FUNDAMENTALS

OF
NURSING PRACTICE
TESTBANK






Kozier
Erb






FUNDAMENTALS
OF
NURSING PRACTICE
TESTBANK






Barbara Timbey




VITAL SIGNS
1. The clients temperature of 8:00am using an oral electronic thermometer is 36.1C
(97.2F). If the respiration, pulse and blood pressure were within normal range, what
would the nurse do next?
A. Wait 15 minutes and retake it
B. Check what the clients temperature was the last time it was taken
C. Retake it using different thermometer
D. Chart the temperature; it is normal
Rationale: Answer 2
Although temperature is slightly lower than expected for the morning, it would be best to
determine the clients previous temperature range next. This may be a normal range for this
client. Depending on that finding, the nurse might want to retake it in a few minutes-no need to
wait 15 minutes (option 3) or with another thermometer to see if the initial thermometer was
functioning properly. Chart after determining that the temperature has been measured properly.

2. When the nurse enters the room to measure vital signs in preparing the client for
diagnostic test, the client is on the phone. What technique should the nurse use to
determine the respiratory rate?
A. Count the respirations during conversational pauses.
B. Ask the client to end the phone call now and resume it a later time.
C. Wait at the clients bedside until the phone call is completed and then count
respirations
D. Since there is no evidence of distress or urgency, defer the measurement.
RATIONALE: Answer 4
Since the clients needs are always considered first, the measurement should be delayed unless
the client is in distress or there are other urgent reasons. Option A: Respirations should be
measured for 30 seconds to 1 minute and are affected by talking. Option B: There are needs to
be an important reason for interrupting the client. Option C: It is inappropriate to wait and listen
to the clients conversation.

DIAGNOSTIC TESTING
1. A 78-year old male client need to complete a 24 hour urine specimen. In planning his
care, the nurses realizes that which measures is most important?

A. Instruct the client to empty his bladder and save this voiding to start the urine
collection
B. Instruct the client to use sterile individual containers to collect the urine.
C. Post a sign stating Save All Urine in the bathroom
D. Keep the urine specimen in the refrigerator.
Rationale: Answer C
Option C is the most important nursing measure. This will inform the staff that the client is on a
24 hour urine collection. Option A is not appropriate since the first voided is to be discarded.
Option B is not appropriate nursing measure since the specimen container is clean and not
sterile, and one container is need not individual container.

2. The nurse practitioner requests a laboratory blood test to determine how well a client
has controlled her diabetes during the past 3 months. Which blood tests will provide
this information?

A. Fasting Blood glucose
B. Capillary Blood specimen
C. Glycosylated Hemoglobin
D. GGT (Gamma-glutamyl transferase)
Rationale: Answer C
A Glycosylated Hemoglobiin will indicate the glucose levels for a period of time, which is
indicated by the nurse practitioner. Option A and B will provide information about the current
blood glucose and not the past history. Option D is used to assess liver disease.

MEDICATIONS
1. The client tells the nurse, This pill is a different color than the one that I usually take at
home. Which is the best response by the nurse?

A. Go ahead and take your medicine
B. I will recheck your medication orders
C. Maybe the doctor ordered a different medication
D. Ill leave the pill here while I check with the doctors
RATIONALE: Answer B
IF there is any doubt . the medication process should be interrupted until the question is clarified.
Listen to the client. Find out any other information the client may have about that certain
medication. For example, does he know the dosage of the medication taken at home? Do not
administer the medication (Option A).Inform the client that you will check the medication first.
Review the chart to make sure there is no discrepancy between the physicians order and the MAR.
Review the physicians progress notes because the medication may have been increased or
reduced aspart of the treatment plan (Option C). Check with the pharmacist because sometimes, a
pill may be a different color or shape based on the pharmaceutical company. Do not leave the
medication at bedside. Medications should never be left unattended (Option D). Inform the client
about your findings. The client will appreciate that you took the time to make sure that he received
the correct medication. While it takes time to check out the clients statement, you will be glad that
you avoided a potential medical error.
2. An older client with renal insufficiency is to receive a cardiac medication. Which is the
nurse most likely to administer?

A. A decreased dosage
B. The standard dosage
C. An increased dosage
D. Divided dosages
RATIONALE: Answer A
Due to renal insufficiency, the dose of the medication would need to be decreased in order to avoid
accumulation of the medication and the risk of toxicity.
3. Proper administration of an otic medication to a 2 year old client includes which of the
following?

A. Pull the ear straight back
B. Pull the ear down and back
C. Pull the ear up and back
D. Pull the ear straight forward.
RATIONALE: Answer B
To straighten the ear canal in children less than 3 years of age, the ear must be pulled down and
back. In individual over 3 years of age, the ear is pulled up and back.
SKIN INTEGRITY AND WOUND CARE
1. Your client has a Braden Scale score of 17. Which is the appropriate nursing action?

A. Assess the client again in 24 hours; the scores within normal limits
B. Implements a turning schedule, the client is at increases risk of skin breakdown
C. Apply a transparent wound barrier to major pressure sites; the client is at moderate risk
of skin breakdown
D. Request an order for a special low-air-loss bed; the client is at very high risk of skin
breakdown
RATIONALE: Answer B
A score ranging from 15-18 is considered at risk and turning schedule is appropriate. Option A
requires a score above 18 (normal and ongoing assessment is indicated). Option C, moderate risk,
for which a transparent barrier would be appropriate is applied to persons with 13 to 14. Option
D,very high risk. is assigned for those with a score of 9 or less.
2. Proper technique for performing a wound culture includes which of the following?

A. Cleansing the wound prior to obtaining the specimen.
B. Swabbing for the specimen in the area with the largest collection of drainage
C. Removing crusts or scabs with the sterile forceps and the culturing the site beneath
D. Waiting 8 hours following a dose of antibiotic to obtain the specimen.
RATIONALE: Answer A
Wound culture specimen should be obtained from a cleaned area of the wound. Microbes
responsible for the infection are more likely to be found in viable tissue. Collected drainage contains
old and mixed organism. An appropriate specimen can be obtained without causing the client the
discomfort of debriding. The nurse does not generally debride the wound to obtain the specimen.
Once the systemic antibiotics have begun, the interval following a dose will not significantly affect
the concentration of wound organisms.
3. A client has a pressure ulcer with a shallow, partial skin thickness, eroded area but no
necrotic areas. The nurse would treat the area with which dressing?

A. Alginate
B. Dry Gauze
C. Hydrocolloid
D. No dressing is indicated
RATIONALE: Answer C
Hydrocolloids dressing protects the shallow ulcers and maintain an appropriate healing
environment. Alginates (Option A) are used for wound with significant drainage ; dry gauze (Option
B) will stick to the new granulation tissue, causing more damage. A dressing is needed to protect
the wound and enhance healing.
4. Thirty (30) minutes after applications is initiated, the client requests that the nurse leave
the heating pad in place. The nurse explains to the client that:
A. Heat application for longer than 30 minutes can actually cause the opposite effect
(constriction) of the one desired (dilation)
B. It will be acceptable to leave the pad in place if the temperature is reduced
C. It will be acceptable to leave the pad in place for another 30 minutes if the site appears
satisfactory when assessed.
D. It will be acceptable to leave the pad in place as long as it is moist heat.
RATIONALE: Answer A
The heating pad needs to be removed. After 30 minutes of heating application, the blood vessel in
the area will begin to exhibit the rebound effect resulting in vasoconstriction. Lowering the
temperature, but still delivering hear-dry or moist- will not prevent the rebound effect. The visual
appearance of the site on inspection (option C) does not indicate if rebound is occurring.
5. Which statement, if made by the client or family member would indicate the need for
further teaching?
A. If a skin area gets red but then the red goes away after turning, I should report it to the
nurse
B. Putting foam pads under the heels or other bony areas can help decrease pressure
C. If a person cannot turn himself or herself in bed, someone should help the person
change position every 4 hours.
D. The skin should be washed with only warm water (not hot) and lotion put on while it is
still a little wet.
RATIONALE: Answer C
Immobile and dependent persons should be repositioned at least every 2 hours, not every 4 hours,
so this client or family member requires further teaching. Warm water and moisturizing damp skin
are correct techniques for skin care. Red areas that do not return to normal skin color should be
reported. It would also be correct to use a foam pad to help relieve pressure.

HYGIENE
A client can bathe most of her body except for the back, hands and feet. She also can
walk to and from the bathroom and dress herself when given clothing. Which functional
level describes this client

A. Totally dependent (+4)
B. Moderately dependent (+3)
C. Semi-dependent (+2)
D. Independent (0)
Rationale: Answer C
The client fits the descriptions for semi-dependent functional level
The client is unresponsive and requires total care by nursing staff. Which assessment
does the nurse check first before providing special oral care to the client?
A. Presence of pain
B. Condition of the skin
C. Gag Reflex
D. Range of motion
RATIONALE: Answer C
Thee client will be positioned in a side-lying position with the head of the bed lowered because
the client is at risk for aspiration. The absence of gag reflex lets the nurse know that the client
has no natural defense (cough) and is at higher risk for aspiration. All other answers are
assessments more appropriate prior to bathing the client.
The nurse is discussing foot care with a client who was recently diagnosed with
Diabetes. Which statement by the client indicates a need for further teaching?
A. I am going to use a mirror to check my feet
B. I enjoy walking barefoot around the house
C. I will file my nails
D. I will increase the time that I wear news shoes each day

Rationale: Answer B
The client needs to avoid walking barefoot that could cause injury that may result in an infection.
Also, neurologic impairment is likely as a result of the diabetes, which may result in decreased
sensation. The client would be unaware of an injury.
The client is complaining of shortness of breath. The respirations are 28 and labored.
The bed is currently in the flat position. The nurse puts the bed in which position?
A. Fowlers
B. Semi-fowlers
C. Trendelenburg
D. Reverse Trendelenburg
RATIONALE: Answer A
Fowlers is a semi-sitting position that should ease the clients breathing. The head of the bed
(HOB) in semi-fowlers is lower (Option B). The HOB is lowered in trendelenburg position
(Option C). Although the HOB is raised in revers Trendelenburg position, it is straight tilt and
may not be as comfortable as Fowlers
ACTIVITY AND EXERCISE
1. To increase the stability during the client transfer, the nurse increases the base of
support by performing which action?

A. Leaning slightly backward
B. Spacing the feet farther apart
C. Tensing the abdominal muscle
D. Bending the knees
Rationale: Answer B
A key word in the questions is base, and the feet provide this foundation. Leaning backward
actually decreases balance. (Option A), and tensing the abdominal muscles alone (Option C) or
bending the knees (Option D) does not affect the base of support.
2. Five minutes after the clients first postoperative exercise, the clients vital signs
have not yet returned to baseline. Which is an appropriate nursing diagnosis?

A. Activity Intolerance
B. Risk for Activity Intolerance
C. Impaired Physical Mobility
D. Risk for Disuse Syndrome
Rationale: Answer A
Vital signs that do not return to baseline 5 minutes after exercising indicate intolerance of
exercise at that time. This is a real problem, not at risk for, as in Option B. There is no
evidence that the client requires assistance (Impaire mobility, option C) or is immobile (Disuse
Syndrome Option D)
3. Which statement from a client with one weak leg regarding use of crutches when
using the stairs indicated need for increased teaching?

A. Going up, the strong leg goes first, then the weaker leg with both crutches."
B. Going down, the weaker leg goes first with both crutches, the strong legs
C. The weaker leg always goes first with both crutches
D. A cane or single crutch may be used instead of both crutches if heln on the weaker
side
Rationale: Answer C
Although the crutches (or cane) are always used along with the weaker leg, the
weaker leg should go down the stairs first. The stronger the leg can support the
body as the weaker leg moves forward. All other statements are correct.

4. When assessing a clients gait, which does the nurse look for and encourage?
A. The spine rotates, initiating locomotion
B. Gaze is slightly downward
C. Toes strike the ground before the heel
D. Arm on the same side as the swing-through foot moves forward at the same
time.
Rationale: Answer A
Normal weight gain involves a level gaze, an initial rotation beginning in the spine, heel
strike with follow-through to the toes, and opposite arm and leg swinging forward.
5. The client is ambulating for the first time after surgery. The client tells the nurse, I
feel faint. Which is the best action by the nurse?
A. Find another nurse to help
B. Return the client to the room as quickly as possible
C. Tell the client to take rapid, shallow breaths
D. Assist the client to a nearby-chair.
Rationale: Answer D
Placing the client in a safe position is the best maneuver. Leaving the client Creates unsafe
conditions because the client may faint before being able to return to her room. (Option A
and B). Rapid, shallow breathing (hyperventilation) may increase the dizziness (Option C)
6. The nurse is performing an assessment of an immobilized client. Which assessment
causes the nurse to take action?
A. Heart rate of 96
B. Reddened area on sacrum
C. Non-productive cough
D. Urine output of 50ml/hour
Rationale: Answer B
The reddened area of the skin can lead to skin breakdown. The other options are within the
normal limits.
1. What is the proper technique with gravity tube feeding?
A. Feeding bag is hung 1 foot higher than the tubes insertion points to the client.
B. Nurse administers the next feeding only if there is less than 25 mL of residual
volume from the previous feeding.
C. Place client in left lateral position.
D. Feeding is administered directly from the refrigerator.

Rationale:C. Gastric secretions are acidic as eveidenced by a ph less than 6. If the
tube were improperly placed in the clients airway ,speaking would usually be
impaired.Gagging during insertions is common and does not indicate that the tube is
in the stomach.Ability to easily instill fluid into the tube does not relate to its
placement.


2. An older asian client has mild dysphagia from a recent stroke. The nurse plans the
client meals based on the need to :
A. Have at least one dairy thick serving of pudding
B. Eliminate the beer usually ingested every evening.
C. Include as many of the clients favorite foods as possible.
D. Increase the calories from lipids.

Rationale: C. Always inquire into the clients favorite foods when planning a diet.
Dairy may not be indicated for this client due to lactose intolerance inindividuals
Asian heritage.Beer can be a source of calories and in moderation is not harmful
and may maintain the client satisfaction with the dietary changes. The nurse will
need to assess the ability to swallow beer.


3. Which action represents the appropriate nursing management of a client wearing a
condom catheter?
A. Ensure that the tip of the penis fits snugly against the end of the condom
B. Check the penis for adequate circulation 30 minutes after applying.
C. Change the condom every 8 hours
D. Tape the collecting tube to the lower abdomen.

Rationale: B. the penis and the condom catheter should be checked one half hour
after application to ensure that is not too tight . a 1 inch space should be left
between the penis and the end of the condom . the condom is changed every 24
hours and the tubing is tape to the leg or attached to a leg bag.




4. Which statements indicates a need for further teaching of the home care client with a
long term indwelling catheter?

A. I will keep the collecting bag below the level of the bladder at all times.
B. Intake of cranberry juice may help decrease the risk of infection.
C. Soaking in a warm tub bath may ease the irritation associated with the catheter.
D. I should use clean technique when emptying the collecting bag.
Rationale: C. Soaking in bathtub can increase the risk of exposure to bacteria.the bag
should be below the levelof the bladder to promote the drainage. Intake of cranberry juice
creates an environment nonconducive to infection.Clean technique is appropriate for
touching the exterior portion of the system

5. A client is with acute crushing chest pain that radiates down on his left arm. The nurse
suspects that which blood tests to be ordered for this client?
A. BUN and creatinin
B. Hgt and hgb
C. Troponin and CK
D. Amylase and Lipase

Rationale: C. CK and trop I are enzymes that are released into the blood when there
is a hypoxia and myocardial damage.


6. A client with Chronic pulmonary disease has a bluish tinge around the lips the nurse
charts which terms to most accurately describe the clients condition.
A. Hypoxia
B. Hypoxemia
C. Dyspnea
D. Cyanosis

Rationale: A. A. a bluish tinged to mucous membranes is called cyanosis. This is
most accurate because it is what the nurse observes.

7. The nurse makes the assessment that which client has the greater risk for a problem
with the transport of oxygen from the lungs to the tissues? A client who has :
A. Anemia
B. An infection
C. A fractured rib
D. A tumor of the medulla
Rationale: A. Anemia is a condition in which a decreased red blood cells and hgb.
HGb is how the oxygen molecules are transported to the tissue

8. The nurse is to perform a percussion and postural drainage. Which is an important
aspect of planning the clients care?
A. Percussion and postural drainage should be done before lunch.
B. The order should be coughing, percussion, and positioning and then suctioning
C. A god term to perform percussion and personal drainage is in the morning after
breakfast when the client is well rested.
D. Percussion and postural drainage should always be preceded by 3 minutes of 100%
oxygen.
Rationale: A. Postural drainage results in expectoration of large amount of mucus.
This procedure shoud be done on an empty stomach to decrease client discomfort.

9. The clients ABG result is ph 7.32; paCO2- 58; HCO32; the nurse interprets this as:
A. Metabolic Acidosis
B. Metabolic alkalosis
C. Respiratory acidosis
D. Respiratory alkalosis

Rationale:B.because of CO2 retention the the PaCO2 is elevated.CO2 involved
in the production of acid, which will result in a decreased in ph.HCo3 will vary,
Metabolic acidosis involves a bicarbonate but no retention of CO2 metabolic
alkalosis involves a loss of acid or retention of CO2. Respiratory alkalosis
involves a loss of CO2 resulting in increased pH.
10. An elderly nursing home resident has refused to at or drink for several days and is
admitted to the hospital. The nurse should expect which assessment finding?
A. increase blood pressure
B. weak rapid pulse
C. moist mucus membranes
D. jugular vein distention
Rationale: B. All other option are indicative of fluid volume excess .
11. A client reports to the nurse that she has been taking barbiturate sleeping pills every night
for several months and now wishes to stop taking them. Which statement is the most
appropriate advice for the nurse to provide the client?
A. Take the last pill on a Friday night so disrupted sleep can be compensated on a
weekend.
B. continue to take the pills since sleeping without them after such a long time will be
difficult and perhaps impossible.
C. discontinue taking the pills.
D. continue taking the pills and discuss tapering the dose with the primary provider.
Rationale: Rationale: D. suddenly stopping barbiturate sleeping pills can precipitate a
dangerous withdrawal. Doses should be tapered gradually and the tapering process
supervised by the clients primary care provider.
12. During a Yearly physical, a 52 yr. old male client mentions that his wife frequently
complains about his snoring .During the physical exam, the nurse notes that his neck is 18
inches, his soft palate and uvula are reddened and swollen and he is overweight. What is the
most appropriate nursing intervention for the nurse to recommend to this client?
A. Recommended that he and his wife sleep in a separate bedrooms so that his snoring
does not disturb his wife.
B. Refer him to a dietician for a weight loss program
C. Caution him not to drink or take sleeping pills since they may make his snoring worse.
D. refer him to a sleep disorders center for evaluation and treatment of his symptoms.
Rationale: A. The client symptoms combined with his weight , suggest that he has obstructive
sleep apnea and should be referred to a sleep disorder for further evaluation . It would not be
wrong to refer him to a dietician for weight loss counseling, but being evaluated by a sleep
disorder special it is more critical . drinking alcohol or taking sleep pills is not a advised in the
client with sleep apnea because they reduce client ability to get around.
13. A new nursing graduates first job requires the 12 hour night shefts. which strategy will
make it easier for the graduate to sleep during the day and remain awake at night?
A. Wear dark around sunglasses when driving home in the morning and sleep in darkened
bedroom.
B. exercise on the way home to avoid having to stand around waiting for equipment at the
gym
C. drink several cups of strong coffee or 16 oz. of caffeinated soda when beginning the
shift.
D. try to stay in a brightly lit area when working at night.

Rationale:A. Reducing exposure to bright light in the morning, when driving home and when
going to sleep will make it easier to fall sleep after work. exercising before going to to bed will
increase arousal .(option 2) caffeine consumed at the beginning of 12 hr. shift will not assist
the nurse in remaining awake during the latter part of the shift(Option 3). Although working in a
brightly lit area will reduce the drowsiness






14. During the transduction phase of nociception, which method of pain control is most
affective
A. tricyclic antidepressants
B. Opiods
C. Ibuprofen
D. Distraction
Rationale:C. Rationale: C.During the transduction phase, tissue injury triggers the release of
biochemical mediators such as prostaglandin . Ibuprofen works by blocking the production of
prostaglandin. The coanalgesics meditation in option A, would affect the modulation phase
because coanalgesics inhibit the reuptake of norephinephrine and serotonin, which increases
the modulation phase that helps inhibit the painful .

15. A client who had abdominal surgery 4 hours ago is receiving a continuous epidural epidural
infusion of analgesic ;Which of the following observations indicates the nurse should monitor
the client closely.
A. Drowsy drifts off to sleep before completing a sentence.
B. Respirations= 18 minutes
C. Drowsy, easily aroused
D. Pain Rating 1-2/10

RationaleA; this indicates an increase in level of sedation, which can be an early sign of
impending respiratory depression. Option B is normal, Option C can indicate increasing
sedation; however , Option A describes a high level of sedation and intervention such as
notifying the primary care provider. Option D indicates pain management that maybe tolerable
for the client.