affiliated with NCSBN; these are not exam items.
NCLEX-style practice questions with answers for nursing students: safety and restraints, falls, infection control, prioritization, oxygenation, pressure injuries, fluids and electrolytes, IV solutions, elimination, cognition, communication, consent and end-of-life care. All questions are original and every answer is cited to the open Nursing Fundamentals textbook hosted on the NIH National Library of Medicine Bookshelf. Not affiliated with NCSBN; these are not exam items.
Last reviewed · How this key is checked
Studying for this with your unit? Send it to them.
01An adult client is placed in behavioral restraints. What is the longest time a single written order can cover?
4 hours for an adult. The limit is 2 hours for ages 9 to 17 and 1 hour for clients under 9.
VERIFIED AGAINST THE SOURCE
“Each written order for a physical restraint or seclusion is limited to 4 hours for adults, 2 hours for children and adolescents ages 9 to 17, or 1 hour for clients under 9.”
— Open RN Nursing Fundamentals, 2nd ed. (NIH NLM Bookshelf) ↗02Within its time limits, how long in total can an original restraint or seclusion order be renewed?
Up to a total of 24 hours.
VERIFIED AGAINST THE SOURCE
“The original order may only be renewed in accordance with these limits for up to a total of 24 hours.”
— Open RN Nursing Fundamentals, 2nd ed. (NIH NLM Bookshelf) ↗03Once restraint or seclusion has started, how soon must a physician or licensed independent practitioner see and evaluate the client?
Within one hour after the restraint or seclusion begins.
VERIFIED AGAINST THE SOURCE
“A physician or licensed independent practitioner must see and evaluate the need for the restraint or seclusion within one hour after the initiation.”
— Open RN Nursing Fundamentals, 2nd ed. (NIH NLM Bookshelf) ↗04A provider wants an as-needed order for wrist restraints in case a client becomes aggressive overnight. Why can't the nurse accept it?
Restraint or seclusion orders can never be written as standing or PRN (as needed) orders.
VERIFIED AGAINST THE SOURCE
“Orders for the use of seclusion or restraint can never be written as a standing order or PRN (as needed).”
— Open RN Nursing Fundamentals, 2nd ed. (NIH NLM Bookshelf) ↗05When a restraint really is the only viable option, when should it be removed?
At the earliest possible time.
VERIFIED AGAINST THE SOURCE
“When a restraint is the only viable option, it must be discontinued at the earliest possible time.”
— Open RN Nursing Fundamentals, 2nd ed. (NIH NLM Bookshelf) ↗06A confused, nonviolent client keeps pulling at an IV line, and soft wrist restraints are applied. Is this a medical or a behavioral restraint?
A medical restraint. Restraints that manage nonviolent, non-self-destructive behavior are medical restraints.
VERIFIED AGAINST THE SOURCE
“Restraints used to manage nonviolent, non-self-destructive behaviors are referred to as medical restraints.”
— Open RN Nursing Fundamentals, 2nd ed. (NIH NLM Bookshelf) ↗07A client is kicking staff and threatening to hurt others, and restraints are applied. What type of restraint is this?
A behavioral restraint, the type used to manage violent, self-destructive behavior.
VERIFIED AGAINST THE SOURCE
“Restraints used to manage violent, self-destructive behaviors are referred to as behavioral restraints.”
— Open RN Nursing Fundamentals, 2nd ed. (NIH NLM Bookshelf) ↗08When does raising the side rails count as a restraint?
When the purpose is to stop the client from voluntarily getting out of bed or trying to exit the bed.
VERIFIED AGAINST THE SOURCE
“If the purpose of raising the side rails is to prevent a client from voluntarily getting out of bed or attempting to exit the bed, then use of the side rails would be considered a restraint.”
— Open RN Nursing Fundamentals, 2nd ed. (NIH NLM Bookshelf) ↗09Name interventions a long-term care unit can use instead of restraints.
Routine daily schedules, regular feeding times, intentional rounding, frequent toileting, and effective pain management.
VERIFIED AGAINST THE SOURCE
“Common interventions used as alternatives to restraints include routine daily schedules, regular feeding times, intentional rounding, frequent toileting, and effective pain management.”
— Open RN Nursing Fundamentals, 2nd ed. (NIH NLM Bookshelf) ↗10Diversion has not calmed a restless client. Which further measures still count as alternatives to restraints?
Bed and chair alarms, or a sitter at the bedside.
VERIFIED AGAINST THE SOURCE
“If these techniques are not successful, bed and chair alarms or the use of a sitter at the bedside are also considered alternatives to restraints.”
— Open RN Nursing Fundamentals, 2nd ed. (NIH NLM Bookshelf) ↗11After restraints are applied, which basic needs must the nurse make sure are still met?
Hydration, nutrition, and toileting.
VERIFIED AGAINST THE SOURCE
“Nurses must also ensure the client’s basic needs (i.e., hydration, nutrition, and toileting) are met.”
— Open RN Nursing Fundamentals, 2nd ed. (NIH NLM Bookshelf) ↗12Which physical complications can the immobility caused by restraints lead to?
Pressure injuries, contractures, and muscle loss.
VERIFIED AGAINST THE SOURCE
“Furthermore, immobility that results from the use of restraints can cause pressure injuries, contractures, and muscle loss.”
— Open RN Nursing Fundamentals, 2nd ed. (NIH NLM Bookshelf) ↗13How can a restraint itself cause a fall or a death?
A restrained person tends to struggle to remove it and can fall or become fatally entangled in it.
VERIFIED AGAINST THE SOURCE
“A restrained person has a natural tendency to struggle and try to remove the restraint and can fall or become fatally entangled in the restraint.”
— Open RN Nursing Fundamentals, 2nd ed. (NIH NLM Bookshelf) ↗14What is seclusion?
Confining a client in a locked room that they cannot leave on their own.
VERIFIED AGAINST THE SOURCE
“Seclusion is defined as the confinement of a client in a locked room from which they cannot exit on their own.”
— Open RN Nursing Fundamentals, 2nd ed. (NIH NLM Bookshelf) ↗15A client feels light-headed every time they stand up. Which fall risk factor does this point to?
Orthostatic hypotension: blood pressure drops on standing, causing light-headedness or dizziness that can lead to falls.
VERIFIED AGAINST THE SOURCE
“Orthostatic hypotension: Clients whose blood pressure drops upon standing often experience light-headedness or dizziness that can cause falls.”
— Open RN Nursing Fundamentals, 2nd ed. (NIH NLM Bookshelf) ↗16What device should the nurse use when helping a client transfer or walk?
A gait belt, according to agency policy.
VERIFIED AGAINST THE SOURCE
“Use a gait belt when assisting clients to transfer or ambulate per agency policy.”
— Open RN Nursing Fundamentals, 2nd ed. (NIH NLM Bookshelf) ↗17Where should a hospitalized client's cane or walker be kept?
In good repair at the bedside, within safe reach.
VERIFIED AGAINST THE SOURCE
“All clients should have any needed assistive devices, such as canes or walkers, in good repair at the bedside and within safe reach.”
— Open RN Nursing Fundamentals, 2nd ed. (NIH NLM Bookshelf) ↗18A client has just been helped back into bed. Which three safety steps finish the transfer?
Lower the bed to its lowest position, raise the side rails as indicated, and put the call light within reach.
VERIFIED AGAINST THE SOURCE
“If the client is returning to bed, place the bed in the lowest position, raise the side rails as indicated, and ensure the call light is within reach.”
— Open RN Nursing Fundamentals, 2nd ed. (NIH NLM Bookshelf) ↗19Name the three categories of transmission-based precautions.
Contact, droplet, and airborne precautions.
VERIFIED AGAINST THE SOURCE
“There are three categories of transmission-based precautions: contact precautions, droplet precautions, and airborne precautions.”
— Open RN Nursing Fundamentals, 2nd ed. (NIH NLM Bookshelf) ↗20Which hand hygiene method should staff use when caring for a client with C. difficile infection?
Soap and water only.
VERIFIED AGAINST THE SOURCE
“Use only soap and water for hand hygiene in clients with C. difficile infection.”
— Open RN Nursing Fundamentals, 2nd ed. (NIH NLM Bookshelf) ↗21How can antibiotic treatment lead to C. diff diarrhea?
Antibiotics can deplete the normal gut flora, which gives pathogenic bacteria such as C. difficile an advantage to colonize.
VERIFIED AGAINST THE SOURCE
“For example, treatment with antibiotics can significantly deplete the normal flora of the gastrointestinal tract, providing an advantage for pathogenic bacteria such as Clostridium difficile (C-diff) to colonize and cause diarrheal infection.”
— Open RN Nursing Fundamentals, 2nd ed. (NIH NLM Bookshelf) ↗22Why do infection control measures target the links in the chain of infection?
Breaking one or more links stops the spread of infection.
VERIFIED AGAINST THE SOURCE
“By implementing interventions to break one or more links in the chain of infection, the spread of infection can be stopped.”
— Open RN Nursing Fundamentals, 2nd ed. (NIH NLM Bookshelf) ↗23A nurse is stuck by a used needle. What should happen first?
Wash or flush the site immediately, then report the exposure so careful monitoring can occur.
VERIFIED AGAINST THE SOURCE
“When a nurse or other health care worker experiences exposure due to a needlestick injury or the splashing of body fluids, it should be immediately washed or flushed and then reported so that careful monitoring can occur.”
— Open RN Nursing Fundamentals, 2nd ed. (NIH NLM Bookshelf) ↗24What are the most common causes of blood-borne pathogen exposure for nurses?
Needlesticks and sharps injuries.
VERIFIED AGAINST THE SOURCE
“Needlesticks and sharps injuries are the most common causes of blood-borne pathogen exposure for nurses.”
— Open RN Nursing Fundamentals, 2nd ed. (NIH NLM Bookshelf) ↗25Which two methods of hand hygiene are accepted?
Soap and water, or an alcohol-based hand sanitizer.
VERIFIED AGAINST THE SOURCE
“Accepted methods for hand hygiene include using either soap and water or alcohol-based hand sanitizer.”
— Open RN Nursing Fundamentals, 2nd ed. (NIH NLM Bookshelf) ↗26Which concepts does a nurse use to decide which client need comes first?
Maslow’s Hierarchy of Needs, the ABCs (airway, breathing, circulation), and acute, uncompensated conditions.
VERIFIED AGAINST THE SOURCE
“There are several concepts used to prioritize, including Maslow’s Hierarchy of Needs, the “ABCs” (Airway, Breathing and Circulation), and acute, uncompensated conditions.”
— Open RN Nursing Fundamentals, 2nd ed. (NIH NLM Bookshelf) ↗27On Maslow's pyramid, which needs take top priority?
The bottom levels: physiological needs intertwined with safety.
VERIFIED AGAINST THE SOURCE
“The bottom levels of the pyramid represent the top priority needs of physiological needs intertwined with safety.”
— Open RN Nursing Fundamentals, 2nd ed. (NIH NLM Bookshelf) ↗28Besides Maslow and the ABCs, what else does the nurse weigh when ranking client problems?
Whether the client's condition is an acute or a chronic problem.
VERIFIED AGAINST THE SOURCE
“In addition to using Maslow’s Hierarchy of Needs and the ABCs of airway, breathing, and circulation, the nurse also considers if the client’s condition is an acute or chronic problem.”
— Open RN Nursing Fundamentals, 2nd ed. (NIH NLM Bookshelf) ↗29What does the primary survey check at every client encounter?
Level of consciousness, airway, breathing, and circulation, with emergency care started if needed.
VERIFIED AGAINST THE SOURCE
“Primary Survey: Used during every client encounter to briefly evaluate level of consciousness, airway, breathing, and circulation and implement emergency care if needed.”
— Open RN Nursing Fundamentals, 2nd ed. (NIH NLM Bookshelf) ↗30List the components of the nursing process.
Assessment, diagnosis, outcomes identification, planning, implementation, and evaluation.
VERIFIED AGAINST THE SOURCE
“The nursing process includes the components of assessment, diagnosis, outcomes identification, planning, implementation, and evaluation.”
— Open RN Nursing Fundamentals, 2nd ed. (NIH NLM Bookshelf) ↗31Which mnemonic helps a nurse write an outcome statement with all five required components?
SMART.
VERIFIED AGAINST THE SOURCE
“Outcome statements should contain five components easily remembered using the “SMART” mnemonic”
— Open RN Nursing Fundamentals, 2nd ed. (NIH NLM Bookshelf) ↗32A client becomes anxious, restless, and newly confused. Which oxygenation problem can these be early signs of?
Hypoxia. Anxiety, confusion, and restlessness are early signs because the brain is starved of oxygen.
VERIFIED AGAINST THE SOURCE
“Early signs of hypoxia are related to the brain becoming starved of oxygen and include anxiety, confusion, and restlessness.”
— Open RN Nursing Fundamentals, 2nd ed. (NIH NLM Bookshelf) ↗33Is cyanosis an early or a late sign of hypoxia?
A late sign. Cyanosis is a bluish discoloration of the skin and mucous membranes.
VERIFIED AGAINST THE SOURCE
“Late signs of hypoxia include bluish discoloration of the skin and mucous membranes called cyanosis.”
— Open RN Nursing Fundamentals, 2nd ed. (NIH NLM Bookshelf) ↗34An adult's resting heart rate is 112. What oxygenation problem can this be an early sign of?
Hypoxia. A resting heart rate above 100 in an adult can be an early sign.
VERIFIED AGAINST THE SOURCE
“An elevated heart rate (above 100 beats per minute in adults) at rest can be an early sign of hypoxia.”
— Open RN Nursing Fundamentals, 2nd ed. (NIH NLM Bookshelf) ↗35What SpO2 target range is often used for a client with COPD?
Often 88% to 92%, although the provider should specify the acceptable range.
VERIFIED AGAINST THE SOURCE
“For clients with chronic oxygenation conditions such as COPD, the target range for SpO2 is often lower at 88% to 92%, although the acceptable SpO2 range should be specified by the provider.”
— Open RN Nursing Fundamentals, 2nd ed. (NIH NLM Bookshelf) ↗36A client is short of breath. How does raising the head of the bed to high Fowler's help?
It promotes chest expansion and diaphragm descent, maximizes inhalation, and decreases the work of breathing.
VERIFIED AGAINST THE SOURCE
“Raising the head of the bed to high Fowler’s position promotes effective chest expansion and diaphragmatic descent, maximizes inhalation, and decreases the work of breathing.”
— Open RN Nursing Fundamentals, 2nd ed. (NIH NLM Bookshelf) ↗37In Fowler's position, at what angle is the head of the bed placed?
At 45 to 90 degrees.
VERIFIED AGAINST THE SOURCE
“In Fowler’s positioning, the head of bed is placed at a 45- to 90-degree angle.”
— Open RN Nursing Fundamentals, 2nd ed. (NIH NLM Bookshelf) ↗38Why is an incentive spirometer commonly prescribed after surgery?
To expand the lungs and keep alveoli open, reduce fluid buildup in the lungs, and prevent pneumonia.
VERIFIED AGAINST THE SOURCE
“An incentive spirometer is a medical device commonly prescribed after surgery to expand the lungs to keep alveoli open, reduce the buildup of fluid in the lungs, and prevent pneumonia.”
— Open RN Nursing Fundamentals, 2nd ed. (NIH NLM Bookshelf) ↗39How does pursed-lip breathing help a client with dyspnea?
It decreases dyspnea by teaching the client to control their oxygenation and ventilation.
VERIFIED AGAINST THE SOURCE
“Pursed-lip breathing is a technique that decreases dyspnea by teaching people to control their oxygenation and ventilation.”
— Open RN Nursing Fundamentals, 2nd ed. (NIH NLM Bookshelf) ↗40Which clients are at risk for aspiration that could lead to pneumonia and hypoxia?
Clients with muscle disorders or clients who have had a stroke.
VERIFIED AGAINST THE SOURCE
“Clients with muscle disorders or those who have experienced a stroke (i.e., cerebral vascular accident) are at risk for aspiration, which could lead to pneumonia and hypoxia.”
— Open RN Nursing Fundamentals, 2nd ed. (NIH NLM Bookshelf) ↗41Why is swallowing food dangerous for a client with dysphagia?
Food can be aspirated into the lungs and cause pneumonia.
VERIFIED AGAINST THE SOURCE
“Difficulty swallowing, called dysphagia, can make it dangerous for the client to swallow food because it can result in pneumonia from aspiration of food into the lungs.”
— Open RN Nursing Fundamentals, 2nd ed. (NIH NLM Bookshelf) ↗42What is the most dangerous adverse effect of opioid analgesics?
Respiratory depression.
VERIFIED AGAINST THE SOURCE
“The most dangerous adverse effect of opioid analgesics is respiratory depression.”
— Open RN Nursing Fundamentals, 2nd ed. (NIH NLM Bookshelf) ↗43Who should be given naloxone?
Anyone suspected of an opioid overdose.
VERIFIED AGAINST THE SOURCE
“Naloxone should be administered to anyone suspected of an opioid overdose.”
— Open RN Nursing Fundamentals, 2nd ed. (NIH NLM Bookshelf) ↗44Which effects should the nurse keep monitoring for in a client receiving opioids?
Oversedation, respiratory depression, constipation, nausea and vomiting, urinary retention, and pruritus.
VERIFIED AGAINST THE SOURCE
“Clients receiving opioids should be continually monitored for oversedation, respiratory depression, constipation, nausea and vomiting, urinary retention, and pruritus.”
— Open RN Nursing Fundamentals, 2nd ed. (NIH NLM Bookshelf) ↗45Over a client's sacrum, the skin is intact with a localized area of redness that does not blanch. What stage of pressure injury is this?
Stage 1.
VERIFIED AGAINST THE SOURCE
“Stage 1 pressure injuries are intact skin with a localized area of nonblanchable erythema where prolonged pressure has occurred.”
— Open RN Nursing Fundamentals, 2nd ed. (NIH NLM Bookshelf) ↗46A heel wound shows partial-thickness skin loss with exposed dermis. What stage of pressure injury is it?
Stage 2.
VERIFIED AGAINST THE SOURCE
“Stage 2 pressure injuries are partial-thickness loss of skin with exposed dermis.”
— Open RN Nursing Fundamentals, 2nd ed. (NIH NLM Bookshelf) ↗47A pressure injury has full-thickness tissue loss with visible fat, but no exposed cartilage, tendon, ligament, muscle, or bone. What stage is it?
Stage 3.
VERIFIED AGAINST THE SOURCE
“Stage 3 pressure injuries are full-thickness tissue loss in which fat is visible, but cartilage, tendon, ligament, muscle, and bone are not exposed.”
— Open RN Nursing Fundamentals, 2nd ed. (NIH NLM Bookshelf) ↗48What separates a Stage 4 pressure injury from a Stage 3?
Stage 4 also has exposed cartilage, tendon, ligament, muscle, or bone.
VERIFIED AGAINST THE SOURCE
“Stage 4 pressure injuries are full-thickness tissue loss, like in Stage 3 pressure injuries, but also have exposed cartilage, tendon, ligament, muscle, or bone.”
— Open RN Nursing Fundamentals, 2nd ed. (NIH NLM Bookshelf) ↗49Why is a deep Stage 4 pressure injury often less painful than expected?
The wound damages nerve endings.
VERIFIED AGAINST THE SOURCE
“There may be pain associated with Stage 4 pressure ulcers, although they are often less painful because the wound damages nerve endings.”
— Open RN Nursing Fundamentals, 2nd ed. (NIH NLM Bookshelf) ↗50Why can a Stage 1 pressure injury be hard to detect on darkly pigmented skin?
Dark skin may not show visible blanching.
VERIFIED AGAINST THE SOURCE
“Skin with dark pigmentation may not demonstrate visible blanching, so it can be challenging to detect Stage 1 pressure injuries.”
— Open RN Nursing Fundamentals, 2nd ed. (NIH NLM Bookshelf) ↗51What does the Braden Scale measure?
A client's risk for developing pressure injuries.
VERIFIED AGAINST THE SOURCE
“The Braden Scale is a standardized, evidence-based assessment tool commonly used in health care to assess and document a client’s risk for developing pressure injuries.”
— Open RN Nursing Fundamentals, 2nd ed. (NIH NLM Bookshelf) ↗52To help prevent shear, at what angle should a client's position be kept, when appropriate?
30 degrees or less.
VERIFIED AGAINST THE SOURCE
“Maintain a client’s position at 30 degrees or less, as appropriate, to prevent shear.”
— Open RN Nursing Fundamentals, 2nd ed. (NIH NLM Bookshelf) ↗53For a bed-bound client, how high should the head of the bed be raised, and how often should they be turned?
30 to 45 degrees, unless medically contraindicated, with turning and repositioning every two hours.
VERIFIED AGAINST THE SOURCE
“For bed-bound clients, elevate the head of the bed to 30 to 45 degrees to promote lung expansion, unless medically contraindicated, and turn and reposition the client every two hours.”
— Open RN Nursing Fundamentals, 2nd ed. (NIH NLM Bookshelf) ↗54Which signs and symptoms are expected with hyperkalemia?
Mostly cardiac ones: irritability, cramping, diarrhea, and ECG abnormalities.
VERIFIED AGAINST THE SOURCE
“Signs and symptoms of hyperkalemia are generally cardiac in nature and include irritability, cramping, diarrhea, and electrocardiogram (ECG) abnormalities.”
— Open RN Nursing Fundamentals, 2nd ed. (NIH NLM Bookshelf) ↗55If hyperkalemia keeps worsening, what can the ECG abnormalities progress to?
Cardiac dysrhythmias and cardiac arrest.
VERIFIED AGAINST THE SOURCE
“As hyperkalemia worsens, ECG abnormalities may progress to cardiac dysrhythmias and cardiac arrest.”
— Open RN Nursing Fundamentals, 2nd ed. (NIH NLM Bookshelf) ↗56A client taking a potassium-wasting diuretic has had several days of vomiting. Which electrolyte imbalance is the client at risk for?
Hypokalemia.
VERIFIED AGAINST THE SOURCE
“Hypokalemia can be caused by excessive vomiting, diarrhea, potassium-wasting diuretics, and insulin use, as well as lack of potassium in the diet.”
— Open RN Nursing Fundamentals, 2nd ed. (NIH NLM Bookshelf) ↗57Which signs and symptoms suggest hypokalemia?
Weakness, arrhythmias, lethargy, and a thready pulse.
VERIFIED AGAINST THE SOURCE
“Signs and symptoms of hypokalemia include weakness, arrhythmias, lethargy, and a thready pulse.”
— Open RN Nursing Fundamentals, 2nd ed. (NIH NLM Bookshelf) ↗58Which symptoms are expected with hyponatremia?
Headache, confusion, seizures, and coma.
VERIFIED AGAINST THE SOURCE
“Symptoms of hyponatremia are headache, confusion, seizures, and coma.”
— Open RN Nursing Fundamentals, 2nd ed. (NIH NLM Bookshelf) ↗59What can cause hyponatremia?
Excess water intake, or giving too much hypotonic IV solution.
VERIFIED AGAINST THE SOURCE
“Hyponatremia can be caused by excess water intake or excessive administration of hypotonic IV solutions.”
— Open RN Nursing Fundamentals, 2nd ed. (NIH NLM Bookshelf) ↗60Tapping over the facial nerve makes the client's facial muscles twitch. What is this sign, and what does it suggest?
Chvostek's sign, a classic sign of acute hypocalcemia.
VERIFIED AGAINST THE SOURCE
“Chvostek’s sign is a classic sign of acute hypocalcemia and is an involuntary twitching of facial muscles when the facial nerve is tapped.”
— Open RN Nursing Fundamentals, 2nd ed. (NIH NLM Bookshelf) ↗61A hand spasm develops after a blood pressure cuff is kept inflated above systolic pressure for three minutes. What is this sign?
Trousseau's sign, a classic sign of acute hypocalcemia.
VERIFIED AGAINST THE SOURCE
“A second classic sign of acute hypocalcemia is Trousseau’s sign where a hand spasm is caused by inflating a blood pressure cuff to a level above the client’s systolic pressure for three minutes.”
— Open RN Nursing Fundamentals, 2nd ed. (NIH NLM Bookshelf) ↗62How can prolonged immobilization cause hypercalcemia?
Calcium leaches out of the bones and into the serum.
VERIFIED AGAINST THE SOURCE
“Hypercalcemia refers to an increased calcium level. It can be caused by prolonged immobilization that allows calcium to leach out of the bones and into the serum.”
— Open RN Nursing Fundamentals, 2nd ed. (NIH NLM Bookshelf) ↗63Which findings are expected with hypermagnesemia?
Bradycardia, a weak and thready pulse, lethargy, tremors, hyporeflexia, muscle weakness, and cardiac arrest.
VERIFIED AGAINST THE SOURCE
“Signs and symptoms of hypermagnesemia include bradycardia, weak and thready pulse, lethargy, tremors, hyporeflexia, muscle weakness, and cardiac arrest.”
— Open RN Nursing Fundamentals, 2nd ed. (NIH NLM Bookshelf) ↗64Which type of IV solution is used to raise blood pressure in a client with fluid volume deficit?
An isotonic solution.
VERIFIED AGAINST THE SOURCE
“Isotonic solutions are used for clients with fluid volume deficit (also called hypovolemia) to raise their blood pressure.”
— Open RN Nursing Fundamentals, 2nd ed. (NIH NLM Bookshelf) ↗65Is 0.45% sodium chloride an isotonic, hypotonic, or hypertonic solution?
Hypotonic.
VERIFIED AGAINST THE SOURCE
“An example of a hypotonic IV solution is 0.45% sodium chloride (0.45% NaCl).”
— Open RN Nursing Fundamentals, 2nd ed. (NIH NLM Bookshelf) ↗66What are hypotonic IV fluids used to treat?
Cellular dehydration.
VERIFIED AGAINST THE SOURCE
“For this reason, hypotonic fluids are used to treat cellular dehydration.”
— Open RN Nursing Fundamentals, 2nd ed. (NIH NLM Bookshelf) ↗67A hypertonic solution containing sodium is infusing. Which lab value should be monitored closely?
The client's serum sodium level.
VERIFIED AGAINST THE SOURCE
“Additionally, if hypertonic solutions with sodium are given, the client’s serum sodium level should be closely monitored.”
— Open RN Nursing Fundamentals, 2nd ed. (NIH NLM Bookshelf) ↗68Name common causes of deficient fluid volume.
Excessive diuretic use, severe bleeding, vomiting, diarrhea, and inadequate oral fluid intake.
VERIFIED AGAINST THE SOURCE
“Intravascular fluid loss can be caused by several factors, such as excessive diuretic use, severe bleeding, vomiting, diarrhea, and inadequate oral fluid intake.”
— Open RN Nursing Fundamentals, 2nd ed. (NIH NLM Bookshelf) ↗69Which routine measurement gives important clues about a client's fluid balance?
Accurate daily weights.
VERIFIED AGAINST THE SOURCE
“Accurate daily weights can provide important clues to fluid balance.”
— Open RN Nursing Fundamentals, 2nd ed. (NIH NLM Bookshelf) ↗70How many bowel movements per week typically leads to a diagnosis of constipation?
Fewer than three per week.
VERIFIED AGAINST THE SOURCE
“Typically a client is diagnosed with constipation if they have less than three bowel movements per week.”
— Open RN Nursing Fundamentals, 2nd ed. (NIH NLM Bookshelf) ↗71If constipation is suspected, where should the nurse palpate for stool?
The left lower quadrant.
VERIFIED AGAINST THE SOURCE
“If constipation is suspected, palpate the client’s left lower quadrant for signs of stool presence.”
— Open RN Nursing Fundamentals, 2nd ed. (NIH NLM Bookshelf) ↗72What expected outcome is set when treating constipation?
A normal bowel pattern for that client, with a bowel movement at least every 72 hours regardless of intake.
VERIFIED AGAINST THE SOURCE
“The goal of interventions implemented to treat constipation is to establish what is considered a normal bowel pattern for each client and to set an expected outcome of a bowel movement at least every 72 hours regardless of intake.”
— Open RN Nursing Fundamentals, 2nd ed. (NIH NLM Bookshelf) ↗73An older adult has normal bladder control but arthritis makes it hard to reach the toilet in time. What type of incontinence is this?
Functional incontinence.
VERIFIED AGAINST THE SOURCE
“Functional incontinence occurs in older adults who have normal bladder control but have a problem getting to the toilet because of arthritis or other disorders that make it hard to move quickly or manipulate zippers or buttons.”
— Open RN Nursing Fundamentals, 2nd ed. (NIH NLM Bookshelf) ↗74A client with an infection suddenly becomes confused. Is this more consistent with delirium or dementia?
Delirium: an acute cognitive impairment that typically comes on suddenly from a physiological cause such as infection.
VERIFIED AGAINST THE SOURCE
“Delirium is an acute state of cognitive impairment that typically occurs suddenly due to a physiological cause, such as infection, hypoxia, electrolyte imbalances, drug effects, or other acute brain injury.”
— Open RN Nursing Fundamentals, 2nd ed. (NIH NLM Bookshelf) ↗75How does dementia progress over time?
Gradually and progressively, and it is irreversible.
VERIFIED AGAINST THE SOURCE
“Dementia is gradual, progressive, and irreversible.”
— Open RN Nursing Fundamentals, 2nd ed. (NIH NLM Bookshelf) ↗76Once the cause of delirium is found, how is it treated?
Treatment targets the cause to reverse the effects.
VERIFIED AGAINST THE SOURCE
“After the cause of delirium is determined, treatment is targeted to the cause to reverse the effects.”
— Open RN Nursing Fundamentals, 2nd ed. (NIH NLM Bookshelf) ↗77What is the most common surgical complication in older adults?
Delirium.
VERIFIED AGAINST THE SOURCE
“Delirium is the most common surgical complication for older adults”
— Open RN Nursing Fundamentals, 2nd ed. (NIH NLM Bookshelf) ↗78A client with Alzheimer's becomes agitated and confused as daylight fades each evening. What is this called?
Sundowning.
VERIFIED AGAINST THE SOURCE
“Sundowning is restlessness, agitation, irritability, or confusion that typically begins or worsens as daylight begins to fade and can continue into the night, making it hard for clients with Alzheimer’s to sleep.”
— Open RN Nursing Fundamentals, 2nd ed. (NIH NLM Bookshelf) ↗79What do the letters in SBAR stand for?
Situation, Background, Assessment, and Recommendation.
VERIFIED AGAINST THE SOURCE
“SBAR (Situation, Background, Assessment, and Recommendation)”
— Open RN Nursing Fundamentals, 2nd ed. (NIH NLM Bookshelf) ↗80English is not a client's primary language. What should the nurse arrange before teaching?
A medical interpreter, plus written handouts in the client's preferred language when possible.
VERIFIED AGAINST THE SOURCE
“Language differences: If English is not your client’s primary language, it is important to seek a medical interpreter and to also provide written handouts in the client’s preferred language when possible.”
— Open RN Nursing Fundamentals, 2nd ed. (NIH NLM Bookshelf) ↗81A client wears glasses and hearing aids. What should the nurse check before talking with them?
That the glasses and hearing aids are in place.
VERIFIED AGAINST THE SOURCE
“For example, if a client has glasses and/or hearing aids, be sure these devices are in place before communicating.”
— Open RN Nursing Fundamentals, 2nd ed. (NIH NLM Bookshelf) ↗82What are the two main sections of HIPAA?
The Privacy Rule and the Security Rule.
VERIFIED AGAINST THE SOURCE
“There are two main sections of HIPAA law, the Privacy Rule and the Security Rule.”
— Open RN Nursing Fundamentals, 2nd ed. (NIH NLM Bookshelf) ↗83What makes a client's consent informed?
It is written consent, signed voluntarily by a competent client who understands its terms, without any coercion.
VERIFIED AGAINST THE SOURCE
“Informed consent is written consent voluntarily signed by a client who is competent and understands the terms of the consent without any form of coercion.”
— Open RN Nursing Fundamentals, 2nd ed. (NIH NLM Bookshelf) ↗84Who signs informed consent if the client is a minor or has been deemed incompetent?
A parent or legal guardian.
VERIFIED AGAINST THE SOURCE
“In the event the client is a minor or deemed incompetent to make their own decisions, a parent or legal guardian signs the informed consent.”
— Open RN Nursing Fundamentals, 2nd ed. (NIH NLM Bookshelf) ↗85When interviewing a client about pain, which type of question helps the client elaborate?
Open-ended questions.
VERIFIED AGAINST THE SOURCE
“While interviewing a client about pain, use open-ended questions to allow the client to elaborate on information that further improves your understanding of their concerns.”
— Open RN Nursing Fundamentals, 2nd ed. (NIH NLM Bookshelf) ↗86A family begins grieving when a loved one receives a terminal diagnosis, before any death. What type of grief is this?
Anticipatory grief: grief before a loss, linked to the diagnosis of an acute, chronic, or terminal illness.
VERIFIED AGAINST THE SOURCE
“Anticipatory grief is defined as grief before a loss, associated with diagnosis of an acute, chronic, and/or terminal illness experienced by the client, family, or caregivers.”
— Open RN Nursing Fundamentals, 2nd ed. (NIH NLM Bookshelf) ↗87What is the common name for terminal secretions at the end of life?
The death rattle.
VERIFIED AGAINST THE SOURCE
“Terminal secretions, commonly known as the “death rattle,” can be a distressing and frightening symptom for family members”
— Open RN Nursing Fundamentals, 2nd ed. (NIH NLM Bookshelf) ↗88Why is polypharmacy a safety concern?
Using many medications increases the risk of adverse medication effects.
VERIFIED AGAINST THE SOURCE
“Polypharmacy, the use of many medications, increases a person’s risk of adverse medication effects.”
— Open RN Nursing Fundamentals, 2nd ed. (NIH NLM Bookshelf) ↗89What is the leading cause of legal blindness in people over 60?
Macular degeneration.
VERIFIED AGAINST THE SOURCE
“Macular degeneration is the leading cause of legal blindness in individuals over 60 years of age.”
— Open RN Nursing Fundamentals, 2nd ed. (NIH NLM Bookshelf) ↗Know questions we're missing?
Submit your own Q&A pairs. AI reviews them for quality, then they go live for everyone.
Study these as flashcards
Load all 89 questions into a free study set — flashcards, a practice test, and spaced repetition. No account.
Works on any PDF, doc or web page too — not just military training.
Veteran? vetaid.ai — free VA benefits help.