Fundamentals Exam Practice Questions
Which Braden Scale score range would alert the nurse that a patient is at moderate risk for pressure injury development? Record your answer as whole numbers separated by a hyphen. ______
13-14
Match the unexpected skin assessment finding to its description. A. Blue skin B. Pinpoint, flat, red spots C. Red skin D. Bruise
A. Cyanosis B. Petechiae C. Erythema D. Ecchymosis
Match the wound bed condition to its cues. A. Pale, soft, wrinkled B. Beefy red, shiny, moist C. Black, hard, dry D. Purulent yellow
A. Macerated B. Granulated C. Necrotic D. Infected
Place the patients in the order in which the nurse would prioritize their care from highest priority to lowest priority. A. Patient who is experiencing shock from a profusely bleeding wound B. Patient who just had an incision eviscerate C. Patient with a stage 4 pressure injury
A. Patient who is experiencing shock from a profusely bleeding wound B. Patient who just has an incision eviscerate C. Patient with a stage 4 pressure injury
Match the type of wound drainage to the color of fluid the nurse would observe on a patient's dressing. A. Clear and watery B. Pink to pale red C. Bright red D. Greenish, yellow
A. Serous B. Serosanguineous C. Sanguineous D. Purulent
Place the anatomic structures in the order through which urine passes as it moves from the kidneys to the exterior of the body. A. Renal pelvis B. External urethral sphincter C. Urinary meatus D. Bladder E. Internal urethral sphincter F. Ureter
A.Renal pelvis F.Ureter D.Bladder E. Internal urethral sphincter B. External urethral sphincter C. Urinary meatus
Lists steps of normal micturition in the correct order. A. The bladder muscle contracts and the urethral sphincters relax B. Nerve endings in the bladder are stimulated by distention C. The brain registers a message of urgency D. Urine flows out of the body through the urinary meatus
B.Nerve endings in the bladder are stimulated by distention C.The brain registers a message of urgency A.The bladder muscle contracts and the urethral sphincters relax D. Urine flows out of the body through the urinary meatus
In which ways does pregnancy alter urinary elimination? A. Bladder compression B. Increased urine output C. Increased urinary frequency D. Constriction of ureteral sphincters E. Decreased urinary frequency
a, b, c
Which primary areas, if injured in the patient, would prompt the nurse to develop the hypothesis Impaired Tissue Integrity? A. Bone B. Tendon C. Muscle D. Dermis E. Epidermis
a, b, c
Which primary parameters are measured when using the Norton Scale? A. Activity B. Mobility C. Mental state D. Friction and shear E. Sensory perception
a, b, c
Which steps would the nurse take to measure the dimensions of a sacral pressure injury? A. Measure the depth by inserting the end of a sterile cotton-tipped applicator into the deepest portion of the wound B. Measure the width laterally from left to right at the widest portion of the wound C. Measure the depth of the undermining by laterally inserting a sterile cotton-tipped applicator into the widest section of the undermining. D. Measure the length vertically from the top to the bottom at the widest open area of the wound E. Measure the width laterally by using a clean cotton-tipped applicator at the largest portion of the wound from left to right
a, b, c, d
Which parameters would the nurse assess when performing a focused wound assessment? A. Location B. Drainage C. Wound bed D. Level of pain tolerance E. Presence of tunneling
a, b, c, e
Which cues related to skin integrity may reflect an overall health problem? A. Cracking B. Tenting C. Warm skin temperature D. Pathogens identified in a would culture E. Immunocompetence
a, b, d
Which cues would the nurse observe for a patient with an infected lateral malleolus wound? A. Erythema noted on the superior portion of the wound B. Purulent, malodorous drainage C. 1.5-cm wound with serous drainage and tissue epithelialization D. Temperature of 102 F (38.9 C) E. Pain level of 2/10
a, b, d
Which factors may impact the development of pressure injuries or nonhealing wounds? A. Smoking B. Diabetes C. Specific gender D. Urinary incontinence E. Skin tone
a, b, d
Which multidisciplinary team members would the nurse consult for a thin, homeless patient who has a Stage 2 pressure injury on the sacrum? A. Wound, ostomy, and continence nurse (WOCN) B. Social worker C. Surgeon D. Nutritionist E. X-ray technician
a, b, d
Which patient cues, when analyzed together, would prompt the nurse to select the hypothesis Impaired Skin Integrity? A. Low prealbumin levels B. Immobility C. Inexperience with wound care D. Stage 2 pressure injury E. Stage 4 pressure injury
a, b, d
For which patient hypotheses would the nurse select turning and positioning as a solution? A. Impaired Skin Integrity B. Risk for Pressure Ulcer/Injury C. Malignant Wound D. Impaired Tissue Integrity E. Risk for Impaired Skin Integrity
a, b, d, e
Which categories can the nurse use to organize and link the patient's skin integrity cues? A. Type of wound B. Type of wound bed tissue C. Type of infection D. Unexpected assessment findings E. Unexpected laboratory findings
a, b, d, e
Which components to promote skin integrity and wound healing would the nurse include when caring for a patient with a leg wound who will be discharged in several days? A. Therapies consistent with guidelines for treatment of wounds B. Recommendations from collaborating health care professionals, such as a wound, ostomy, and continence nurse (WOCN) C. Ability of the patient to maintain a pain rating of 8/10 during activities of daily living D. Agreement of the patient with the treatment plan E. Capability of the patient to purchase supplies for home care as required
a, b, d, e
Which factors can make a patient prone to pressure injuries? A. Inactivity B. Immobility C. Young age D. Incontinence E. Malnourishment
a, b, d, e
Which factors can place a patient at risk for a pale, dry wound? A. Anemia B. Diabetes C. Wound infection D. Vascular disease E. Nutritional deficiencies
a, b, d, e
Which steps are involved in measuring wound undermining? A. Administer pain medication B. Laterally insert the cotton-tipped applicator into the widest section C. Measure any changes in the surrounding skin that may indicate infection D. Mark the area on the stick end of the applicator that is even with the edges of the skin E. Measure the distance from the top of the applicator to the marked area
a, b, d, e
The nurse recognizes which findings as normal in a urine specimen from a healthy adult? A. Creatinine B. Electrolytes C. Bacteria D. Ammonia E. Parasites F. Urea
a, b, d, f
Which patient situations are of immediate concern? A. A patient is experiencing shock B. A patient is profusely bleeding from a wound C. A patient has an infected wound D. A patient has an eviscerated wound E. A patient has a stage 4 pressure injury
a, b,d
A patient newly diagnosed with kidney disease is learning about basic kidney functions during a patient education session. Which statements would the nurse include? A. The kidneys regulate electrolytes and fluid in the blood B. Kidney function does not affect blood pressure C. The kidneys helps maintain the body's red blood cell count D. The kidneys help regulate blood pH E. The kidneys synthesize the active form of vitamin K
a, c, d
Which alterations in urinary function are typical with certain surgical and diagnostic procedures? A. Temporary urine retention with anesthesia B. Temporary urine incontinence with anesthesia C. Changes in urine color with procedures causing bleeding D. Increased urine concentration and decreased volume after procedures that include intravenous fluids E. Urinary retention with procedures causing urethral swelling
a, c, e
Which tasks related to skin integrity and wound care would the nurse likely delegate to an unlicensed assistive personnel (UAP) who is caring for a patient with a wound? A. Repositioning the patient B. Administering medication for wound pain C. Assessing and evaluating a patient's skin and wounds D. Reporting any changes in patient's skin integrity or condition E. Applying a nonsterile dressing for chronic wounds with an established treatment plan
a, d, e
Which components are likely damaged when the nurse chooses the hypothesis Impaired Skin Integrity for a patient? A. Dermis B. Bone C. Muscle D. Tendon E. Epidermis F. Subcutaneous tissue
a, e
=Which interpretation would the nurse make about a patient's wound culture that is positive? A. It is infected B. It is hemorrhaging C. It is eviscerated D. It is nonhealing
a.
In which way do changes in fluid intake affect urinary elimination? A. Increased fluid intake results in increased urine output B. Decreased fluid intake results in less concentrated urine C. Increased fluid intake results in more concentrated urine D. Increased fluid intake results in decreases urine output
a.
The nurse would use which organization's guidelines to direct care for a patient's back wound? A. Agency for Healthcare Research and Quality (AHRQ) B. National Council of State Boards of Nursing (NCSBN) C. International Confederation of Dietetic Associations (ICDA) D. The Joint Commission (TJC)
a.
Which cue about a wound is an immediate concern? A. Excessive bleeding B. Staples in place C. Packing in a wound D. Infected wound
a.
Which finding is expected in a physical skin assessment? A. Elastic skin turgor B. Nonintact skin C. Stage 1 pressure injury D. Cool, dry skin
a.
Which hypothesis would the nurse develop for an immobile patient who has intact skin? A. Risk for Impaired Skin Integrity B. Traumatic Wound C. Risk for Impaired Tissue Integrity D. Pressure Ulcer/Injury
a.
Which hypothesis would the nurse select for a patient with a breakdown in the dermis from external forces? A. Impaired Skin Integrity B. Risk for Impaired Skin Integrity C. Impaired Tissue Integrity D. Burn Wound
a.
Which patient is likely at risk for developing a pressure injury? A. Patient with unrelieved pressure who has a fractured hip B. Patient with a history of sports-related injuries and concussions C. Left-handed patient with a broken left wrist D. Paralyzed patient who is being turned and repositioned every 2 hours
a.
Which patient would the nurse see first after receiving report? A. A patient with a profusely bleeding wound B. A patient with a wound dehiscence C. A patient with an early wound infection D. A patient experiencing a wound from a surgical incision
a.
Which process is directly affected by nephron damage? A. Regulation of blood components B. Voluntary control of bladder emptying C. Internal urethral sphincter relaxation D. Neurologic awareness of bladder fullness
a.
Which term would the nurse use to describe excessive moisture on the pateint's skin? A. Diaphoresis B. Ashen C. Purpura D. Icterus
a.
Which SMART outcomes would the nurse develop for the patient who is recovering from a small abdominal incision with a hypothesis of Surgical Wound? A. Patient will be infection-free B. Patient will eat a high-protein diet at every meal C. Patient will help with transfers within 24 hours D. Patient's wound will heal normally E. Patient's incision will have proper healing
b, c
Which cues are relevant for an infected wound? A. Decreased white blood cell count B. Positive culture growth C. Purulent drainage D. Induration around edges E. Granulated wound bed
b, c, d
Which obesity factors contribute to a nonhealing wound? A. Excess of needed nutrients B. Lack of blood vessels in adipose tissue C. Undue pressure on wound edges D. Presence of a pale wound bed E. Decreased oxygen and nutrients to the wound
b, c, e
Which statements by the nurse caring for a postoperative patient who suffered a spinal cord injury indicate correct understanding about assessment tools? A. "I can use the Braden Scale to asses for the risk for infection." B. "The Norton Scale is used to asses my patient's surgical incision." C. "I can use the Braden Scale to assess my patient's surgical incision." D. "When assessing for open wounds, I can use the Wound Characteristic Instrument." E. "The Pressure Ulcer Scale for Healing tool is used to track wound healing."
b, d
Urinary continence depends on adequate muscle tone of which structures? A. Abdominal wall B. Bladder C. Vaginal wall D. Urethral sphincters E. Pelvic floor
b, d, e
The nurse is caring for a patient who has developed urinary retention. While reviewing the patient's medications, the nurse recognizes which medication type as known to contribute to the risk of developing urinary retention? A. Drugs that act on kidneys to increase urine formation an excretion B. Drugs that act on the autonomic nervous system C. Drugs that act on the heart to strengthen muscle contraction D. Supplements with diuretic effects
b.
The nurse is planning a short presentation for unit nurses that will include cultural aspects of urinary elimination. Which information would the nurse include? A. Urination is generally considered a public matter to people in American culture. Privacy during toileting varies culturally B. Culture influences the decision to seek help for problems with urinary elimination C. Most cultures are accepting of nursing care delivered by a nurse of either sex. D. Cultural background generally is not a priority issue in hospitalized patients
b.
Which nursing-derived outcome relates directly to a patient who has a break in the skin from an external force, such as trauma or an accident? A. Patient's pressure injury will decrease at least 1 to 2 cm in size per week B. Patient's wound will exhibit granulation tissue in the wound by 1 week C. Patient will demonstrate wound care after receiving teaching D. Patient will have intact skin throughout hospital stay
b.
Which reasoning explains why a nurse measures wound size during an intial wound assessment? A. To determine the proper medication amount for the wound B. To help assess progression of wound healing C. To provide evidence for the presence of infection D. TO reassure patients they are receiving proper care
b.
Enlargement of the prostate may directly affect which structure in the male urinary system? A. Kidney B. Ureter C. Urethra D. Urinary meatus
c.
Which overall goal would the nurse develop for a patient with a leg incision? A. Encourage participation in position changes within 48 hours B. Reduce pain level to a 5/10 after treatment C. Promote complete healing of wound D. Enhance generation of solutions
c.
Which question would the nurse ask to determine the patient's health history about skin integrity? A. Does your skin pain feel sharp, achy, or dull? B. When did you notice the lesion on your skin? C. Has anyone in your family had a skin disorder? D. Can a family member help you care for the lesion?
c.
Which type of fluid would the nurse likely observe if the patient was hemorrhaging? A. Serous B. Serosanguineous C. Sanguineous D. Purulent
c.
Which assessment technique indicates the nurse properly determined if the patient's incision is healing or is becoming infected? A. Asking the patient health history questions B. Charting the incision line's color and tenderness C. Removing all sutures and/or staples around the wound Palpating the area of induration around the incision line
d.
Which cue is relevant for a patient who has a wound? A. Living in a northern state B. Having a high creatinine level C. Being male D. Having a low prealbumin level
d.
Which expected outcome would the nurse select for a patient who has a hypothesis of Pressure Ulcer/Injury? A. Patient will demonstrate wound care after receiving teaching B. Patient will have intact skin throughout hospital stay C. Patient's diet will be low in protein for each meal D. Patient's Braden Scale score will stay the same or increase within 72 hours
d.
Which outcome is appropriate for the patient recovering from abdominal surgery who reports not wanting to look at the incision and not wanting to eat? A. Ingest 25% of each meal during hospitalization B. Report that pain management regimen lowers pain level to 6/10 or lower within the shift C. Show acceptance of the change in body image by continuing to have the nurse change the dressing after 1 week D. Exhibit signs of healing as evidenced by presence of granulation tissue in the wound within 1 week
d.
Which patient statement alerts the nurse that teaching was successful about the goals of treatment for a healing arm wound? A. "My participation is not needed for position changes" B. "I will be infection-free by the time I go home" C. "I will need to meet with the mental health professional before discharge" D. "My wound will look beefy red within 1 week"
d.
Which structure is located at the junction of the neck of the urinary bladder and the urethra? A. External urethral sphincter B. Urinary meatus C. Ureter D. Internal urethral sphincter
d.