Fundamentals of Nursing Exam Materials
Course Introduction
Fundamentals of Nursing introduces students to the basic concepts and skills essential for effective nursing practice. The course explores foundational knowledge in patient care, safety, communication, infection control, and the nursing process. Emphasis is placed on developing clinical competencies such as vital sign assessment, personal care techniques, and documentation, while fostering critical thinking and ethical decision-making. Through a combination of theoretical instruction and hands-on lab practice, students gain the confidence and competence necessary to begin providing compassionate, holistic care to individuals across the lifespan.
Recommended Textbook
Fundamentals of Nursing Active Learning for Collaborative Practice 1st Edition by Yoost
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42 Chapters
1050 Verified Questions
1050 Flashcards
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Page 2
Chapter 1: Nursing, Theory, and Professional Practice
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25 Verified Questions
25 Flashcards
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Sample Questions
Q1) The nurse is caring for a patient admitted for the removal of an infected appendix. Which actions by the nurse would indicate an understanding of the 2012 hospital safety goals? (Select all that apply.)
A) Places an identification band on the right arm
B) Marks the surgical site with a black-felt pen
C) Checks medications three times before administration.
D) Washes hands between patients and/or when soiled.
E) Removes allergy bands prior to transfer to surgery.
Answer: A, B, C, D
Q2) The nurse is conducting a health assessment on a patient from a foreign country. Which of the following should be addressed during the interview? (Select all that apply.)
A) Food preferences
B) Religious practices
C) Health beliefs
D) Family orientation
E) Politics
Answer: A, B, C, D
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3
Chapter 2: Values, Beliefs, and Caring
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Sample Questions
Q1) Enduring ideas about what a person considers is desirable or has worth in life is known as a:
A) value.
B) first-order belief
C) higher order belief
D) stereotype
Answer: A
Q2) The nurse is observed sitting at the bedside of a patient discussing the nursing care plan for the shift. Which theory or model most accurately reflects this nurse-patient relationship?
A) Swanson's Theory of Caring
B) Travelbee's Human-to-Human Relationship Model
C) Watson's Theory of Caring
D) Leininger Cultural Care Theory
Answer: A
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4
Chapter 3: Communication
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Sample Questions
Q1) A nurse has been working with a patient for the entire shift. Which action by the nurse is unacceptable?
A) Sharing a personal mobile phone number
B) Touching the patient's hand during a painful procedure
C) Standing 6 feet away from the patient when conversing
D) Using the SBAR method of hand-off communication
Answer: A
Q2) The nurse is admitting a patient with a foul smelling leg wound. Which behavior by the nurse indicates an understanding of appropriate body language?
A) Using hand gestures to enhance verbal communication
B) Standing at the end of the bed with arms crossed
C) Facial grimacing at the sight of the wound
D) Gentle touching of the patient's shoulder
Answer: D
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5
Chapter 4: Critical Thinking in Nursing
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Sample Questions
Q1) The nursing student is admitting a patient with abdominal distention and severe nausea. The physician orders the insertion of a nasogastric tube. The student reviews the procedure, gathers the supplies, and tells the instructor, "I'm ready to begin." Which of the following critical thinking traits suggest that the student is prepared for the task?
A) Risk taking
B) Curiosity
C) Confidence
D) Perseverance
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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Sample Questions
Q1) The nursing process is the foundation of professional nursing practice. As such, the nursing process can be defined as:
A) The framework that nurses used to provide care.
B) A complex process during which nurses think about their thinking.
C) The process that allows nurses to collect essential data.
D) Thinking like a nurse in developing plans of care.
Q2) The nurse is assisting a patient to bed when the patient says, "My chest hurts and my left arm feels numb. What's wrong with me?" What is the type and source of data obtained from the patient's complaint?
A) Objective data from a primary source
B) Objective data from a secondary source
C) Subjective data from a primary source
D) Subjective data from a secondary source
Q3) In which step of the nursing process does the nurse prioritize the nursing diagnoses and identify interventions to address the patient goals?
A) Assessment
B) Planning
C) Implementation
D) Evaluation
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Page 7
Chapter 6: Assessment
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Sample Questions
Q1) The nurse is caring for a patient with pneumonia. The patient is a retired soldier who served in World War II. In light of this, the nurse should:
A) shake the patient's hand and allow the patient time to "warm up."
B) expect the patient to be optimistic and question everything.
C) allow the patient to multitask and talk in short "sound bites."
D) understand that the patient is probably technologically literate.
Q2) The nurse is attempting to get the patient to sign the operative consent. When asked if the health care provider explained the procedure to the patient, the patient replies "Not much." The nurse should:
A) develop a comprehensive teaching plan related to the surgical procedure.
B) ask the patient what information the doctor has explained about the surgery.
C) contact the surgeon and ask for further clarification of information given to patient.
D) focus on postoperative exercises and home-care following surgery.
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Chapter 7: Nursing Diagnosis
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Sample Questions
Q1) A nurse completes a care plan for an assigned patient diagnosed with an inflammation of the pericardium. Which diagnosis written on the plan indicates a need for further instruction on using the nursing process?
A) Pericarditis
B) Acute pain
C) Risk for decreased cardiac output
D) Activity intolerance
Q2) Nursing students are analyzing the following nursing diagnostic statement during a study group session. Acute pain related to pressure on lumbar spinal nerves as evidenced by a pain level of 9, patient verbalizations of pain, and grimacing when walking. The students would be correct if they stated that the etiology of the patient's problem is:
A) patient verbalizations of pain.
B) acute pain.
C) pressure on lumbar spinal nerves.
D) grimacing when walking.
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9
Chapter 8: Planning
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Sample Questions
Q1) The significance of developing organized plans of care for patients cannot be stressed enough. In the planning phase, the nurse must take seriously the responsibility of: (Select all that apply.)
A) prioritizing patient needs.
B) developing mutually agreed-on goals.
C) determining outcome criteria.
D) identifying interventions.
E) implementation of the patient's plan of care.
Q2) Medication administration is what type of nursing intervention?
A) Independent
B) Dependent
C) Collaborative
D) Interdisciplinary
Q3) Dependent nursing interventions include:
A) ordering heel protectors.
B) preadmission teaching.
C) medication reconciliation.
D) administer antipyretic medications as appropriate.
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Chapter 9: Implementation and Evaluation
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Q1) After the nurse completes a patient's initial assessment and develops a plan of care:
A) continual reassessment of the patient is required.
B) no changes to the care interventions should be allowed.
C) reassessment should be done randomly.
D) the nursing process becomes static to maintain the course of the cure.
Q2) The nurse is learning to identify readiness to learn in patients. Which one of the following patients would the nurse identify correctly as ready to learn?
A) The patient requesting pain medication for treatment of severe discomfort
B) The patient with nausea and vomiting
C) The patient who learned 30 minutes ago that she has cancer of the pancreas
D) The patient who was recently diagnosed with diabetes mellitus and is scheduled to be discharged in 2 days
Q3) The final phase of the nursing process is evaluation, which focuses on:
A) recording the care that was implemented.
B) medical and nursing goals for the welfare of the patient.
C) long-term goals only.
D) the patient responses to interventions and outcomes.
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Chapter 10: Documentation, Electronic Health Records, and Reporting
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Sample Questions
Q1) 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.
Q2) 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.
Q3) 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.
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Chapter 11: Ethical and Legal Considerations
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29 Verified Questions
29 Flashcards
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Sample Questions
Q1) A nurse has been asked to care for a patient who is an inmate from a nearby prison. During shift report, the nurse asks, "Why was the man convicted and imprisoned?"
Another nurse responds that this is not important since nurses are required to provide compassionate care for all people in all circumstances. The responding nurse has displayed what concept?
A) Beneficence
B) Advocacy
C) Confidentiality
D) Autonomy
Q2) Which one of the following actions by the nursing student would be considered uncivil?
A) Prompt arrival to class
B) Texting during class
C) Attentive listening
D) Active participation in class
Q3) 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.
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Chapter 12: Leadership and Management
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Sample Questions
Q1) The nurse manager of the emergency room believes that efficiency is the expected standard for her department. She also believes that efficiency lies in following established rules, policies, and guidelines. The only way to change procedures is to changes rules, policies, and guidelines. In order to run the emergency room with this philosophy, the nurse manager must take on the role of:
A) laissez-faire leader.
B) democratic leader.
C) bureaucratic leader.
D) autocratic leader.
Q2) An effective manager must: (Select all that apply.)
A) understand the concepts of budgeting.
B) run a unit efficiently without regard to cost.
C) be able to staff the unit effectively.
D) be adept at information management.
E) achieve desired outcomes in any way possible.
Q3) Which of the following was delegated inappropriately?
A) Personal hygiene by the UAP
B) Assistance with eating breakfast by the UAP
C) Assistance with toileting by the UAP
D) Interpretation of abnormal vital signs by the UAP
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Chapter 13: Evidence-Based Practice and Nursing Research
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Sample Questions
Q1) The nurse is preparing to conduct a study involving the "post-prandial" blood sugars in patients who have received intensive diabetic rehabilitation versus diabetics undergoing "usual care." In order for the consent to be valid, the nurse would have to:
A) change the language of the consent.
B) keep explanations to a minimum to reduce stress.
C) keep potential risks undisclosed.
D) insist that the participant sign the consent right away.
Q2) The nurse correctly devises a dissemination plan at what point during the research process?
A) Conclusion of the study
B) After the literature review
C) The beginning of the research process
D) While conducting research
Q3) A human subject is defined as a living individual about whom an investigator conducting research obtains:
A) data without direct or indirect interaction or intervention.
B) information that is not expected to be made public.
C) no diagnostic information and does not manipulate the subjects environment.
D) information without any communication/contact during the research.
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Page 15
Chapter 14: Health Literacy and Patient Education
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Sample Questions
Q1) The nurse is preparing to teach a 90-year-old patient. In teaching an elderly patient, the nurse realizes that:
A) most elderly patients are highly literate.
B) cognitive abilities always decline with age.
C) sensory alterations often occur with aging.
D) teaching methods are the same as for the middle aged.
Q2) The nurse has established a teaching plan including goals. This type of education is termed:
A) formal teaching.
B) informal teaching.
C) psychomotor teaching.
D) affective teaching.
Q3) In determining patient goals, the nurse should:
A) allow patients to identify what is most important to them.
B) take the lead and determine what is best for the patient.
C) should focus on health promotion and staying healthy.
D) explain the importance of avoiding complications.
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16
Chapter 15: Nursing Informatics
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22 Flashcards
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Sample Questions
Q1) When technology such as a bar-code medication administration (BCMA) system is used as part of the process of medication administration, fewer errors are made. The proper procedure when using the BCMA includes:
A) signing into the system using the patient's ID number.
B) typing in the patient's name and room number.
C) scanning the patient's ID, MAR, and medication.
D) discontinuing the medication if the system signals an error.
Q2) The director of nursing on a medical-surgical floor has met education and experience requirements in nursing informatics. The nurse might expect administration to request that he/she pursue:
A) technical competencies.
B) utility competencies.
C) certification from ANCC.
D) leadership competencies.
Q3) 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.
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Chapter 16: Health and Wellness
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Sample Questions
Q1) The economic stability of individuals or families can determine whether they are willing to seek preventive care or screening examinations. Which statements about screening examinations are true? (Select all that apply.)
A) Free or low-cost screening ensures patient screening.
B) People may not screen due to fear of testing positive.
C) Early screening ensures minimal treatment costs
D) Employment stability is enhanced by early screening.
E) Treatment of disorders often means lost wages.
Q2) The nursing goal for all individuals and their families seeking preventive care is to have individuals and families:
A) take responsibility for their health and wellness.
B) abandon the use of electronic educational media.
C) make lifestyle changes after diseases occur.
D) use temporary changes until the danger has passed.
Q3) When caring for patients with chronic illness, the nurse needs to:
A) help the patient face the reality that he will not get better.
B) emphasize to the patient that the illness is not his fault.
C) emphasize improving quality of life through preventive behaviors.
D) acknowledge the limitations placed on the patient by his suffering.
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Page 18
Chapter 17: Human Development: Conception through Adolescence
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Sample Questions
Q1) 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
Q2) The nurse is teaching parents about actions to assist in developing a critical skill in the concrete operations phase of Piaget's developmental theory. What activities does the nurse suggest the parents participate with their child in? (Select all that apply.)
A) Separating a collection of toy horses into functions each type performs.
B) Exploring a space and astronomy museum and planetarium together.
C) Making a scrapbook of leaves sorted by color or type of tree.
D) Having the child explore how common objects can be used for different purposes.
E) Asking the child to describe an event from several different points of view.
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Chapter 18: Human Development Young Adult to Older Adult
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Sample Questions
Q1) An adult caregiver for an older adult reports the adult is doing well other than sleeping more frequently and for longer periods. What response by the nurse is best?
A) Assess the older adult for exercise habits.
B) Perform a screening for depression.
C) Reassure the caregiver that this is normal.
D) Ask the older adult to provide a sleep diary.
Q2) A nurse notes an older adult puts excessive amounts of salt on her food. What intervention by the nurse is best?
A) Teach the adult how salt intake relates to hypertension.
B) Ask the older adult why she puts so much salt on food.
C) Encourage the older adult to use less salt on her food.
D) Explore other herbs and flavor enhancers with the adult.
Q3) A young adult asks the nurse why she should participate in health screening and educational events. What response by the nurse is best?
A) "Your choices now affect your future health."
B) "It's free and full of good information."
C) "Wouldn't you want to know if you had a problem?"
D) "You can change bad habits now if you know about them."
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Chapter 19: Vital Signs
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Sample Questions
Q1) A patient's blood pressure is 142/76 mm Hg. What does the nurse chart as the pulse pressure?
A) 28
B) 42
C) 58
D) 66
Q2) The nursing student learns that the purpose of measuring vital signs includes which rationale? (Select all that apply.)
A) Monitor body systems functioning.
B) Identify early signs of problems.
C) Evaluate effectiveness of interventions.
D) Determine if a cure has been obtained.
E) Provide a baseline to compare against.
Q3) Which parameters does the nurse include when assessing pain? (Select all that apply.)
A) Facial expression
B) Muscle spasms
C) Shallow respirations
D) Immobility
E) Temperature
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Chapter 20: Health History and Physical Assessment
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Q1) A nurse is assessing a patient's abdomen and hears bowel sounds every 20 to 25 seconds. What action by the nurse is best?
A) Avoid palpating this patient's abdomen.
B) Document the findings in the patient's chart.
C) Have another nurse verify the findings.
D) Ask the patient when the last food intake was.
Q2) A new nurse is conducting a patient interview. What behaviors observed by the experienced nurse require education on this process? (Select all that apply.)
A) Typing intently on a keyboard when asking questions.
B) Allowing family to accompany the patient as requested.
C) Using gestures and eye contact to demonstrate interest.
D) Closing the door to the room to ensure privacy.
E) Providing non-verbal cues to negative thoughts.
Q3) A student nurse is preparing to auscultate a patient's lungs. What action by the student leads the instructor to intervene?
A) Student asks to turn the television volume down.
B) Student warms the bell of the stethoscope before use.
C) Student uses the stethoscope bell to listen to bowel sounds.
D) Student places the stethoscope diaphragm on the patient's skin.
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Page 22
Chapter 21: Ethnicity and Cultural Assessment
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Q1) The nurse is caring for a patient from a different cultural background. What action by the nurse best demonstrates cultural maintenance?
A) Assist the patient with a healing ritual.
B) Teach the patient a heart healthy diet.
C) Instruct the patient on monitoring blood glucose.
D) Discuss what self-care activities the patient is willing to do.
Q2) A patient refuses to take his blood pressure medication because "I feel totally fine and don't need it." What action by the nurse is best?
A) Assess the patient's time orientation.
B) Document the patient's non-compliance.
C) Educate the patient about the medication.
D) Warn the patient about possible complications.
Q3) A nursing student wants to observe enculturation practices of an ethnic minority community. What action by the student is best?
A) Attend a community dance.
B) Learn to cook an ethnic meal.
C) Visit the group's worship service.
D) Observe a grandmother teaching a child.
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23
Chapter 22: Spiritual Health
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Q1) A patient in the hospital is an adherent Muslim. Which of the five pillars of Islam can the nurse assist the patient in meeting?
A) Praying five times a day
B) Having privacy
C) Personal cleanliness
D) Giving alms
E) Maintaining modesty
Q2) A patient is considering a life-saving procedure that is not accepted by his faith community. What nursing diagnosis is a priority as the nurse plans care?
A) Spiritual distress
B) Impaired religiosity
C) Moral distress
D) Decisional conflict
Q3) A patient who claims to be very involved in church is near death. What action by the nurse is best?
A) Get permission to contact the religious leader.
B) Allow the family to stay at the patient's bedside.
C) Call the hospital chaplain to come to the bedside.
D) Ask if the patient and family want to pray.
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Page 24
Chapter 23: Public Health, Community Base, and Home
Health Care
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Q1) The student nurse learns the ANA's Scope and Standards of Practice for public health nursing include which of the following? (Select all that apply.)
A) Ethical practice
B) Conducting research
C) Ethical behavior
D) Responsible resource use
E) Advocacy
Q2) 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
Q3) A nurse is discharging a patient and is planning on what material to give the patient to take home. What action by the nurse is best?
A) Assess the patient's ability to read and understand.
B) Determine if the patient wants to take written material home.
C) Give the patient the same material as other patients get.
D) Ask the patient if he/she has a need for written material.
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Chapter 24: Human Sexuality
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Q1) A nurse in the emergency department wants to screen a patient for domestic violence, but the woman's partner won't leave. What action by the nurse is best?
A) Ask the questions anyway.
B) Tell the partner to leave.
C) Go with the patient to the bathroom.
D) Skip the abuse assessment.
Q2) 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
Q3) A patient asks the nurse to recommend a non-prescription contraceptive. What options does the nurse discuss?
A) Diaphragm
B) Cervical cap
C) Condom
D) Intrauterine device
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Chapter 25: Safety
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Q1) The nurse is visiting a patient with cardiac disease who has been experiencing increased episodes of shortness of breath when she tries to exercise. The nurse is concerned that her decrease in activity may lead to:
A) orthostatic hypotension.
B) increase risk of heart disease.
C) loss of short-term memory.
D) worsening shortness of breath.
Q2) The nurse recognizes that a patient is using a portable generator in the house as a power source. What source of poisoning does the nurse appropriately identify?
A) Lead
B) Carbon monoxide
C) Antifreeze
D) Pesticide
Q3) Many health care facilities use the fire emergency response defined by the acronym: A) RACE.
B) PASS.
C) PACE.
D) QSEN.
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Chapter 26: Asepsis and Infection Control
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Q1) The nurse is providing education to a patient who is being discharged home on antibiotic therapy. Which of the following statement(s) by the patient indicates further education is needed? (Select all that apply.)
A) "I should take antibiotics every time I am sick."
B) "I should take all antibiotics as prescribed."
C) "I should save all unused antibiotics."
D) "I should stop taking antibiotics when I feel better."
Q2) The nurse notes that a patient's albumin is low and is concerned about the patient's ability to fight infection related to antibodies being made from what?
A) Protein
B) Carbohydrates
C) Fats
D) Vitamins
Q3) The patient is on protective precautions. Which is true regarding these precautions? (Select all that apply.)
A) A positive-pressure room with a HEPA filtration system is required.
B) Special respirator masks should be available and one size fits all.
C) No live plants are allowed in the room.
D) The patient may eat any foods desired.
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Page 28
Chapter 27: Hygiene and Personal Care
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Q1) Regarding perineal care, which nursing action is appropriate? (Select all that apply.)
A) The nurse applies gloves prior to performing perineal care
B) The nurse ignores the erection of a male patient during perineal care
C) The nurse documents the perineal care.
D) The nurse only completes perineal care with daily bathing
Q2) The nurse knows that routine hygienic care does not include:
A) massage with lotion.
B) oral care with a toothbrush.
C) shaving with a disposable razor.
D) ear hygiene with cotton-tipped applicators.
Q3) The nurse is caring for a patient with swallowing concerns and decreased level of consciousness. The nurse knows to put the patient in what position for oral care?
A) High Fowler's
B) Prone
C) Side lying
D) Low Fowler's
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Chapter 28: Activity, Immobility, and Safe Movement
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Q1) The nurse knows the following items should be included in the documentation of the patient on falls precautions: (Select all that apply.)
A) History of any falls
B) Falls risk assessment scores
C) Patient and family education
D) Use of assist devices
E) Any fall or reported fall
F) None of the above
Q2) The nurse is correctly assisting the patient in using a cane when the patient demonstrates the following: (Select all that apply.)
A) The top of the cane is level with the patient's bent elbow.
B) The patient holds the cane on his/her weaker side.
C) The patient moves the cane forward first.
D) The patient's arm is comfortably bent when walking.
Q3) The nurse knows active assistive range of motion is:
A) when the patient is able to independently move all joints.
B) when the patient is able to partially move all joints.
C) when the caregiver must move the patient's joints.
D) when the patient is performing isotonic exercises.
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Chapter 29: Skin Integrity and Wound Care
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Q1) The nurse knows an appropriate goal for a patient with a stage III pressure ulcer with the nursing diagnosis Impaired physical mobility is:
A) the patient will remain free of wound infections during the hospitalization.
B) the patient will report pain management strategies and reduce pain to a tolerable level.
C) the patient will turn self in bed using over trapeze every two hours using assistance when needed.
D) the patient will consume adequate nutrition to meet nutritional requirements within 1 week.
Q2) The nurse is educating the patient about the signs and symptoms of a wound infection. Which statement indicates a need for further education?
A) "The wound will be red."
B) "The wound will have pus."
C) "The wound will be warm."
D) "The wound will need to be treated."
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Chapter 30: Nutrition
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Q1) The nurse is caring for an adolescent patient with anorexia nervosa. She knows the best treatment option is:
A) hospitalization with skill nursing care.
B) compulsory tube feedings.
C) individually determined by a collaborative team.
D) outpatient treatment.
Q2) The nurse is measuring his patient's height. Which of the following steps of the procedure indicates a need for further education on this skill?
A) He instructs the patient to remove his shoes.
B) He measures from the top of the patient's head to the bottom of the patient's foot arch.
C) He positions the head against the headboard or measuring device.
D) He makes sure the patient is standing erect.
Q3) The nurse is caring for a patient who is receiving total parenteral nutrition (TPN). The nurse knows she should change the tubing every:
A) 72 hours.
B) 48 hours.
C) 24 hours.
D) 12 hours.
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Chapter 31: Cognitive and Sensory Alterations
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Q1) The nurse is delegating care to an unlicensed assistive personnel (UAP) to a patient who has sensory overload. Which statement by the UAP indicates a need for further orientation?
A) "I should keep the noise levels low."
B) "I should schedule all the care together."
C) "I should keep the room well lit."
D) "I should allow the family to visit."
Q2) The nurse is preparing discharge instructions for a patient who has tactile alterations in his legs. Which instructions should be included? (Select all that apply.)
A) Verify bath water temperature is approximately 39.5° C.
B) Do not use hot or cold therapy on any extremity.
C) Use sturdy shoes when walking outside or on hard surfaces.
D) Report any changes in skin color on your legs to your health care provider.
E) Set your water heater so that scalding is not possible.
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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Chapter 32: Stress and Coping
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Q1) The nurse knows that one theory explaining the variation in response to stress among individuals is called:
A) stress appraisal.
B) sense of coherence.
C) allostasis.
D) homeostasis.
Q2) The nurse is performing a physical assessment of patient who is undergoing a bone marrow biopsy. What finding by the nurse indicates the patient is experiencing stress?
A) Blood pressure of 120/84
B) Temperature of 37.5° C
C) Heart rate of 110 beats/min
D) Respiratory rate of 10 breaths/min
Q3) The nurse is educating the patient about alternative therapies. Which statement by the patient indicates a need for more information?
A) Alternative therapies can include relaxation techniques.
B) Alternative therapies are used in conjunction with medical therapies.
C) Alternative therapies can be used when patients are experiencing stress.
D) Some alternative therapists require certification.
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Chapter 33: Sleep
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Q1) The nurse knows the usual progression of sleep is:
A) NREM 1-4 then REM, then back through NREM 1 and 2.
B) REM then NREM 1-4, then back through NREM 2 and 3.
C) NREM 1-4 then back through NREM 3 and 2 then REM.
D) REM then NREM 1-4 then back through NREM 3.
Q2) The nurse knows an appropriate goal for the nursing diagnosis Disturbed sleep pattern during hospitalization is:
A) the patient will fall asleep within 15 minutes of going to bed.
B) the patient will report an ability to concentrate on tasks.
C) the patient will repeat medication instructions on discharge.
D) the patient will be able to sleep for at least 2 hours at a time.
Q3) The nurse knows the following risk factors are associated with obstructive sleep apnea (OSA): (Select all that apply.)
A) Deviated septum
B) Recessed chin
C) Alcohol use
D) Large neck
E) Tonsillectomy
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35
Chapter 34: Diagnostic Testing
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Q1) The nurse is caring for a patient who is undergoing a liver biopsy. Which interventions will be included in the patient's care plan for the diagnosis of Risk for infection: r/t invasive diagnostic procedure? (Select all that apply.)
A) Monitor for and report redness, warmth, discharge, or fever promptly to the physician.
B) Carefully maintain the sterile field during the biopsy procedure.
C) Teach patient how to care for the biopsy site when procedure is completed.
D) Provide a supportive, caring presence to minimize patient anxiety.
E) Provide information about the pathophysiology and treatment options for liver cancer.
F) Consider using healing touch and other mind-body-spirit interventions.
Q2) The nurse is caring for a patient who is sedated following a colonoscopy. Which is the priority action of the nurse?
A) Provide a quiet, dark environment so that the patient can rest comfortably.
B) Monitor the patient's pulse oximetry and respirations closely.
C) Inform the patient that the procedure has been completed.
D) Assess the patient's bowel sounds and passage of flatus.
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Chapter 35: Medication Administration
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Q1) 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.
Q2) The nurse carefully reviews the patient's medication list. Which observation about the list indicates the highest risk for serious drug-drug interactions?
A) The patient has been taking the same medications for a long time.
B) The patient is taking a large number of medications.
C) Most of the drugs on the list are prescribed at high doses.
D) The patient takes oral, injected, and inhaled medications.
Q3) Which medication has the highest potential for abuse?
A) Methylphenidate (Ritalin) - schedule II
B) Alprazolam (Xanax) - schedule IV
C) Acetaminophen & codeine (Tylenol #3) - schedule III
D) Diphenoxylate & atropine (Lomotil) - schedule V
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Chapter 36: Pain Management
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Q1) The nurse is caring for a cancer patient with ongoing pain from widespread metastasis to her bones. The nurse notes that the patient's morphine dosage had to be increased to sufficiently manage her discomfort. What is the nurse's interpretation of this assessment finding?
A) The patient became tolerant to the previous morphine dosage.
B) The patient is becoming addicted to her pain medication.
C) The patient has been abusing her prescribed pain medications.
D) The patient is seeking to end her life with an overdose of morphine.
Q2) The nurse is caring for a patient who has severe abdominal pain caused by acute cholecystitis. What type of pain is this patient experiencing?
A) Visceral pain
B) Somatic pain
C) Radiating pain
D) Referred pain
Q3) Which patient is best suited for PCA analgesia?
A) A patient who is confused after a head injury
B) A patient recovering from total hysterectomy surgery
C) A patient who has severe psychogenic pain
D) A patient with arthritis who is unable to push the nurse call button
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Page 38
Chapter 37: Perioperative Nursing Care
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Q1) The nurse is caring for a postoperative patient who is very sleepy following general anesthesia and administration of pain medication. The nurse notes that the patient is making snoring sounds and his pulse oximetry has dropped to 88%. What is the best action of the nurse?
A) Insert an oral airway and administer oxygen.
B) Call for anesthesia to immediately reintubate the patient.
C) Remove the pillow from behind the patient's head.
D) Elevate the head of the patient's bed.
Q2) The nurse is caring for a patient with advanced colon cancer. The patient is to have surgery to relieve a bowel obstruction that has been causing unrelenting vomiting and abdominal pain. What type of surgery will this patient undergo?
A) Palliative
B) Reconstructive
C) Diagnostic
D) Ablative
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Chapter 38: Oxygenation and Tissue Perfusion
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Q1) The preceptor is working with a new nurse to provide care for a patient with a chest tube to relieve a pneumothorax. Which action by the new nurse indicates need for additional teaching about chest tube care?
A) The suction is discontinued when the patient is ambulated to the bathroom.
B) The collection device is emptied at the end of the shift and output recorded in the chart.
C) The patient's bed is placed in the semi-Fowler's position to facilitate lung reexpansion.
D) The patient is encouraged to use his incentive spirometer at least 10 times every hour.
Q2) The nurse is performing a respiratory assessment on a patient. Which assessment findings indicate to the nurse that the patient has a history of long-standing chronic respiratory disease? (Select all that apply.)
A) All of the patient's fingernails are noticeably clubbed.
B) The patient needs to sleep on at least four to five pillows at night.
C) The patient's chest has equal antero-posterior and transverse diameters.
D) The patient's lower legs have large areas of brownish spotted discoloration.
E) The patient reports puffiness of both feet when standing for long periods.
F) The patient's forced vital capacity test result is 3.8 L of air.
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Chapter 39: Fluid, Electrolytes, and Acid-Base Balance
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Q1) The nurse is caring for a patient who has a central venous catheter (CVC). Which nursing intervention is the most important for the nurse to include in the patient's plan of care?
A) Carefully document all assessments of the catheter site.
B) Use strict sterile procedure when performing dressing changes.
C) Label each new dressing with the date, time, and nurse's initials.
D) Ensure that the CVC is discontinued as soon as possible.
Q2) The nurse is caring for a patient with syndrome of inappropriate antidiuretic hormone secretion (SIADH) who has a serum sodium level of 118 mEq/dL and symptoms of fluid overload. Which IV fluid will the nurse expect to administer to this patient in order to correct the patient's fluid imbalance?
A) 0.33% normal saline
B) 0.45% normal saline
C) 0.9% normal saline
D) 3% normal saline
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Chapter 40: Bowel Elimination
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Q1) The nurse is caring for a patient who is recovering from bowel surgery. Which assessment finding best indicates that the bowel is starting to resume function and the patient will be able to resume oral intake soon?
A) The patient has bowel sounds x 4 quadrants and is passing gas.
B) The patient has no nausea, and abdominal pain is minimal.
C) The patient feels hungry for chicken soup and hot tea.
D) The patient's nasogastric tube was discontinued the previous day.
Q2) The nurse is caring for a patient who takes laxatives and enemas regularly to ensure that he has a large daily bowel movement. The patient states that he feels constipated if he does not defecate every day. Which nursing diagnosis is most appropriate for this patient?
A) Health-seeking behaviors related to self-prescribed daily bowel regimen
B) Perceived constipation related to professed need for daily laxatives
C) Effective therapeutic regimen management related to defecation routine
D) Disturbed thought processes related to obsession with daily bowel movements
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42
Chapter 41: Urinary Elimination
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Q1) The nurse is caring for a patient who is to undergo computed tomography (CT) of the kidneys and ureters. Which assessment finding by the nurse must be reported to the physician and radiologist before the patient has the procedure?
A) The patient is allergic to bananas and latex.
B) The patient thinks that she might be pregnant.
C) The patient has a family history of bladder cancer.
D) The patient currently has a urinary tract infection.
Q2) The nurse is caring for a patient with diabetes insipidus. The patient has constant severe thirst, drinks fluids continuously, and voids 3 to 4 L of clear yellow urine daily. Which term will the nurse use in the record to describe this patient's urinary output?
A) Anuria
B) Oliguria
C) Polyuria
D) Enuresis
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Chapter 42: Death and Loss
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Q1) The nurse is caring for a patient who has just died in a motor vehicle accident. What is the priority action of the nurse before the patient's family arrives to see the patient's body?
A) Gently wash the body and provide perineal care.
B) Remove the patient's dentures and jewelry.
C) Ensure that the death certificate has been signed.
D) Determine which funeral home will pick up the body.
Q2) The nurse is caring for a patient who just died after a lengthy illness. Which portions of postmortem care may be delegated to the nursing assistant? (Select all that apply.)
A) Gently washing the body and closing the patient's eyes
B) Offering support and empathy to the patient's family members
C) Documenting the patient's time of death in the medical record
D) Notifying all of the patient's consulting physicians of the patient's death
E) Removing the patient's hospital ID band, IV lines, and urinary catheter
F) Gathering the patient's belongings so they may be taken home by the family
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