FUNDAMENTALS OF NURSING EXAM QUESTIONS

A nurse has had the opportunity to share personal prescriptions with family members when they were in need of pain medication or antibiotics. Which set of rules would govern this moral decision?

Ethics

The nurse assesses urine output following administration of a diuretic. Which step of the nursing process does this nursing action reflect?

Evaluation

A nurse is caring for a client who is visually impaired. Which of the following is a recommended guideline for communication with this client?

Explain reason for touching client before doing so

An obstetrics nurse is preparing to help a client up from her bed and to the bathroom 3 hours after the woman gave birth. Which action should the nurse perform first?

Explain to the patient how the nurse will assist her

A nurse is delegating the collection of urinary output to an unlicensed assistive personnel (UAP). What should the nurse tell the UAP to do while measuring the urine?

wear gloves when handling a patients urine

A client who was previously awake and alert suddenly becomes unconscious. The nursing plan of care includes an order to increase oral intake. Why would the nurse review the plan of care?

to be sure interventions are individualized

The husband of a client who died of breast cancer is still grieving for his wife 2 years later. What type of grief is he experiencing?

unresolved

A client tells the nurse, "Every time I sneeze I wet my pants". What is this type of involuntary escape of urine called?

urinary incontinence

A nurse is conducting an interview for a health history. In addition to asking the client about medications being taken, what else should be asked to assess the risk for drug interaction?

use of herbal supplements

The nurse is caring for a client who speaks Chinese. An appropriate approach for communication with this client includes:

using a caring voice and repeating messages frequently

What independent nursing intervention can be implemented to stimulate appetite?

Encourage or provide oral care

The nurse maintains a journal in which she reflects on her clinical practice. Which entry is an example of reflection for action?

Next time I will assess the client before obtaining the medication

Why is it important for the nurse to teach and role model proper body mechanics?

To promote health and prevent illness

A nurse is educating a preoperative client on how to cough effectively. What can the nurse tell the client to do to facilitate coughing?

"Hold a pillow or folded bath blanket over the incision."

A nurse is teaching an older adult at home about taking newly prescribed medications. Which information would be included?

"I have written the names of your drugs with times to take them.

A client tells the nurse, 'I'm an atheist, I do not believe in God." What should be an appropriate response by the nurse?

"I respect what you choose to believe in."

Which of the following provides the nurse with the most reliable basis on which to choose a nursing diagnosis?

A cluster of several significant cues of data that suggest a particular health problem

A staff nurse asks a student, "Why in the world are you studying nursing theory?" How would the student best respond?

"It helps explain how nursing is different from medicine."

A physician has ordered peak and trough levels of medication. When would the nurse schedule the trough level specimen?

30 minutes before the next dose

Which client will have an increased metabolic rate and require nutritional interventions?

A person with a serious infection and fever

Which of the following best describes stress?

A response to changes in the normal balanced state

Which of the following is the most frequent reason for revocation or suspension of a nurse's license?

Alcohol or drug abuse

A nurse is caring for a client who is 2 days postoperative after abdominal surgery. What nursing intervention would be important to promote wound healing at this time?

Assist in moving to prevent strain on the suture line

A nurse is discharging a client from the hospital. When should discharge planning be initiated?

At the time of admission to an acute health care setting

A student is reviewing a client's chart before giving care. She notes that following diagnoses in the contents of the chart: "appendicitis" and "acute pain". Which of the diagnoses is a medical diagnosis?

Appendicitis

A nurse has drafted an SBAR communication before contacting the primary care provider of a client whose condition has worsened suddenly. How should the nurse best conclude this communication?

Ask the care provider to come and assess the client.

A client refuses to have pain medication administered by injection. The nurse states, "if you don't let me give you the shot, I will get help to hold you down and give it". What crime may the nurse be committing?

Assault

Which guideline should a nursing instructor provide to nursing students who are now responsible for assessing their clients?

Assessment data about the client should be collected continuously

After surgery, a postoperative client has not voided for 8 hours. Where should the nurse assess the bladder for distention?

Between the symphysis pubis and the umbilicus

Which of the following health care practices may be influenced by a young woman's religion?

Birth-control measures

A dietitian is providing an in-service for the nurses on a medical-surgical unit. During the in-service, the dietitian informs the group that there are six classes of nutrients, and three supply the body with energy. What are the three sources of energy?

Carbohydrates, protein, and lipids

Which method of documenting client data is least likely tp hold up in court if a case of negligence is brought against a nurse?

Charting by exception

What is the primary focus of communication during the nurse-client relationship?

Client and client needs

A nurse organizes client data using the SOAP format. Which information would be recorded under "S" of this acronym?

Client complaints of pain

A hospital utilizes the SOAP method of charting. Within this model, which of the nurse's statements would appear at the beginning of a charting entry?

Client reporting that her abdominal pain rated at 8/10

A nurse is evaluating an established plan of care. After identifying the evaluative criteria and standards (expected patient outcomes), what must the nurse do next?

Collect data about patient responses

A student nurse is working in the library on her plan of care for a clinical assignment. The client's name is written at the top of her plan. Which ethical responsibility is the student violating?

Confidentiality

While reviewing an adult client's chart, a nurse notes average daily intake of fluids as 2,000 mL/day. What will the nurse do based on this information?

Continue with care; this is a normal fluid intake.

A nurse is manually documenting information related to a client's condition. When documenting this information, the nurse makes an error on the manual record sheet. What is the best technique for recording an error made in documentation?

Cross out the incorrect statement with a single line

A lawsuit has been brought against a nurse for malpractice. The client fell and suffered a skull fracture, resulting in a longer hospital stay and need for rehabilitation. What does the description of the client and his injuries represent as proof of malpractice?

Damages

A nurse is caring for older adult clients in an assisted-living facility. Which effect of aging should the nurse consider when performing a urinary assessment?

Decreased bladder contractility may lead to urine retention and stasis, which increase the likelihood of urinary tract infection

A woman age 83 years who has suffered a cerebrovascular accident and is unable to swallow refuses the insertion of a feeding tube. That is an example of what ethical principle?

Demonstration of autonomy

A 22-year-old college student recently engaged in sexual intercourse with a new partner. When a nurse tells her that she is pregnant, she tells the nurse "that's not possible, I got my period last week". This is an example of what defense mechanism?

Denial

A nurse is conducting an interview with a patient to collect a medication history. Which of the following questions would be used to ensure safe medication administration?

Do you have any allergies to medication

Legally speaking, how would the nurse ensure that care was not negligent?

Documenting the nursing actions in the client's record

A middle aged client is reporting acute joint pain to a nurse who is assessing the client's pain in a clinic. Which question related to pain assessment should the nurse ask the client?

Does your pain level change after taking medications?

The nurse is preparing to administer a medication via a nasogastric tube. Which guideline is appropriate for the nurse to follow when administering a drug via this route?

Flush the tube with water between each drug administered.

A dying client tells the nurse that he doesn't want to see his family because he doesn't want to cause them more sadness. Which action by the nurse is most appropriate?

Help the patient clarify his values

Based on an established plan of care, a nurse turns a client every 2 hours. What part of the nursing process is the nurse using?

Implementing

Of all the benefits of using nursing diagnoses, which one is probably the most important to nurses?

Improving communication among nurses

A nurse administers a medication for pain but forgets to document it in the client's health care record. Legally, what does this mean?

In the eyes of the law, if it is not documented, it was not done

A client tells a nurse that he does not think he can have the recommended heart surgery because transfusions are against his religion. What is the best response of the nurse in this situation?

Obtain all the information needed for the client to make an informed decision

Nurses provide care to meet needs in all the human dimensions. What is one intervention nurses can implement to meet spiritual needs?

Offer a compassionate presence

Which client would be most likely to have decreased anxiety about, and response to, pain as a result of past experiences?

One who had pain but got adequate relief

The nurse is preparing to move a client from bed into a wheelchair to eat lunch. What client data would the nurse check to see if the assistance of another nurse is needed?

Patient restrictions

The nurse would recognize which of these devices as an open drainage system?

Penrose drain

When measuring the size, depth, and wound tunneling of a client's stage IV pressure ulcer, what action should the nurse perform first?

Perform hand hygiene

A home health nurse reviews the nursing care plan with the client and family. Then, they mutually discuss the expected outcomes of the nursing care to be provided. Which step of the nursing process is the nurse illustrating?

Planning

As the beginning student in nursing, what is essential to the mastery of technical skills, such as giving an injection?

Practice giving injections in the learning laboratory until you feel comfortable

Upon evaluation of the client's plan of care, the nurse determines that the expected outcomes have been achieved. Based upon this response, the nurse will:

Terminate the plan of care.

A nurse researcher is studying perceptions of vocational rehabilitation for clients after a spinal cord injury. What type of research method will be used to study the perceptions of this group of individuals?

Qualitative research

A nurse is taking a client's temperature and wants the most accurate measurement, based on core body temperature. What site should be used?

Rectal

A nurse has a duty of nonmaleficence. Which of the following would be considered a contradiction to that duty?

Refuse to administer pain medication as ordered

A nurse teaches a client deep-breathing exercises to help control his anxiety. This is considered what type of stress management technique?

Relaxation

The nurse notes that the blood glucose level of a client has increased and is planning to notify the health care provider by telephone. Which technique would be most appropriate for the nurse to use when communicating with the health care provider?

SBAR

What statement most accurately describes Florence Nightingale's influence on nursing knowledge?

She differentiated between health nursing and illness nursing

As adults age, the walls of their arterioles become less elastic, increasing resistance and decreasing compliance. How does this affect the blood pressure?

The blood pressure increases

A man with urinary incontinence tells the nurse he wears adult diapers for protection. What risks should the nurse discuss with this client?

Skin breakdown and UTI

A staff development nurse is discussing techniques to prevent back injury with a group of nurse aides. The nurse informs the group that back stress and injury can be prevented by:

Spreading feet shoulder-width apart to broaden the base of support

A client is admitted with symptoms of psychosis. The nurse hurries to the client's room when she hears the client calling for help. She finds the client lying on the ground. The nurse assists the client back to the bed and performs a thorough assessment. The nurse informs the physician and completes the incident report. Which statement should the nurse document in the incident report?

The client was found lying on the floor

A home care nurse is caring for a quadriplegic client who needs regular position changes and back massages. A gentleman identifying himself as a family friend inquires if he can be of any help to the family. What should the nurse's response be?

The nurse should ask the gentleman to talk to the family directly

A nurse is assessing the blood pressure of an obese woman. What error might occur if the cuff used is too narrow?

The reading is erroneously high

A nurse providing palliative care for a dying man and his family knows that the goal of palliative care is what?

To aggressively treat the symptoms of the disease

What is the goal of the nurse in a helping relationship with a client?

To assist the client to identify and achieve goals

A nurse working in a PACU is responsible for conducting assessments on immediate postoperative clients. What is the purpose of these assessments?

To prevent complications from anesthesia and surgery

A client is requesting to view all medical record information regarding the care received while hospitalized. What right does the client have regarding accessing the medical record according to HIPAA regulations? Select all that apply.

To see the health record To copy the health record To restrict certain disclosures of the health record

A nurse in the emergency department is completing an emergency assessment for a teenager just admitted from a car crash. Which of the following is objective data?

Unable to palpate femoral pulse in left leg

When documenting subjective data, the nurse should:

Use the client's own words placed in quotation marks

A nurse is caring for a client with acute back pain. When should the nurse assess the client's pain?

Whenever the vital signs are measured and documented

Which client would be classified as having chronic pain?

a client with rheumatoid arthritis

A client returning to the floor after orthopedic surgery is reporting nausea. The nurse is aware that an appropriate intervention is to:

avoid strong smelling foods

A physician has ordered that a medication be given "stat" for a client who is having an anaphylactic drug reaction. At what time would the nurse administer the medication?

immediately after the order is noted

Two nurses are discussing a client's condition in an elevator full of visitors. With what crime might the nurses be charged?

invasion of privacy

The nurse is providing education to a client regarding pain control after surgery. What time does the nurse inform the client is the best time to request pain medication?

before the pain becomes severe

What are the two major processes involved in the inflammatory phase of wound healing?

blood clotting is initiated, WBCs move into the wound

What phrase best describes the science of nursing?

body of nursing knowledge

A nurse is assessing a client the first day after colon surgery. Based on knowledge of the effects of anesthesia and manipulation of the bowel during surgery, which focused assessment will be included?

bowel sounds

According to the Harvard University Medical School Committee, what function must be irreversibly lost to define death?

brain function

A client with terminal cancer is taking high doses of a narcotic for pain. The nurse will teach the client or family about which common side effect of opioids?

constipation

A client responds to bad news regarding test results by crying uncontrollably. What is the term for this response to a stressor?

coping mechanism

What cognitive processes must the nurse use to measure client achievement of outcomes during evaluation?

critical thinking

When the nurse inspects a postoperative incision site for infection, which one of the following types of assessments is being performed?

focused

Which of the following modes of value transmission is most likely to lead to confusion and conflict?

laissez-faire

An older woman who is a resident of a long-term care facility has to get up and void several times during the night. This can be the result of what physiologic change with normal aging?

diminished kidney ability to concentrate urine

A female client is scheduled for liposuction surgery to reduce her weight. Based on urgency, how is this surgery classified?

elective

A nurse is caring or a client who is ambulating for the first time after surgery. Upon standing, the client reports dizziness and faintness. The client's blood pressure is 90/50. What is the name for this condition?

orthostatic hypotension

Which group of terms best describes the nursing process?

patient-centered, systematic, outcomes-oriented

An infant has had diarrhea for several days. What assessments will the nurse make to identify risks from the diarrhea?

skin turgor

A nurse is providing care for a client who has been newly admitted to the long-term care facility. What is the primary criterion for the nurse's decision whether to use a mechanized assistive device for transferring the client?

the clients ability to assist