Fundamentals of Nursing 1- Practice Example Questions PDF

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Goes over practice questions regarding the nursing course, Fundamentals of Nursing for Adult Health Care....

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Name: _________________________________________________________________ Date:_______________ 1. Elizabeth Kubler-Ross identified five stages of death and dying. Loss, grief, and intense sadness are symptoms of which stage? a. Denial and isolation b. Depression c. Anger d. Bargaining RATIONALE: According to Kübhler-Ross, the five stages of death and dying are denial and isolation, anger, bargaining, depression, and acceptance. In denial, the client denies aspects of the illness and death. Loss, grief, and intense sadness indicate depression. In anger, the client has hostility that may be directed to family members, God, heath care workers, and others. In bargaining, the client asks God for more time, and in return promises to do something good. 2. To help minimize calcium loss from a hospitalized client's bones, the nurse should: a. reposition the client every 2 hours. b. encourage the client to walk in the hall c. provide the client daily products at frequent intervals d. provide supplemental feedings between meals. RATIONALE: Calcium absorption diminishes with reduced physical activity because of decreased bone stimulation. Therefore, encouraging the client to increase physical activity such as by walking the hall, helps minimize calcium loss. Turning or repositioning the client every 2 hours wouldn’t increase activity sufficiently to minimize bone loss, Providing dairy products and supplemental feedings wouldn't lessen calcium loss - even if the dairy products and feedings contained extra calcium — because the additional calcium doesn’t increase bone stimulation or osteoblast activity. 3. Which statement regarding heart sounds is correct? a. S1 and s2 sound equally loud over the entire cardiac area. b. S1 and sound fainter at the apex than at the base. c. S and 2 sound fainter at the base than at the apex. d. S1 is loudest at the apex, and S2 is loudest at the base. Rationale: The S1 sound — the “lub” sound — is loudest at the apex of the heart. It sounds longer, lower, and louder there than the S2 — the “dub” sound — is loudest at the base. It sounds shorter, sharper, higher, and louder there than the S1. 4. A client has a nursing diagnosis of Ineffective airway clearance related to poor coughing. When planning this client’s care, the nurse should include which intervention? a. Increasing fluids to 2,500 ml/day b. Teaching the client how to deep-breathe and cough c. Improving airway clearance d. Suctioning the client every 2 hours RATIONALE: Interventions should address the etiology of the client's problem — poor coughing. Teaching deep breathing and coughing addresses this etiology. Increasing fluids may improve the client’s condition, but this intervention doesn't address poor coughing. Improving airway clearance is too vague to be considered an appropriate intervention. Suctioning isn't indicated unless other measures fail to clear the airway. 5. A nurse is using the computer when a client calls for pain medication. Which action by the nurse is the best? a. Staying logged on, leaving the terminal on, and administering the medication immediately b. telling the client that he’ll have to wait 15 minutes while she completes the entry c. Asking a coworker to log out for her and administering the medicine right away d. Logging out of the computer, then administering the pain medication RATIONALE: A nurse should meet a client’s request for pain medication as quickly as possible after she logs out of the computer. A nurse shouldn't ask a client to wait for as long as 15 minutes for requested pain medication. If the nurse leaves the terminal without logging out, others may view confidential information or use her password. Asking a coworker to log her out isn't safe computer practice.

6. What is the most appropriate nursing diagnosis for the client with acute pancreatitis? a. Deficient fluid volume b. Excess fluid volume c. Decreased cardiac output d. Ineffective gastrointestinal tissue perfusion RATIONALE: Clients with acute pancreatitis often experience deficient fluid volume, which can lead to hypovolemic shock. Vomiting, hemorrhage (in hemorrhagic pancreatitis), and plasma leaking into the peritoneal cavity may cause the volume deficit. Hypovolemic shock will cause a decrease in cardiac output. Gastrointestinal tissue perfusion will be ineffective if hypovolemic shock occurs, but this wouldn't be the primary nursing diagnosis. 7. One aspect of implementation related to drug therapy is: a. developing a plan of care b. documenting drugs given. c. establishing outcome criteria. d. setting realistic client goals. RATIONALE: Athough documentation isn't a step in the nursing process, the nurse is legally required to document activities related to drug therapy, including the time of administration, the quantity, and the client's reaction. Developing a plan of care, establishing outcome criteria, and setting realistic client goals are parts of planning rather than implementation. 8. A nurse notes that a client’s I.V. insertion site is red, swollen, and warm to the touch. which action should the nurse take first? a. Discontinue the I.V. infusion. b. Apply a warm, moist compress to the I.V. site. c. Assess the I.V. infusion for patency. d. Apply an ice pack to the I.V. site. RATIONALE: Because redness, swelling, and warmth at an I.V. site are signs of infection, the nurse should discontinue the infusion immediately and restart at another site. After doing this, the nurse should apply warmth to the original site. Checking infusion patency isn't warranted because assessment findings suggest infection and inflammation, not infiltration. Heat, not cold is the appropriate treatment for inflammation. 9. A nurse is caring for a client with a history of falls. The nurse's first priority when caring for a client at risk for falls is: a. placing the call light for easy access. b. keeping the bed in the lowest possible position. c. instructing the client not to get out of the bed without assistance d. keeping the bedpan available so that the client doesn’t have to get out of bed. RATIONALE: Keeping the bed at the lowest possible position the first priority for clients at risk for falling. Keeping the call light easy accessible is important but isn’t a top priority. Instructing the client not to get out of bed may not effectively prevent falls — for example, if the client is confused. Even when the client needs assistance to get out of bed, the nurse should place the bed in the lowest position. The client may not require a bedpan. 10. A nurse is caring for a client who is exhibiting signs and symptoms characteristic of a myocardial infarction (MI). which statement describes priorities the nurse should establish while performing the physical assessment? a. Assess the client's level of pain and administer prescribed analgesics. b. Assess the client’s level of anxiety and provide emotional support. c. Prepare the client for pulmonary artery catheterization. d. Ensure that the client's family is kept informed of his status. RATIONALE: The cardinal symptom of MI is persistent, crushing substernal pain or pressure. The nurse should first assess the client's pain and prepare to administer nitroglycerin or morphine for pain control. The client must be medically stabilized before pulmonary artery catheterization can be used as a diagnostic procedure. Anxiety and a feeling of impending doom are characteristic of MI, but the priority is to stabilize the client medically. Although the client and his family should be kept informed at every step of the recovery process, this action isn’t the priority when treating a client with a suspected MI.

11. A nurse is monitoring a client for adverse reactions during barbiturate therapy. What is the major disadvantage of barbiturate use? a. Prolonged half-life b. Poor absorption c. Potential for drug dependence d. Potential for hepatotoxicity RATIONALE: Clients can become dependent on barbiturates, especially with prolonged use. Because of the rapid distribution of some barbiturates, no correlation exists between duration of action and half-life. Barbiturates are absorbed well and don't cause hepatotoxicity, but because barbiturates are metabolized in the liver, existing hepatic damage does require cautious use of these drugs. 12. A nurse is caring for a client who required chest tube insertion for a pneumothorax. To assess for pneumothorax resolution, the nurse anticipates that the client will require: a. monitoring of arterial oxygen saturation , b. arterial blood gas (ABG) studies. c. chest auscultation. d. a chest x-ray. Rationale: Chest x-ray confirms diagnosis by revealing air or fluid in the pleural space. SaO2 values may initially decrease with a pneumothorax but typically return to normal within 24 hours. ABG studies may show hypoxemia, possibly with respiratory acidosis and hypercapnia not related to a pneumothorax. Chest auscultation will determine overall lung status, but it's difficult to determine if the chest has reexpanded sufficiently. 13. During her morning assessment, a nurse notes that a client has severe dyspnea, his respirations are 34 breaths/minute and labored. Oxygen saturation is 79% on 3L of oxygen. The nurse remembers that the client's chart includes his living will, When considering best practice, the nurse should: a. withhold all potentially life-prolonging treatments in accordance with the client's living will b. increase the oxygen flow rate to 4L, but avoid initiating other interventions c. call the client’s family and ask what they think is best. d. initiate potentially life-prolonging treatment unless the client refuses. RATIONALE: A living will doesn't go into effect unless the client is unable to make his own decisions. A nurse shouldn't withhold care for an alert client unless he specifically refuses care. The nurse should give all appropriate care while also maintaining the client's right to refuse treatment. Increasing the oxygen flow rate might be an appropriate response, but isn't the best action at this time. The family isn't responsible for determining care at this time. 14. A client is to receive a glycerin suppository. Which nursing action is appropriate when administering a suppository? a. Removing the suppository from the refrigerator 30 minutes before insertion b. Applying a lubricant to the suppository c. Dissolving the suppository in 3 ml of warm water d. Instructing the client to bear down during insertion RATIONALE: A suppository must be lubricated before insertion. Because suppositories melt at body temperature, they usually require refrigeration until administration. It isn’t appropriate to dissolve a suppository in warm water. It should remain in a solid state. Instructing the client to bear down would cause the anal sphincter to contract, making insertion difficult. 15. A physician orders regular insulin 10 units LV. along with 50 ml of dextrose 50% for a client with acute renal failure. What problem is this client most likely experiencing? a. Hypercalcemia b. Hypernatremia c. Hyperglycemia d. Hyperkalemia Rationale: Administering regular IV concomitantly with 50 ml of dextrose 50% helps shift potassium from the extracellular fluid into the cell, which normalizes serum potassium levels in the client with hyperkalemia. This combination doesn't he reverse the effects of hypercalcemia, hypenatremia, or hyperglycemia.

16. A nurse identifies a client’s responses to actual or potential health problems during which step of the nursing process? a. Assessment b. Diagnosis c. Planning d. Evaluation RATIONALE: The nurse identifies human responses to actual or potential health problems during the diagnosis step of the nursing process, which encompasses the nurse’s ability to formulate a nursing diagnosis. During the assessment step, the nurse systematically collects data about the client or his family. During the planning step, she develops strategies to resolve or decrease the client’s problem. During the evaluation step, the nurse determines the effectiveness of the care plan. 17. In a client with a urine specific gravity of 1.040, a subnormal serum osmolality, and a serum sodium level of 128 mEq/L, the nurse should question an order for which I.V. fluid? a. dextrose 5% in half-normal saline solution. b. normal saline solution. c. dextrose 5% on water (D5W) d. lactated Ringer’s solution. RATIONALE: An elevated urine specific gravity, a subnormal serum osmolality, and a subnormal serum sodium level indicate that the client is excreting too many solutes. Because the client is in a hypotonic state, the nurse shouldn't give him a hypotonic I.V. solution. D5W, also referred to as free water, is hypotonic when given I.V. and can further hemodilute the clent. Dextrose 5% half-normal saline solution is hypertonic, normal saline solution is isotonic, and lactated Ringer's solution is isotonic. For this client, each of these three choices are more acceptable than D5w. 18. A 10-year-old child with rheumatic fever must have his heart rate measured while he's awake and while he’s sleeping. Why are two readings necessary? a. To obtain a heart rate that isn't affected by medication b. To eliminate interference from the jerky movements of chorea c. To ensure that the child can't consciously raise or lower his heart rate d. To compensate for activity's effects on the child’s heart rate RATIONALE: Tachycardia may be a sign of heart failure. The nurse can detect mild tachycardia more easily when the child is asleep than when he's awake because activity can increase his heart rate. Medications given for rheumatic fever and rheumatic heart disease, such as digoxin (Lanoxin), exert their influence both day and night. Chorea, a symptom of rheumatic fever, is the loss of voluntary muscle control. It doesn't affect pulse because the child would be sitting quietly while the nurse measured his heart rate and wouldn't be involved in purposeful movement. A 10-year-old child probably doesn't know how to consciously raise or lower his heart rate. 19. A nurse preparing to administer a sustained-release capsule to a client. Which is an appropriate nursing intervention? a. Administering the capsule whole with a glass of water b. Crushing the capsule and mixing the medication with applesauce c. Opening the capsule, shaking the contents into water, and administering it to the client d. Having the client chew the capsule before swallowing

20. After receiving an I.M. injection, a client complains of burning pain at the injection site. which nursing action would be most appropriate at this time? a. Applying a cold compress to decrease swelling b. Applying a warm compress to dilate the blood vessels c. Massaging the area to promote absorption of the drug d. Instructing the client to tighten his gluteal muscles to promote better absorption of the drug RATIONAI.E: Applying heat increases blood flow to the area, which, in turn, increases medication absorption. Cold decreases pain but allows the medication to remain in the muscle longer. Massage is a good intervention, but applying a warm compress is better. Tightening the gluteal muscles may cause additional burning if the drug irritates muscular tissues.

21. A client undergoes a total abdominal hysterectomy. When assessing the client 10 hours later, the nurse identifies which finding as an early sign of shock?

a. Confusion b. Pale, warm, dry skin c. Heart rate of 110 beats/minute d. Urine output of 30 ml/hour RATIONALE: Early in shock, inadequate perfusion leads to anaerobic metabolism, which causes metabolic acidosis. As the respiratory rate increases to compensate, the client’s carbon dioxide level decreases, causing alkalosis and subsequent confusion and combativeness. Inadequate tissue perfusion causes pale, cool, clammy skin (not pale, warm, dry skin). An above-normal heart rate is a late sign of shock. A urine output of 30 ml/hour is within normal limits. REFERENCE: Smeltzer, S.C., and Bare, B. Brunner&Suddarth’s Texthook of MedicalSurgical Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 2526. 22. Cross-tolerance to a drug is defined as: a. one drug that can prevent withdrawal symptoms from another drug. b. an allergic reaction to a class of drugs. c. one drug reduces response to another drug. d. one drug increases another drug’s potency. RATIONALE: Cross-tolerance occurs when a drug with a similar action causes a decreased response to another drug. A drug that can prevent withdrawal symptoms from another drug describes cross-dependence. Cross-tolerance isn't an allergic reaction to a class of drugs. A drug's ability to increase the potency of another drug describes potentiating effects. 23. A nurse caring for a client wth a fecal impaction should watch for: a. liquid or semiliquid stools. b. hard, brown, formed stools. c. loss of urge to defecate. d. increased appetite. RATIONALE: Passage of liquid or semiliquid stools results from seepage of unformed bowel contents around the impacted stool in the rectum. Clients with fecal impaction don’t pass hard, brown, formed stools because the feces can't move past the impaction. These clients typically report the urge to defecate (although they can't pass stool) and decreased appetite. 24. A physician orders an intestinal tube to decompress a client's GI tract. when gathering equipment for this procedure, a nurse should obtain a: a. Sengstaken-Blakemore tube. b. Miller-Abbott tube. c. Levin tube. d. Salem sump tube. RATIONALE: A Miller-Abbott tube is an intestinal tube. A Sengstaken-8lakemore tube is an esophageal tube. Levin tubes and Salem sump tubes are nasogastric tubes. REFERENCE: Smeltzer, S.C., and Bare, B. Brunner & Suddarth’s Textbook of Medical Surgica Nursing, 2008, p. 1175. 25. A client has a blood pressure of 152/86 mm Hg. The nurse should document the client’s pulse pressure as: a. 66mm Hg. b. 238 mm Hg. c. 86 mm Hg. d. 152 mm Hg. RATIONALE: Pulse pressure is the difference between the systolic and diastolic pressures — in this case, 66 mm Hg. 26. A client has a nursing diagnosis of Risk for Injury related to adverse effects of potassiumwasting diuretics. What is a correctly written client outcome for this nursing diagnosis? a. “By discharge, the client correctly identifies three potassium-rich food sources.” b. “The client knows the importance of consuming potassium-rich foods daily.” c. “Before discharge, the client knows which food sources are high in potassium.” d. “The client understands all complications of the disease process." RATIONALE: A client outcome must be measurable, objective, concise, realistic for the client, and attainable through nursing management. For each client outcome, the nurse should include only one client behaviour. She should express that behaviour in terms of client expectations and should indicate a time frame in which to accomplish. Knowing the importance of consuming potassium-rich foods and knowing which foods are high in potassium aren't measurable outcomes. Understanding all complications of a disease process isn't measurable or specific to the nursing diagnosis listed.

27. When caring for a client with a 3-cm stage I pressure ulcer on the coccyx, which action may the nurse institute independently? a. Using a povidone-iodine wash on the ulceration three times per day b. Using normal saline solution to clean the ulcer and applying a protective dressing as necessary c. Applying an antibiotic cream to the area three tines per day d. Massaging the area with an astringent every 2 hours 28. A client with burns on his groin has developed blisters. As the client is bathing, a few blisters break. The best action tor the nurse to take is to: a. remove the raised skin because the blister has already broken. b. wash the area with soap and water to disinfect it. c. apply a weakened alcohol solution to clean the area. d. clean the area with normal saline solution and cover it with a protective dressing. RATIONALE: The nurse should clean the area with a mild solution such as normal saline, and then cover it with a protective dressing. Soap and water and alcohol are too harsh. The body's first line of defense broke when the blisters opened: removing the skin exposes a larger area to the risk of infection. 29. A nurse is assisting with a subclavian vein central be insertion when the client's oxygen saturation drops rapidly. ...