Foundations of Nursing Care Review Questions
Course Introduction
Foundations of Nursing Care introduces students to the core principles and essential skills required for effective nursing practice. The course covers fundamental topics such as patient assessment, vital sign monitoring, infection prevention, communication techniques, and basic clinical procedures. Students learn about the nursing process, ethical and legal considerations, and the importance of providing holistic, patient-centered care. Emphasis is placed on developing critical thinking, cultural competence, and safe caregiving practices within a diverse healthcare environment, thereby preparing students for further clinical experiences and advanced nursing coursework.
Recommended Textbook
Fundamentals of Nursing Active Learning for Collaborative Practice 1st Edition by Yoost
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Page 2
Chapter 1: Nursing, Theory, and Professional Practice
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Sample Questions
Q1) During a staff meeting, the nurse manager announces that the hospital will be seeking Magnet status. In order to explain the requirements for this award, the nurse manager will contact the:
A) American Nurses Association (ANA).
B) American Nurses Credentialing Center (ANCC).
C) National League for Nursing (NLN).
D) Joint Commission.
Answer: B
Q2) Which nurse established the American Red Cross during the Civil War?
A) Dorothea Dix
B) Linda Richards
C) Lena Higbee
D) Clara Barton
Answer: D
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Chapter 2: Values, Beliefs, and Caring
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Sample Questions
Q1) A values system is a set of somewhat consistent values and measures that are organized hierarchically into a belief system on a continuum of relative importance. A value system is also:
A) culturally based.
B) unique to each individual.
C) a poor basis for making decisions.
D) rigid and uniform within a culture.
Answer: A
Q2) The nurse is planning to change a dressing on an anxious patient. The best approach for the nurse is to:
A) ask another staff member to perform the task.
B) tell the patient the dressing change will take 30 minutes.
C) schedule a time in collaboration with the patient.
D) review the physician's order prior to the procedure.
Answer: C
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4
Chapter 3: Communication
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Sample Questions
Q1) The nurse is caring for a patient scheduled for a partial mastectomy resulting from advanced cancer. The patient tells the nurse, "I'm sure when the surgeon operates on me, he will not find any cancer in my breast. It looks just fine." The patient is using which defense mechanism to cope with the medical diagnosis?
A) Suppression
B) Sublimation
C) Displacement
D) Denial
Answer: D
Q2) The nurse is collaborating with a patient to determine interventions to ensure compliance with medication administration after his pending discharge. The goals and nursing interventions would be agreed upon in the:
A) Preinteraction phase.
B) Orientation phase.
C) Working phase.
D) Termination phase.
Answer: D
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Page 5
Chapter 4: Critical Thinking in Nursing
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Q1) The nurse completes the health interview and physical exam on a patient admitted with an infection of the gallbladder. The nurse reviews the medical record and compares the abnormal lab results to the normal standards. Which critical thinking skill is the nurse using in this part of the nursing process?
A) Interpretation
B) Analysis
C) Evaluation
D) Inference
Q2) The nursing student is observing a staff nurse demonstrating a subcutaneous injection during a skills competency fair. The student tells the nurse that nursing textbooks indicate that aspirating for blood is not necessary. The nurse replies, "I prefer to check for blood, just in case. This is the way I learned to give shots and it works for me." The nurse's response is most likely related to:
A) illogical thinking.
B) a bias.
C) closed-mindedness.
D) an erroneous assumption.
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Chapter 5: Introduction to the Nursing Process
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Q1) The nurse is admitting a patient experiencing chest discomfort and shortness of breath. The patient also has a history of stroke. The nurse documents the nursing diagnosis "Risk for stroke related to history of stroke." The risk factor for this patient is:
A) stroke.
B) history of stroke.
C) chest discomfort.
D) shortness of breath.
Q2) The nurse is gathering data on a patient with acute bacterial pneumonia. This is an example of which step of the nursing process?
A) Assessment
B) Planning
C) Implementation
D) Evaluation
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Chapter 6: Assessment
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Sample Questions
Q1) After the patient's data are collected, validated, and interpreted, the nurse organizes the information in a framework (format) that facilitates access by all members of the health care team. The framework that provides the most holistic view of the patient's condition is:
A) the head-to-toe pattern
B) Marjory Gordon's Functional Health Patterns.
C) the cephalic-caudal pattern.
D) the body systems model.
Q2) Which of the following examples given indicate objective data? (Select all that apply.)
A) Respirations - 24 breaths per minute
B) Platelet count - 350,000 mmS1U1P13S1S1P0
C) Wound size - 3 cm X 2 cm
D) Temperature - 98.4° F (36.8° C)
E) Complaints of severe abdominal pain.
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Chapter 7: Nursing Diagnosis
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Q1) The nurse is developing a plan of care for a patient with gastritis and an inflammation of the intestines. The patient is complaining of severe abdominal discomfort and nausea. The patient also reports having restless leg syndrome and an inability to urinate. As a problem statement of the nursing diagnosis, the nurse should write:
A) Gastritis related to inflammation.
B) Alterations in comfort and ability to void.
C) Abdominal pain and nausea related to inflammation.
D) Alteration in comfort related to restless leg syndrome and inflammation.
Q2) A patient is receiving an experimental drug for leukemia. The nurse is worried that the drug may cause a reduction in platelets leading to intestinal tract bleeding. Which type of nursing diagnosis should the nurse use to address this concern?
A) Risk
B) Actual
C) Health-promotion
D) Medical diagnosis
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Chapter 8: Planning
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Q1) The nurse is formulating the patient's care plan. In determining when to evaluate the patient's progress, the nurse is aware that evaluations:
A) must be done at the end of every shift.
B) should be done at least every 24 hours.
C) depend on intervention and patient condition.
D) are always done at time of discharge.
Q2) Which statement is correct regarding diversity considerations?
A) The male gender may struggle less with health care terminology.
B) High numbers of minority populations do not understand health teachings.
C) Older adults have an easier time understanding health teachings because of life experience.
D) Disabilities have no impact on the development of patient care goals.
Q3) Goals are broad statements of purpose that describe the aim of nursing care. As such, goals:
A) are considered short term if achieved within a month of identification.
B) always have established time parameters, such as "long-term" or "short-term."
C) are mutually acceptable to the nurse, patient, and family.
D) can be vague to facilitate evaluation of achievement.
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Chapter 9: Implementation and Evaluation
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Q1) Documentation is a vital nursing role since the patient's health record:
A) should be completed accurately and in a timely manner.
B) should not be computerized (EHR) because of disclosure risks.
C) is not a legal document although they can be helpful in lawsuits.
D) cannot be used in determining billing and reimbursement issues.
Q2) The nurse has many roles. One is to support and work on behalf of patients for whom he/she has concern. This role is known as:
A) advocate.
B) primary care provider.
C) collaborator.
D) delegator.
Q3) Change of shift report, collaboration with other health care members, and ensuring availability of needed equipment are examples of:
A) indirect care.
B) direct care.
C) referrals.
D) delegation
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11
Chapter 10: Documentation, Electronic Health Records, and Reporting
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Q1) The nurse is charting using the DAR charting system. This form of charting requires documentation about: (Select all that apply.)
A) the patient problems.
B) subjective data.
C) any actions initiated.
D) objective data.
E) the patient's response to interventions.
Q2) The nurse is charting using paper nursing notes. The nurse is aware that:
A) attorneys are not allowed access to medical records during litigation.
B) when mistakes are made in documentation, the nurse should scribble out the entry.
C) only one nurse should document on a sheet so that it can be removed in case of error.
D) the medical record is the most reliable source of information in any legal action.
Q3) The process of making a change-of-shift report (handoff):
A) is an uncommon occurrence of little importance.
B) occurs only at change of shift and only to oncoming nurses.
C) can lead to patient death if done incorrectly.
D) does not allow for collaboration or problem solving.
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Chapter 11: Ethical and Legal Considerations
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Sample Questions
Q1) The nurse is caring for a patient who has had many admissions and readmissions. The nurse believes that the patient keeps coming to the hospital because the patient "wants his drugs," and is "non-compliant" at home with his diabetic therapy. To reduce the risk of slander against this patient, the nurse should:
A) write observations and opinions in the medical record only.
B) never share observations.
C) make judgmental statements only when necessary.
D) Avoid stating judgmental statements.
Q2) Which of the following nurses has committed a serious documentation error?
A) Susan documents all medications for her patients prior to administration.
B) Jim documents medication administration as the medications are given.
C) Jane documents assessments as they are completed.
D) Jon documents meal intake as he picks up meal trays.
Q3) The nurse is providing end-of-life care. It is essential for the nurse to:
A) tell the patient what he might like to hear to relieve anxiety.
B) begin making health care decisions for the patient.
C) provide the patient with the nurse's personal opinions.
D) offer unconditional support for the patient and family.
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Chapter 12: Leadership and Management
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Sample Questions
Q1) When delegating to other health care providers, the nurse understands that the task: (Select all that apply.)
A) must be within the scope of the person to whom it is being delegated.
B) is one that can be delegated to other health care providers.
C) can be delegated whenever assessments are required.
D) may be re-delegated by the person to whom it was first delegated.
E) may require the nurse to procure resources to complete the task.
Q2) The nurse has a question regarding scope of practice and delegation. Where should the nurse seek clarification? (Select all that apply.)
A) The state's Nurse Practice Act
B) Theory X management
C) Nurse's Code of Ethics
D) The NCSBN website
E) NCSBN journal articles
Q3) Communication skills are most essential for the nurse:
A) when they become nurse managers.
B) except when delegation is required.
C) to decrease nurse-family interaction.
D) to obtain information from patients.
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Page 14
Chapter 13: Evidence-Based Practice and Nursing Research
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Sample Questions
Q1) The nurse researcher audiotaped interviews with subjects and would like to play these tapes during dissemination. What steps might this require?
A) Inform the participants that they cannot hear the tapes beforehand.
B) None, if the tape is of a group, since there is no expectation of anonymity.
C) None, since the tape is a direct "quote" and voice recognition is not controllable.
D) A release will need to be obtained from the subjects.
Q2) While conducting a controlled research study, the nurse wants greater assurance that the result is due to treatment itself and not another factor. For this purpose, the researcher should include:
A) a treatment group.
B) an independent variable.
C) a dependent variable.
D) a control group.
Q3) An institutional review board (IRB) is a review committee established to:
A) approve research involving animal subjects.
B) approve research that is not government funded.
C) function differently than scholarly journals do.
D) protect the rights of human research subjects.
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Chapter 14: Health Literacy and Patient Education
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Q1) The nurse must provide patient education to a patient who has just been told by the patient that he has stage III lung cancer. The patient is complaining of chest and bone discomfort. Before providing the needed education, the nurse should: (Select all that apply.)
A) draw the curtain in the semi-private room.
B) medicate the patient to ease his pain.
C) place the patient in a private room if possible.
D) perhaps wait until later in the day.
E) keep the room dark to provide solitude.
Q2) The nurse is working with a diabetic patient, and is attempting to teach psychomotor skills. This is occurring when the nurse has the patient:
A) verbally describe his feelings about diabetes.
B) answer three of five true-or-false questions about diabetes.
C) identify 3 positive lifestyle changes to manage blood sugar.
D) draw up and self-inject insulin correctly.
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16
Chapter 15: Nursing Informatics
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Sample Questions
Q1) The integration of nursing, computers, and information science for the management and communication of data, information, knowledge, and wisdom is:
A) nursing informatics.
B) computer science.
C) medical informatics.
D) informatics.
Q2) The use of telemonitoring offers the opportunity to: (Select all that apply.)
A) reduce cost of health care.
B) improve patient satisfaction.
C) increase duplicate orders.
D) improve patient outcomes.
E) improve organization.
Q3) The focus of nursing informatics is:
A) direct patient care.
B) increasing documentation time.
C) the introduction of different EHRs.
D) how patient care can be improved.
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Chapter 16: Health and Wellness
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Sample Questions
Q1) The patient asks the nurse to explain collaborative health care partnerships. The nurse gives a correct description when stating that collaborative care:
A) does not require participation of the patient.
B) is individual and cannot be mandated or legislated.
C) education needs are delegated to assistive personnel.
D) is designed to provide care to the patient as a whole.
Q2) Several models exist that describe the relationship between health and wellness. The model used to understand the interrelationship between elements of basic requirements for survival and the desires that drive personal growth and development and is represented as a pyramid is:
A) Maslow's hierarchy of needs.
B) Health Belief Model.
C) Health Promotion Model.
D) Holistic Health Model.
Q3) The World Health Organization defines health as
A) the absence of disease.
B) the lack of infirmity.
C) complete well-being.
D) being independent of fiscal responsibility.
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Page 18
Chapter 17: Human Development: Conception through Adolescence
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Sample Questions
Q1) A school-aged child is scheduled for a minor procedure and is very nervous. What response by the nurse is best?
A) Reassure the child the procedure is too minor to worry about.
B) Read the child a pamphlet about what to expect during the procedure.
C) Tell the child you will have the provider "put her to sleep" during the procedure.
D) Explain the procedure and what to expect in simple terms.
Q2) The nurse is collecting a history from the parents of a 4-year-old female at a well-child visit. The parents express concern that they often find their daughter performing what appears to be masturbation. The nurse offers reassurance by explaining which stage of development according to Freud?
A) Oral
B) Phallic
C) Anal
D) Latency
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19
Chapter 18: Human Development Young Adult to Older Adult
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Q1) The nurse is planning an educational workshop on health risks for the young adult. What topics does the nurse plan to include as priorities? (Select all that apply.)
A) Sexually transmitted diseases
B) Falling
C) Responsible alcohol use
D) Intimate partner and sexual violence
E) Distracted driving
Q2) The student of adult development learns that cognitive abilities improve during the young adult stage because of the influence of which experiences? (Select all that apply.)
A) Physical growth of the brain
B) Formal education
C) Occupational training
D) Overall life experiences
E) Specific profession chosen
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Chapter 19: Vital Signs
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Q1) A nurse performs orthostatic blood pressure readings on a patient with the following results: lying 148/76 mm Hg, standing 110/60 mm Hg. What action by the nurse is best?
A) Instruct the patient not to get up without help.
B) Document the findings and continue to monitor.
C) Reassure the patient that these findings are normal.
D) Reassess the blood pressures in 1 hour.
Q2) The nurse is delegating taking vital signs to an unlicensed assistive personnel (UAP). What instructions does the nurse provide the UAP? (Select all that apply.)
A) "Let me know if Mr. Smith's blood pressure is low."
B) "Take Mrs. Jones' blood pressure every 15 minutes."
C) "Call me if Ms. Walsh's systolic blood pressure drops to under 100 mm Hg."
D) "Do you want me to demonstrate using the electronic blood pressure cuff?"
E) "I'll take Mr. Derby's blood pressure since he is not stable."
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21
Chapter 20: Health History and Physical Assessment
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Q1) A nurse has finished examining a patient. What actions does the nurse take next? (Select all that apply.)
A) Document all findings.
B) Provide privacy for dressing.
C) Provide any hygiene material needed.
D) Tells the patient he/she can leave.
E) Cleans the room after the patient leaves.
Q2) A nurse conducting the general survey of a patient includes which items? (Select all that apply.)
A) Hygiene and grooming
B) Affect and mood
C) Sex and gender orientation
D) Sexual preferences and practices
E) Age
Q3) The nurse is assessing a patient's cranial nerve III. What technique is best?
A) Have patient identify a common scent with closed eyes.
B) Shine a light into the patient's eyes to assess pupil response.
C) Have the patient read a newspaper or use the Snellen chart.
D) Assess if patient can hear both spoken and whispered words.
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Page 22
Chapter 21: Ethnicity and Cultural Assessment
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Q1) A faculty member is contrasting culture and ethnicity to students. Which statement is most accurate?
A) Culture is biologically determined; ethnicity is chosen.
B) Culture is socially transmitted; ethnicity is identification with a group.
C) Culture is a chosen identity whereas ethnicity is biologically based.
D) Culture and ethnicity are similar constructs used interchangeably.
Q2) The nurse is using Giger and Davidhizar's Transcultural Assessment Model to gain information about a patient from an unfamiliar culture. What questions does the nurse ask that are relevant to this mode? (Select all that apply.)
A) "Who would you like present to help answer questions?"
B) "What do you believe caused your current illness?"
C) "How important is planning for the future to you?"
D) "Why don't you want to shake my hand?"
E) "What activities would you do to control your health?"
Q3) What does the nursing student learn about race?
A) It is biologically based.
B) It is a social construct.
C) It is chosen by the person.
D) It helps establish superiority.
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Page 23
Chapter 22: Spiritual Health
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Q1) The nurse concerned about a patient's spiritual needs can best address this by which action?
A) Leaving a note on the chart for other professional
B) Calling the chaplain to come see the patient
C) Collaborating during interdisciplinary rounds
D) Informing the provider of the patient's needs
Q2) A patient asks the nurse to pray with him. The nurse is an atheist and uncomfortable with this request. What action by the nurse is best?
A) Deny the request because of atheistic beliefs.
B) Offer to call the chaplain instead.
C) Agree to sit with the patient while he prays.
D) Ask the patient if he will meditate instead.
Q3) When does the nurse assess patients' spirituality? (Select all that apply.)
A) Upon admission
B) New diagnosis
C) Life-changing diagnosis
D) When the chaplain makes rounds
E) When facing treatment decisions
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Chapter 23: Public Health, Community Base, and Home
Health Care
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Q1) A nurse is assessing social determinants of health. Which does the nurse include in the assessment? (Select all that apply.)
A) Vaccination compliance
B) Family structure
C) Communication patterns
D) Roles for women
E) Education
Q2) The public health nurse volunteers for a missionary group caring for Ebola patients in Africa. The nurse is reviewing the data using analytic epidemiology methods. What information does the nurse collect as the priority?
A) Cultural norms in burial practices
B) Genetic variables in disease acquisition
C) Statistics related to incidence and prevalence
D) Autopsy data on direct cause of death
Q3) The student learns that which is the best definition of a public health nurse?
A) Works with the public
B) Works in public areas
C) Works with the greater community
D) Works with public funding
25
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Chapter 24: Human Sexuality
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Q1) A nurse understands that which characteristics of family dynamics impact a patient's sexuality? (Select all that apply.)
A) Religion
B) Age
C) Ethnicity
D) Culture
E) Geographic location
Q2) The nurse is working with a patient who has a sexual dysfunction. What statement by the patient indicates progress toward an important goal?
A) "I am beginning to enjoy sex more these days."
B) "I'm glad my partner is understanding of the lack of sex."
C) "I wish I didn't need these pills but I know they are important."
D) "I hope one day to have a sexual partner again."
Q3) The nursing student learns that the function of the hypothalamus is to do which of the following?
A) Cause lactation to begin
B) Produce spermatozoa
C) Release follicle-stimulating hormone
D) Release gonadotropin-releasing hormone
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Chapter 25: Safety
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Q1) The nurse is educating the patient about the proper disposal of medications in the home. Which statement by the patient indicates she has a good understanding of the information?
A) "Remove the label from the bottle and throw in the trash."
B) "Flush the medication."
C) "Mix the medications with kitty litter and place the mixture in a jar and put the jar in the trash."
D) "Dissolve the medication in water and pour down the drain."
Q2) Which statement by the patient indicates a teaching need regarding safety in the home?
A) "I will put a night light in every room."
B) "I will not use an extension cord to plug in multiple items."
C) "I will wash my throw rugs in the bathroom regularly."
D) "I will keep all cleaning supplies out of reach of children."
Q3) The nurse knows that which of the following is an appropriate way to tie restraints?
A) Knot tied to the bed frame
B) Quick-release knot tied to the side rail
C) Bow tied to the bed frame
D) Quick-release knot tied to the bed frame
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Page 27
Chapter 26: Asepsis and Infection Control
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Q1) The nurse is teaching a group of patient about diseases such as Rocky Mountain Spotted Fever that are transmitted by ticks. The nurse's explanation would be correct if she states that the tick functions as:
A) vectors.
B) bacteria.
C) viruses.
D) fungi.
Q2) The nurse is caring for a patient who is comatose. Her intervention is appropriate when she performs oral care:
A) every shift.
B) twice daily.
C) every 4 hours.
D) daily.
Q3) The nurse is preparing to perform suctioning on a new tracheostomy with the potential for forceful expulsion of secretions. What PPE should be worn?
A) Gloves and eyewear
B) Gloves, gown, and mask
C) Eyewear and gown
D) Eyewear, mask, gown, gloves
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Chapter 27: Hygiene and Personal Care
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Q1) Which member of the collaborative team is most appropriate to cut the toenails of a diabetic patient?
A) Nurse
B) Physical therapist
C) Occupational therapist
D) Podiatrist
Q2) The nurse notes that a trauma patient has multiple tangles in the hair. Which of the following actions taken by the nurse is appropriate? (Select all that apply.)
A) Work the tangles to the ends of the hair, then trim with scissors.
B) Apply warm water and conditioner.
C) Apply detangler as available.
D) Use a comb or fingers to work through tangles.
Q3) The nurse is providing care to a post-stroke patient on the rehabilitation floor with a nursing diagnosis of hygiene self-care deficit. Which goal is most appropriate on day one?
A) Patient will ambulate independently twice a day.
B) Patient will perform all of own ADLs.
C) Patient will consume 75% of all meals.
D) Patient will begin to perform 50% of own ADLs.
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Page 29
Chapter 28: Activity, Immobility, and Safe Movement
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Q1) The nurse appropriately delegates care to the UAP when she:
A) instructs the UAP to assess the patient's skin during a bath.
B) instructs the UAP to reposition the patient using the trapeze.
C) instructs the UAP to assess the patient's ability to perform range-of-motion exercises.
D) instructs the UAP to notify the health care provider of any changes.
Q2) The nurse knows the following indicates orthostatic hypotension: (Select all that apply.)
A) A decrease in systolic blood pressure by 30 mm Hg
B) A decrease in diastolic blood pressure by 10 mm Hg
C) An increase in heart rate by 30 beats/min
D) An increase in systolic blood pressure by 20 mm Hg
Q3) The nurse knows that manual lifting should only be done in the following situations:
A) Patients who are less than 150 lb
B) Life-threatening situations
C) Postsurgical patients
D) Patients who are less than 200 lb
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Chapter 29: Skin Integrity and Wound Care
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Sample Questions
Q1) The nurse knows that cold therapy is contraindicated in the following conditions: (Select all that apply.)
A) Edema
B) Shivering
C) Bleeding
D) Circulatory issues
Q2) The nurse knows that the following factors contribute to the development of wounds and lead to delays in wound healing: (Select all that apply.)
A) A patient who has diabetes
B) A patient with COPD on long-term steroid therapy
C) A patient with on bed rest who is repositioned
D) A patient who is obese and sweats excessively
E) None of the above
Q3) The nurse knows a stage III pressure ulcer is:
A) a pressure ulcer that involves exposure of bone and connective tissue.
B) a pressure ulcer that does not extend through the fascia.
C) a pressure ulcer that does not include tunneling.
D) a partial-thick wound that involves the epidermis.
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Chapter 30: Nutrition
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Sample Questions
Q1) The nurse is providing education to patient about the difference between simple and complex carbohydrates. Which statement by the patient indicates a need for further education?
A) "Simple carbohydrates give me quick energy."
B) "Complex carbohydrates come from fruit."
C) "Complex carbohydrates take longer to break down."
D) "Simple carbohydrates come from milk products."
Q2) The nurse is educating her patient about the risk of heart disease from metabolic syndrome. She knows metabolic syndrome is a cluster of the following symptoms: (Select all that apply.)
A) Elevated blood glucose
B) High waist circumference
C) History of smoking
D) Hypertension
E) Elevation serum cholesterol
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Chapter 31: Cognitive and Sensory Alterations
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Sample Questions
Q1) The nurse is caring for a patient with receptive aphasia. Which interventions will assist the nurse in communicating with the patient? (Select all that apply.)
A) Use simple phrases.
B) Speak softly.
C) Stand in front of the patient.
D) Use a picture board.
E) Be patient and unrushed.
Q2) The nurse is providing discharge education to her patient with diabetes regarding foot care. Which of the following statements by the patient indicates a need for further education?
A) "I can go barefoot outside only in the summer."
B) "I should wear good fitting shoes."
C) "I cannot soak my feet in a hot tub."
D) "I can use lotion on my feet."
Q3) An appropriate goal for a patient with a diagnosis of social isolation is:
A) the patient will participate in cognitive exercises.
B) the patient will interact with other residents during activities.
C) the patient will communicate basic needs through use of photos.
D) the patient will remain within the unit while in long-term care.
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Page 33
Chapter 32: Stress and Coping
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Sample Questions
Q1) The nurse is caring for a patient with a new diagnosis of diabetes type 2. Which of the following statements indicates a negative coping response?
A) "I will look up information on the Internet about diabetes."
B) "I will join a support group."
C) "I will only focus on learning to manage my medication first."
D) "I will make changes slowly so I can adapt to each change."
Q2) The nurse is educating the patient on the use of relaxing therapy. Which statement by the patient indicates a need for further education?
A) "I should relax my muscles from head to toe."
B) "I visual the relaxed muscle."
C) "I should do this three times a week."
D) "I focus on muscles that are tense."
Q3) The nurse is assessing level of stress in a patient from another culture. Which question is the most appropriate in helping the nurse understand the impact of the patient's belief system?
A) "Do you engage in prayer to help you during times of stress?"
B) "Do you go to church or other form of organized worship?"
C) "Do you have certain beliefs that are helpful during times of stress?"
D) "Do you want spiritual counseling while you are here?"
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Page 34
Chapter 33: Sleep
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Sample Questions
Q1) The nurse is providing discharge instructions for the patient with sleep pattern disturbances. Which statement by the patient indicates a need for further education?
A) "It is a good idea to have a bedtime routine."
B) "My bedtime routine can include watching TV in bed until I fall asleep"
C) "I should keep my regular sleep pattern on the weekend."
D) "If I can't fall asleep, I should get out of bed and do something relaxing."
Q2) The nurse knows that dyssomnias are: (Select all that apply.)
A) difficultly getting to sleep.
B) stages of sleep.
C) inability staying asleep.
D) being excessively sleepy.
E) falling asleep during the day.
Q3) The nurse is providing discharge education for a patient with narcolepsy. The following statement by the patient indicates a need for further education:
A) "Daytime naps are helpful."
B) "Taking the medication will cure it."
C) "High protein meals are helpful."
D) "I should avoid alcohol."
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35
Chapter 34: Diagnostic Testing
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Sample Questions
Q1) The nurse is caring for a patient who will be undergoing flexible sigmoidoscopy testing to screen for colon cancer. What goal will the nurse include in the patient's plan of care?
A) Patient will verbalize understanding of pre-procedure preparation to be completed at home the day before the test.
B) Patient will feel comfortable about the upcoming test and have trust in the health care providers.
C) Patient will learn common side effects of the medications used to prepare the GI tract for endoscopy testing.
D) Patient will realize how important regular sigmoidoscopy testing is in the prevention of colon cancer.
Q2) The nurse is caring for a patient who has had severe acid reflux. Which test will allow the physician to directly check for damage to the esophagus?
A) Upper GI endoscopy
B) MRI scan with contrast
C) Abdominal ultrasound
D) Positron emission tomography (PET) scan
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Chapter 35: Medication Administration
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Sample Questions
Q1) The nurse is caring for a patient who is NPO with a new PEG (percutaneous endoscopic gastrostomy) tube. Which of the patient's medications can the nurse administer through the tube? (Select all that apply.)
A) Edluar (zolpidem tartrate) sublingual tablet 5 mg nightly at bedtime
B) Ondansetron (Zofran) oral disintegrating tablet 8 mg q 8 hours PRN nausea
C) Ceclor (cefaclor for oral suspension) 250 mg q 6 hours
D) Oxymorphone hydrochloride extended release (Opana ER) 40 mg q 12 hours
E) Phenytoin (Dilantin) chewable tablet 100 mg q 12 hours
F) Potassium chloride oral solution 20 mEq daily
Q2) The nurse administers a medication to a patient. Shortly afterward, the patient develops an itchy rash all of his body and reports feeling very unwell. What is the priority action of the nurse?
A) Leave the patient to notify the physician and the pharmacist.
B) Determine if the patient is having any difficulty breathing.
C) Document the reaction in the patient's chart.
D) Obtain an order for hydrocortisone cream to relieve the itching.
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Chapter 36: Pain Management
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Sample Questions
Q1) The nurse administered 100 mcg sublingual fentanyl spray (Subsys) at 10:00 A.M. to a patient experiencing severe breakthrough pain. At what time will the nurse ask the patient if pain relief was obtained?
A) 10:30 A.M.
B) 11:00 A.M.
C) 11:30 A.M.
D) 12:00 noon
Q2) The nurse is caring for a patient who has a PCA pump following total hysterectomy surgery. The nurse sees the visitor push the PCA button while the patient is sleeping quietly. What is the best response of the nurse?
A) "Thank you for pushing the button for her to help keep her comfortable after surgery."
B) "Please do not push the button for the patient-she could receive more medication than she needs."
C) "You can push the button for her now, but please have her do it herself when she awakens."
D) "PCA pumps are great because she doesn't have to wait for me to administer her pain medication."
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Chapter 37: Perioperative Nursing Care
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Q1) The nurse is caring for a postoperative patient on his first day after surgery. The nurse informs the patient that the plan is to sit in the chair and ambulate in the hallway. The patient states that he is in pain and he has no intention of getting out of bed. What is the nurse's best response?
A) "It's important to move around so you don't get a blood clot in your leg."
B) "Your doctor ordered that you are to get out of bed at least twice every day."
C) "I understand. You can rest in bed until tomorrow when the pain is better."
D) "I will call the doctor and let him know that you do not want to get up."
Q2) The nurse is assigned to care for several patients on the surgical unit. Which patient need will the nurse address first?
A) A patient who is waiting for discharge teaching before going home
B) A patient who needs to be ambulated for the first time postoperatively
C) A patient who has not voided since the catheter was removed 8 hours ago
D) A patient who requires a daily dressing change to the surgical incision
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Chapter 38: Oxygenation and Tissue Perfusion
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Sample Questions
Q1) The nurse notes the following findings when assessing a patient with COPD. Which require prompt nursing intervention? (Select all that apply.)
A) The patient is unable to count out loud past 15 after a deep breath.
B) The patient's nails are noticeably clubbed.
C) The patient's sputum has turned from yellow to greenish-brown.
D) The patient has stridor with wheezes heard in all lung fields.
E) The patient's forced vital capacity has increased from 2.8 to 3.4 L.
F) The patient has become confused and mildly disoriented.
Q2) Which of the following patients would benefit from postural drainage?
A) A patient with a heart murmur and jugular venous distention
B) A patient with asthma and audible wheezing
C) A patient with right-sided heart failure and pitting edema
D) A patient with chronic bronchitis and congested cough
Q3) The nurse is caring for a patient with severe COPD who is becoming increasingly confused and disoriented. What is the priority action of the nurse?
A) Obtain an arterial blood gas to check for carbon dioxide retention.
B) Increase the patient's oxygen until the pulse oximetry is greater than 98%.
C) Lower the head of the patient's bed and insert a nasal airway.
D) Administer a mild sedative and reorient the patient as needed.
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Page 40
Chapter 39: Fluid, Electrolytes, and Acid-Base Balance
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Sample Questions
Q1) The nurse is caring for a patient who has a 1200 mL daily fluid restriction. The patient has consumed 250 mL with each of her three meals and had another 150 mL with her medications. The patient has received 150 mL of IV fluids during the day. How many mL of fluid may the patient still consume in order to stay within the prescribed fluid restriction?
A) 100 mL
B) 150 mL
C) 250 mL
D) 300 mL
Q2) The nurse is caring for a patient who has a serum magnesium level of 0.8 mEq/L.
Which is the highest priority goal to include in the patient's plan of care?
A) The patient will maintain urine output of at least 30 mL/hr.
B) The patient will verbalize the importance of sufficient dietary intake of magnesium.
C) The patient's oral mucous membranes will remain free of ulceration and pain.
D) The patient will remain alert and oriented x3 with no confusion or seizure activity.
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Chapter 40: Bowel Elimination
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Sample Questions
Q1) A student nurse is working with a preceptor to administer an enema to the patient. Which action by the student prompts intervention and redirection by the preceptor?
A) Water-soluble lubricant is applied to the end of the enema tubing.
B) The enema tubing is primed with solution that has been warmed.
C) The patient is positioned comfortably in the right side-lying Sims position.
D) The patient's bedpan is put at the bedside in preparation for use.
Q2) The nurse is caring for a postoperative patient who had a colostomy placed 2 days ago. The appliance needs to be changed for the first time. Which ostomy care actions may the nurse delegate to the nursing assistant? (Select all that apply.)
A) Gently cleaning the stoma with warm water and a washcloth.
B) Assessing the stoma and incision for signs of infection or ischemia.
C) Obtaining needed supplies from the clean utility room.
D) Teaching the patient how to care for the ostomy after discharge.
E) Determining which type of ostomy appliance to use.
F) Application of skin protectant to the area surrounding the stoma.
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42
Chapter 41: Urinary Elimination
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Sample Questions
Q1) The nurse is caring for a patient who has just had an intravenous pyelography (IVP) completed. Which assessment is the nurse's highest priority after the patient returns from the test?
A) Carefully calculate of the patient's intake and output.
B) Monitor for discoloration of the patient's urine.
C) Assess for possible iodine or shellfish allergies.
D) Inquire if the patient has burning or pain with urination.
Q2) The nurse is caring for a patient who is recovering from septic shock. While in the ICU, the patient developed renal failure. Which type of renal failure did the patient most likely develop?
A) Prerenal
B) Renal
C) Post-renal
D) Mixed
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43
Chapter 42: Death and Loss
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Q1) The nurse is caring for a patient whose mother recently passed away. The patient states that she has not been able to concentrate or sleep since the funeral and is consuming increasing amounts of alcohol to get through each day. Which goal is most appropriate for this patient?
A) The patient will be referred to medical social services for evaluation and counseling. B) The patient will be encouraged to describe previous stressors and coping mechanisms.
C) Nursing staff support patient's coping attempts and encourage verbalization of feelings.
D) The patient will use effective coping strategies with no alcohol consumption.
Q2) The nurse is caring for a terminally ill patient whose children have come home to be with their mother during her last few days. They spend time looking through picture albums, watching old home movies, and remembering fun times spent together. Which term best describes the activity of the patient's children?
A) Anticipatory grieving
B) Bereavement
C) Caregiver role strain
D) Death anxiety
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