FUNDAMENTALS OF NURSING

SYNERGY REVIEW AND TRAINING CENTER

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A client comes to the walk-in clinic with complaints of abdominal

pain and diarrhea. The nurse takes the clients vital signs. The
nurse is implementing which phase of the nursing process?
a. assessment
b. planning
c. diagnosis
d. d. implementation
The nurse is measuring the clients urine output and straining
the urine to assess for stones. Which of the following should the
nurse record as objective data?
a. The client is complaining of abdominal pain
b. The clients urine output was 450 mL
c. the client stated, I didnt see any stones in my urine.
d. The client stated, I feel like I have passed a stone.
Which of the following demonstrates that the nurse is
participating in critical thinking?
a. The nurse admits he/she does not know how to do a
procedure and requests help.
b. The nurse makes his/her point with clever and persuasive
remarks to win an argument
c. The nurse accepts without question the values acquired in
nursing school
d. The nurse finds a quick and logical answer, even to complex
question
The nurse documents the following outcome goal on the care
plan: Anxiety will be relived within 20 to 40 minutes following
administration of lorazepam(Ativan). The nurse has just
performed an activity in which of the following phases of the
nursing process?
a. Assessment
c. Implementation
b. Planning
d. Evaluation
The nurse reassess a clients anxiety level 30 minutes after
administering lorazepam (Ativan). This is an example of which
type of evaluation?
a. ongoing
c terminal
b. intermittent
d. routine
The nurse documents the nursing diagnostic statement Risk
for impaired skin integrity related to malnutrition on the care
plan. What is the risk factor?
a. Immobility
c. Malnutrition
b. Impaired Skin Integrity
d. Alteration in nutrition
Which activity would be appropriate to delegate to an
unlicensed nursing assistant?
a. Taking vital signs of client of nursing unit
b. Assisting the physician with an invasive procedure
c. Adjusting the arte on an infusion pump
d. Evaluating client outcome goals.
In giving a change of-shift report, which type of client
information given by the nurse is most informative and
complete?
a. Vital signs
b. Client is pleasant, alert, and oriented x3
c. The chest x-ray results were negative
d. Client voided 250 mL of urine 2 hours after urinary catheter
was removed
Twenty minutes after administering a pain medication to the
client, the nurse returns to ask if the clients level of pain has

decreased. The nurse is engaging in which phase of the

nursing process?
a. Diagnosing
c. Implementing
b. Planning
d. Evaluating
10. Before palpating the abdomen during an assessment, the nurse
should do which of the following?
a. Put on sterile gloves
b. Auscultate bowel sounds
c. Elevate the cleints head
d. Percuss all four quadrants
Situation 1. When positioning clients in bed, the nurse can do a
number of things to ensure proper alignment and promote client
comfort and safety. (For Items No. 11 15)
11. When Glenda, age 25, is in the right side-lying position after the
insertion of a left hip prosthesis, Nurse Catherine ensures that
the patient has an abduction pillow placed between the thighs
and that the entire length of the upper leg is supported. The
most important reason for this is to prevent:
A. Strain on the operative site
B. Flexion contractures of the hip joint
C. Thrombus formation in the leg
D. Skin surfaces from rubbing together
12. The position that is indicated for Albert, age 219, after surgery
for a perforated appendix with localized peritonitis is the:
A. Sims' position
B. Semi-Fowler's position
C. Trendelenburg position
D. Dorsal recumbent position
13. After surgery on the neck, Josie, age 28, should be placed in a
high-Fowler's position to:
A. Avoid strain on the incision
B. Provide stimulation for the patient
C. Promote drainage of the wound
D. Reduce edema at the operative site
14. After a total hip replacement surgery, Nurse Cattherine should
avoid placing Junnie, age 25, in the:
A. Supine position
B. Orthopneic position
C. Lateral position
D. Semi-Fowler's position
15. Mary, age 30, is to have gastric gavage. When the gavage tube
is being inserted, Nurse Catherine should place the patient in
the:
A. Supine position
B. High-Fowler's position
C. Mid-Fowler's position
D. Trendelenburg position
Situation 2. Nurse Joseph is assigned to a group of clients with
chest tubes. (For Items No. 16 20)
16. The physician inserts a chest tube to Macial, a 24-year-old
patient who has been stabbed in the chest, and attaches it to a
closed-drainage system. When caring for the patient, Nurse
Joseph should:
A. Apply a thoracic binder to prevent tension on the tube

SYNERGY REVIEW & TRAINING CENTER

B. Observe for fluid fluctuations in the water seal chamber

C. Clamp the tubing securely to prevent a rapid decline in
pressure
D. Administer morphine sulfate, because the patient will be
agitated
17. Jason, age 27, has a chest tube to a Pleur-evac drainage
system attached to wall suction. An order to ambulate the
patient has been received. To ambulate the patient safely,
Nurse Joseph should:
A. Clamp the chest tube and carefully ambulate the patient
a short distance
B. Question the order to ambulate the patient
C. Carefully ambulate the patient, keeping the Pleur-evac
lower than the patient's chest
D. Disconnect the Pleur-evac from the patient's chest
tube, leave it attached to the bed, ambulate the
patient, and then reconnect the chest tube when he is
returned to bed
18. Carlos, a 30-year-old client with a spontaneous pneumothorax,
has had a chest tube for 3 days. On morning rounds, the
physician clamped the chest tube to determine the patient's
readiness to have the chest tube discontinued. Two hours after
having the chest tube clamped, the patient began to have
difficulty breathing. What action should Nurse Joseph take first?
A. Notify the physician
B. Unclamp the chest tube
C. Assess the patient for subcutaneous emphysema
D. Place the patient on 2L nasal cannula oxygen
19. Jehan, a 29-year-old client who has had thoracic surgery, is
admitted to the postanesthesia care unit. After the chest
catheters are attached to a closed drainage system, Nurse
Joseph should:
A. Check that the fluid in the water seal compartment rises
with expiration
B. Ensure the security of the connections from the patient
to the drainage unit
C. Ensure that there is vigorous bubbling in the wet suction
control compartment
D. Empty the drainage container, measure and record the
amount, and send a sample for analysis every 24
hours
20. You noted from the lab exams in the chart of a 29-year-old
patient that he has reduced oxygen in the blood. This condition
is called:
a. Cyanosis
c. Hypoxemia
b. Hypoxia
d. Anemia
21. An adult woman is admitted with metabolic acidosis. Which set
of arterial blood gases should the nurse expect to find in a client
with metabolic acidosis?
a. pH - 7.30; PCO2 - 36; HCO3 - 18
b. pH - 7.28; PCO2 - 55; HCO3 - 26
c. pH - 7.50; PCO2 - 40; HCO3 - 31
d. pH - 7.48; PCO2 - 30; HCO3 - 22
22. A patient's blood gases reflect diabetic acidosis. The nurse
should expect:
a. Increased pH
c. Increased PCO2
b. Decreased PO2
d. Decreased HCO3
23. The nursing process can be defined as the:
a.Implementation of client care by the nurse

b.Activities a nurse employs to identify a client's problem

c.Steps the nurse employs to meet client needs
d.Process the nurse uses to determine nursing goals for the
client
24. When evaluating a patient's status after a head injury by using
the Glasgow Coma Scale, the nurse should know that the most
serious response to pressure applied to the nail beds would be:
a. Flexing
c. Extending
b. Localizing
d. Withdrawing
25. Post IVP, a patient should excrete the contrast medium. The
nurse should instruct the family to include more vegetables in
the diet and:
a. Increase fluid intake
b. Cleansing enema
c. Gastric lavage
d. Barium enema
26. When assessing a client with cancer of the tongue, the specific
adaptation the nurse should expect to find is:
a. Halitosis
c. Bleeding gums
b. Leukoplakia
d. Substernal pain
27. When assessing a client with portal hypertension, the nurse
should be alert for indications of:
a. Liver abscess
b. Hemorrhage from esophageal varices
c. Intestinal obstruction
d. Perforation of the duodenum
28. The nurse should assess a client with liver cirrhosis and hepatic
coma for:
a. Jaundice
c. Uremic frost
b. Urticaria
d. Hemangioma
29. Signs and symptoms that the nurse should expect when
assessing a client with colitis include:
a. Hemoptysis
c. Polycythemia
b. Weight loss
d. Decreased WBCs
31. Essential hypertension ( n0 cause could be found) would be
diagnosed in a 40 yr. old man whose BP readings were
consistently at or above which of the following?
a. 120/90 mm Hg.
C. 130/85 m Hg
b. 140/90 mm Hg
d. 160/80 mm Hg
32. The primary purpose of the Schilling test is to measure the
clients ability to:
a. store Vitamin B 12 c. absorb vitamin B 12
b. digest Vitamin B 12 d. produce Vit. B 12
33. The nurse is aware that she should implement which of the
following actions for the client who is starting a Schillings test?
a. administering methylcellulose (Citrucel)-(x) (interferes with
absorption of Vit. B 12)
b. starting a 24 to 48 hour urine specimen
collection
c. Maintaining NPO status (Not maintain; NPO 8 to 12 hrs
before the test, not during the test)
d. starting a 72 hour stool specimen collection
(x) (Not a part of the test)
34. The nurse caring for a client ordered for transfusion of platelet is
aware that platelets should not be administered under which of
the following conditions? The platelet:
a. bag is cold -(-)
b. are 2 days old (+)
c. bag is at room temperature (+)
d. are 12 hrs old (+)

SYNERGY REVIEW & TRAINING CENTER

35. The nurse is preparing to administer platelets. The nurse

should:
a. check the ABO compatibility (not
necessary)
b. administer the platelet slowly(as fast as can be)
c. gently rotate the bag ( to prevent clumping)
d. use whole blood tubing set-(platelet
tubing)
36. Nurse Evelyn is caring for a client scheduled for elective
splenectomy after failure to respond to conservative treatment
for chronic immune thrombocytopenia purpura. She is aware
that before the client goes to surgery, she should assess the
clients:
a. empty bladder
(before receiving preop meds)
b. vital signs ( the final check to be completed before leaving
the room)
c. signed consent (before transport time)
d. name band (as soon as client arrives in the preoperative
setting)
37. Dona, an elderly neutropenic ((marked decreased in neutrophils
= circulating WBC essential for phagocytosis and proteolysis =
in the blood) client is admitted to the hospital and asks you why
she is in reverse isolation. The nurses best explanation for
why is placed in reverse isolation is that, reverse isolation
helps prevents the spread of organisms:
a. to the client from sources outside the clients environment
(opposite of B.)
b. from the client (x) to the client from outside source) to
health care personnel, visitors and other clients (opposite
of A)
c. by using special techniques to dispose of contaminated
materials (same as D)
d. by using special techniques to handle the clients linens
and personal items. (same as C)
38. The nurse is suctioning an adult client who had a laryngectomy.
What is the maximum amount of time the nurse should suction the
client?
a. 10 seconds
c. 25 seconds
b. 15 seconds
d. 30 seconds
39. A nurse is caring for Mang Lando with tracheostomy tube in
place. When suctioning a tracheostomy or laryngectomy tube,
the nurse is aware that she should follow which of the following
procedures?
a. use a sterile catheter each time the client is suctioned
b. cleanse the catheter in sterile water after each use and
reuse for no longer than 8 hours.
c. protect the catheter in sterile packaging between
suctioning episodes (means reuse)
d. use a clean catheter with each suctioning, and disinfect it
in hydrogen peroxide between uses.
40. Mr. B, an adult client is admitted to the hospital with pneumonia
and has a temperature of 39.4C, is diaphoretic and has a
productive cough. Which of the following measures should the
nurse included in his plan of care?
a. change position q 4 hours (q 2H)
b. nasotracheal suctioning to clear secretions (NI) has
productive cough)
c. change linens frequently (client must be dry to promote
comfort)

d. offer bed pan frequently (NI)

41. The nurse cares for a patient receiving tube feeding. The nurse
knows that the most common complication of a tube feeding is:
a. Edema
c. Diarrhea
b. Hypokalemia
d. Vomiting
42. Prior to taking the health history the nurse should first do which
of the following?
a.Establish a rapport with the patient
b.Offer the patient a beverage of choice
c.Establish that insurance coverage exists
d.Ask the patient to disrobe and put on a gown
43. A patient was to receive an antibiotic intramuscularly. Which of
the following factors might influence the nurse's decision on the
route of administration?
a. Presence of kidney disorder
b. Condition of the muscle tissue
c. Permeability of the skin surface
d. Patient's age and level of alertness
44. For early detection of the patient's problem, the physician
ordered EEG (electroencephalogram). This is:
a. Reading of the electrical activity of the dura matter of the
brain
b. Reading of the electrical activity of the grey matter of the
brain
c. Reading of the electrical activity of the heart
d. Reading of the electrical muscle of the brain
45. The nurse physical preparation for this diagnostic procedure to the
patient must include:
a. A clean body
b. A clean hair
c. A good shampoo
d. An excellent bed bath
46. Which of these must be avoided from 24 to 48 hours prior to EEG?
a. Stimulants and anti-convulsants
b. Tranquilizers and stimulants
c. Anti-convulsants and analgesics
d. Anti-pyretics and stimulants
47. If desired, which of these foods may be allowed for the patient to take
few hours before her EEG?
a. Ice Cream
c. Cola
b. Coffee
d. Tea
48. Post total hip replacement, the patient should be reminded to avoid:
a. Sitting at the bedside
b. Crossing the legs
c. Deep breathing
d. Lying on the back
49. The nurse is caring for a patient 5 hours after a pancreatectomy for
cancer of the pancreas. On assessment, the nurse notes that there is
minimal drainage from the nasogastric tube. It is most important for the
nurse to take which of the following actions?
a. Check the tubing for kinks
b. Notify the physician
c. Monitor Vital signs every 15 minutes
d. Replace the NG tube
50. The advantages of oral care for a patient include all of the following,
except:
a. Improves appetite and taste of food
b. Reduces need to use commercial mouthwash which irritate the
buccal mucosa
c. Improves patients appearance and self-confidence
d. Decreases bacteria in the mouth and teeth

SYNERGY REVIEW & TRAINING CENTER