19 nursing fundamentals items that did not make it onto the site, across 4 sub-sections. Each is shown with the objection that killed it, verbatim.
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The questions on this page are flawed on purpose. The keyed answers and the reasoning behind them are wrong or unsafe in the way each objection describes. Do not memorise anything here as fact. The verified bank is on the practice pages.
Rejected — do not study this as correctBasic sciences
A 65-year-old patient is admitted with a 3-day history of severe vomiting and diarrhea. The patient has been taking furosemide 40 mg daily for heart failure. On assessment, the nurse notes muscle weakness, hypoactive bowel sounds, and a weak, irregular pulse. Which electrolyte imbalance does the nurse suspect?
AHyperkalemia
BHypokalemiaKeyed by the writer
CHyponatremia
DHypercalcemia
What the audit caught
Rationale for Option B incorrectly categorizes a 'weak pulse' as a 'cardiac dysrhythmia.' A weak pulse indicates decreased stroke volume or contractility (or hypovolemia), whereas a dysrhythmia refers specifically to rhythm irregularity. While hypokalemia causes both decreased contractility and dysrhythmias, the rationale conflates distinct clinical assessment findings.
Rejected — do not study this as correctBasic sciences
A 45-year-old patient is admitted with a 3-day history of severe watery diarrhea. Vital signs: BP 100/60 mm Hg, HR 110 bpm, RR 28/min. Arterial blood gas results: pH 7.30, PaCO₂ 35 mm Hg, HCO₃⁻ 18 mEq/L. Which acid-base imbalance does the nurse identify?
AMetabolic acidosis with appropriate respiratory compensationKeyed by the writer
BMetabolic alkalosis with appropriate respiratory compensation
CRespiratory acidosis with appropriate metabolic compensation
DRespiratory alkalosis with appropriate metabolic compensation
What the audit caught
Option C rationale states the patient's PaCO₂ of 35 mm Hg is 'low'. Standard arterial blood gas reference ranges define normal PaCO₂ as 35-45 mm Hg, making 35 mm Hg the lower limit of normal, not definitively low. While the logic rules out respiratory acidosis, the factual claim regarding the value's status is inaccurate.
Rejected — do not study this as correctBasic sciences
A 45-year-old patient is admitted with a three-day history of severe vomiting and diarrhea. The nurse notes poor skin turgor, dry mucous membranes, and orthostatic hypotension. Which intravenous solution should the nurse anticipate administering for fluid resuscitation?
A0.45% sodium chloride
BLactated Ringer's solutionKeyed by the writer
C3% sodium chloride
D5% dextrose in water
What the audit caught
Rationale-Distractor Mismatch: The rationale justifies Lactated Ringer's over Normal Saline (citing hyperchloremic acidosis risk), but Normal Saline is not an option. The actual distractors (0.45% NaCl, 3% NaCl, D5W) are eliminated based on tonicity/osmolarity, not chloride content, creating a construct validity error.
Rejected — do not study this as correctBasic sciences
A 45-year-old patient is admitted with severe vomiting and diarrhea for 3 days. The nurse monitors for which ECG change that is most characteristic of hypokalemia?
AAppearance of prominent U wavesKeyed by the writer
BProlonged PR interval on the ECG
CTall, peaked T waves on the ECG
DWidening of QRS complex on ECG
What the audit caught
Option B rationale incorrectly states prolonged PR interval is 'more commonly associated with hyperkalemia'; PR prolongation occurs in both electrolyte imbalances and is not a defining hallmark of hyperkalemia compared to peaked T waves or QRS widening.
Rejected — do not study this as correctBasic sciences
A 45-year-old patient has had severe watery diarrhea for 3 days. Laboratory results show a serum potassium level of 2.8 mEq/L. The patient reports muscle weakness, and the nurse notes diminished deep tendon reflexes. The nurse understands that these neuromuscular symptoms are primarily caused by which of the following physiological effects of hypokalemia?
ADecreased calcium release from the sarcoplasmic reticulum
BHyperpolarization of the resting membrane potential in nerve and muscle cellsKeyed by the writer
CReduced acetylcholine release at the neuromuscular junction
DIncreased sodium permeability during depolarization
What the audit caught
The rationale for Option B includes a parenthetical teaching note regarding cardiac muscle that should be segregated into the general teaching point field to maintain rationale focus.
Rejected — do not study this as correctFundamentals of nursing
A nurse is assessing an older adult patient who reports feeling lightheaded when getting out of bed. The patient has a history of hypertension and is taking lisinopril. Which action should the nurse take to evaluate for orthostatic hypotension?
AMeasure BP and HR after 5 minutes supine, then immediately upon standing and at 1 and 3 minutes to detect orthostatic changes.Keyed by the writer
BAsk the patient to stand up quickly while you maintain safety and observe for dizziness to confirm orthostatic hypotension.
CAdminister the scheduled lisinopril first, then measure blood pressure in the standing position to assess for orthostatic changes.
DPlace the patient in Trendelenburg position and recheck blood pressure after 5 minutes to evaluate for orthostatic hypotension.
What the audit caught
Content alignment error: The Teaching Point defines Orthostatic Hypotension using the classic 3-minute criterion, but the Keyed Rationale justifies the answer based on detecting Initial Orthostatic Hypotension (immediate measurement). The Teaching Point should explicitly acknowledge Initial OH to support the Key's rationale.
Rejected — do not study this as correctFundamentals of nursing
A 78-year-old patient with a history of dementia and recent hip fracture is being admitted to the medical-surgical unit. The patient is confused, has an unsteady gait, and is at high risk for falls. Which nursing intervention is most appropriate to include in the plan of care to prevent falls?
AApply a vest restraint to keep the patient in bed.
BRequest placement in a room near the nurses' station.Keyed by the writer
CAdminister a prescribed sedative to reduce agitation.
DRaise all four side rails on the bed.
What the audit caught
The rationale for Option D correctly identifies that 'The bed should be kept in the lowest position,' which is a higher-priority, direct nursing intervention for fall prevention than room placement; this gold-standard intervention is incorrectly buried in a distractor rationale rather than offered as a correct option.
Rejected — do not study this as correctFundamentals of nursing
A 78-year-old patient is admitted with community-acquired pneumonia. The patient has a history of two falls in the past month and is currently confused, attempting to get out of bed unassisted. Which nursing intervention is most appropriate to prevent falls?
ACheck the patient every 15 minutes.
BPlace the patient in a room near the nurses' station.
CApply a bed exit alarm to the patient's bed.
DInitiate continuous one-to-one observation of the patient.Keyed by the writer
What the audit caught
Rationale for Option D states the intervention prevents falls 'without restraints,' but per CMS and Joint Commission guidelines, using a sitter to confine a confused patient to bed against their will may be classified as a restraint if the patient is not free to leave; this absolute claim is clinically inaccurate.
Rejected — do not study this as correctFundamentals of nursing
A nurse is preparing to administer the first intermittent enteral feeding to a patient who had a nasogastric tube inserted 30 minutes ago. Which action should the nurse take to verify correct tube placement?
AAuscultate over the epigastrium while injecting 10–20 mL of air into the tube.
BCheck the pH of gastric aspirate obtained from the tube.
CObtain a radiograph to confirm the tube tip is in the stomach.Keyed by the writer
DMeasure the external length of the tube from the naris to the distal port.
What the audit caught
Option C text 'Obtain a radiograph' implies the nurse independently orders or performs the diagnostic; nursing scope typically limits the action to 'Verify radiographic confirmation' or 'Ensure an order is placed', as nurses do not typically 'obtain' (order/perform) radiographs independently.
Rejected — do not study this as correctFundamentals of nursing
A nurse is caring for an 82-year-old patient with dementia who repeatedly attempts to get out of bed unassisted. The patient is identified as a high fall risk. Which intervention is most appropriate to prevent falls in this patient?
AApply a vest restraint to keep the patient in bed and prevent exits.
BUse a bed alarm that alerts staff when the patient tries to get up.
CKeep the bed low, side rails down, and place a floor mat beside the bed.
DAssign a staff member to provide continuous one-to-one supervision of the patient.Keyed by the writer
What the audit caught
Option C rationale correctly notes floor mats have limited evidence, but keeping the bed low is a primary standard of care; the item forces a choice between unproven prevention (D) and proven mitigation (C) without clarifying the priority of 'prevention' vs 'safety' in the stem.
Rejected — do not study this as correctFundamentals of nursing
A nurse is preparing to transfer a patient who is weak and unsteady but able to bear some weight from the bed to a bedside chair. Which action by the nurse best prevents injury?
AUsing a gait belt and asking the patient to stand with minimal assistance.
BUsing a mechanical lift with the help of another staff member.
CHaving the patient place their arms around the nurse's neck for support.
DApplying a gait belt and using a wide base of support while pivoting.Keyed by the writer
What the audit caught
Option D promotes manual pivoting for a 'weak and unsteady' patient, which conflicts with current NIOSH/ANA recommendations to use mechanical assistance for unpredictable/unsteady patients to prevent nurse injury, though this remains the traditional fundamentals textbook answer.
Rejected — do not study this as correctPharmacology
A 60-year-old patient with type 2 diabetes is taking metformin 1000 mg twice daily. The patient is scheduled for a computed tomography (CT) scan with intravenous contrast. The patient's most recent eGFR is 65 mL/min/1.73 m², and the patient is allowed to take oral medications with sips of water before the procedure. Which action should the nurse anticipate?
AAdminister metformin as prescribed before and after the procedure.Keyed by the writer
BHold metformin for 24 hours before and 48 hours after the procedure.
CAdminister metformin only after the procedure once renal function is confirmed stable.
DDiscontinue metformin and initiate sliding-scale insulin for 48 hours.
What the audit caught
Rationale B contains a factual error stating withholding is recommended 'only for patients with eGFR 30–59 mL/min/1.73 m²'; this excludes patients with eGFR <30 mL/min/1.73 m² where metformin is contraindicated and must be withheld, and contradicts current ACR guidelines which do not recommend withholding for eGFR 30–59 mL/min/1.73 m².
Rejected — do not study this as correctPharmacology
A nurse is providing discharge teaching to a patient with stable angina who has been prescribed sublingual nitroglycerin tablets. Which of the following instructions should the nurse include?
ASwallow the tablet with a full glass of water.
BPlace the tablet under the tongue and allow it to dissolve completely.Keyed by the writer
CChew the tablet before placing it under the tongue.
DPlace the tablet between the cheek and gum for buccal absorption.
What the audit caught
Option D rationale contains clinically inaccurate pharmacology: it states the buccal route is 'inappropriate for rapid angina relief,' but buccal absorption is rapid and used for acute angina (e.g., buccal NTG systems); the instruction is incorrect due to prescription labeling, not physiological inability.
Rejected — do not study this as correctPharmacology
A nurse is caring for a patient with heart failure who is receiving digoxin 0.125 mg PO daily and furosemide 40 mg PO daily. The patient's morning laboratory results show a serum potassium level of 3.1 mEq/L. Which action should the nurse take first?
AAssess the patient's apical pulse and check for signs of digoxin toxicity.
BHold the digoxin and notify the prescriber of the potassium level.Keyed by the writer
CAdminister the prescribed digoxin and monitor for signs of toxicity.
DRequest a stat order for an oral potassium supplement.
What the audit caught
Distractor Rationale Cueing: Option A's rationale explicitly states 'The priority is to prevent harm by holding the medication,' which directly validates the logic of Option B and allows test-takers to eliminate Option A without clinical knowledge.
Rejected — do not study this as correctPharmacology
A 58-year-old patient with type 2 diabetes mellitus and an eGFR of 25 mL/min/1.73 m² is scheduled for a CT scan with intravenous contrast. The patient takes metformin 1000 mg twice daily. Which action should the nurse take?
AAdminister the metformin as prescribed before and after the procedure.
BWithhold the metformin for 48 hours after the procedure and until renal function is reassessed.Keyed by the writer
CAdminister the metformin only if the patient's blood glucose is above 200 mg/dL.
DReplace metformin with insulin on the day of the procedure.
What the audit caught
Metformin is contraindicated (not merely withheld) for patients with a baseline eGFR < 30 mL/min/1.73 m² per FDA labeling and ADA Standards of Care; the item implies resumption is safe if renal function is stable, even if stable below 30.
Rejected — do not study this as correctPharmacology
A 58-year-old patient with type 2 diabetes mellitus is scheduled for a computed tomography (CT) scan with intravenous contrast to evaluate abdominal pain. The patient's current medications include metformin 1000 mg twice daily. The most recent estimated glomerular filtration rate (eGFR) was 72 mL/min/1.73 m². Which action should the nurse take regarding the metformin?
AContinue metformin as prescribed, because the patient's eGFR is ≥60 mL/min/1.73 m² and there is no evidence of acute kidney injury.Keyed by the writer
BWithhold metformin for 48 hours after the procedure and restart only after confirming renal function has returned to baseline.
CWithhold metformin only if the patient has a documented history of chronic kidney disease, regardless of current eGFR.
DAdminister a double dose of metformin after the procedure to counteract potential hyperglycemia from the contrast medium.
What the audit caught
Rationale A claims continuation is safe because eGFR is ≥60, but current ACR guidelines allow continuation for eGFR ≥30, making the ≥60 threshold appear more restrictive than current radiology standards.
Rejected — do not study this as correctPhysical assessment
A nurse is assessing a 28-year-old patient who reports abdominal pain that started around the umbilicus and has now localized to the right lower quadrant. The patient also has nausea and a temperature of 37.8°C (100°F). The nurse suspects acute appendicitis. Which assessment technique should the nurse use to evaluate for peritoneal irritation?
AAuscultate for bowel sounds in all four quadrants.
BAsk the patient to cough and note if this reproduces the pain.Keyed by the writer
CPercuss the abdomen to assess for shifting dullness.
DPalpate the right upper quadrant while the patient takes a deep breath.
What the audit caught
Construct Validity: The gold-standard assessment for peritoneal irritation (palpation for rebound tenderness in the RLQ) is absent from the options. Option D offers palpation but in the wrong location (RUQ/Murphy's). This forces the examinee to select a secondary screening maneuver (Cough Test) not because it is the primary best practice, but because the primary maneuver was disqualified by anatomical location, testing elimination rather than positive knowledge of the standard assessment.
Rejected — do not study this as correctPhysical assessment
A nurse is assessing a patient who reports a dull ache and swelling in the right calf that started two days ago. The patient has been on bed rest for the past week following surgery. Which action should the nurse take first?
AMeasure the circumference of both calves.
BPerform Homan's sign on the affected leg.
CPalpate the legs for warmth and tenderness.
DInspect the legs for erythema, visible swelling, and venous distention.Keyed by the writer
What the audit caught
Rationale B states Homan's sign is 'potentially dangerous' as factual evidence; current EBP indicates the risk of embolization is theoretical/unproven, and the maneuver is contraindicated primarily due to poor sensitivity/specificity.
Rejected — do not study this as correctPhysical assessment
A nurse is assessing a 55-year-old patient with known liver cirrhosis and increasing abdominal girth. The nurse suspects ascites. Which of the following techniques should the nurse use to assess for ascites?
APercuss the abdomen from the midline outward with the patient supine, then repeat with the patient in a lateral position, noting a shift in the dullness border.Keyed by the writer
BPlace one hand on the patient's flank and tap the opposite flank, feeling for a transmitted fluid wave.
CMeasure the abdominal circumference at the level of the umbilicus at the end of expiration.
DInspect the abdomen for bulging flanks and an everted umbilicus while the patient is supine.
What the audit caught
Option A describes an incomplete clinical procedure by omitting the mandatory pause (10-15 seconds) after repositioning required for fluid to settle, which is critical for test validity.