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Nursing Fundamentals Final Exam Review 153 Questions with
Verified Answers
Which organization can require nurses to take continuing education courses as a condition of licensure renewal? Select one: a. American Nurses Association b. National League for Nursing c. Sigma Theta Tau d. State Board of Nursing - CORRECT ANSWER State Board of Nursing Which of the following best explains the importance of standards of practice? Select one: a. Nurses and other healthcare providers have the same standards of practice b. Standard of practice only apply to nurses who work in hospital settings. c. Standards of practice identify the knowledge, skills, and attitudes nurses need to provide safe care d. Standards of practice differ among registered nurses because the roles are different based on the population they serve. - CORRECT ANSWER Standards of practice identify the knowledge, skills, and attitudes nurses need to provide safe care. Which of the following best describes the legal definition of a nurse? Assume all education programs are accredited. Select one: a. Graduate of a nursing education program and has passed the National Council Licensure Exam b. Person with advanced training and certified to administer medications in most healthcare settings c. Graduate licensed to practice in an acute care setting or a home care environment d. Graduate with advanced education licensed to practice under the direct supervision of a physician - CORRECT ANSWER Graduate of a nursing education program and has passed the National Council Licensure Exam (NCLEX)
A patient who is being discharged asks the nurse, "Can I take you out for dinner to show my appreciation for all that you have done for me? I really like you." The nurse's best response is which of the following? Select one: a. "Yes, that would be nice. It is really great to be appreciated." b. "No, and please do not ask again. You should have been told that already." c. "Thank you; however, I have to refuse, even though the thought is appreciated." d. "We will have to wait 3 days after you have been discharged to have a relationship." - CORRECT ANSWER Thank you; however, I have to refuse, even though the thought is appreciated. Which of the following concepts refers to conflicts that arise between two or more ethical principles in patient care scenarios? Select one: a. Nursing ethics b. Bioethics c. Ethical dilemma d. Moral distress - CORRECT ANSWER Moral distress A mentally competent patient has an extremely low blood count and will likely die without a blood transfusion. The patient knows the risk, but continues to refuse the blood. Which action by the nurse is the most appropriate? Select one: a. Assume the patient is confused and give the blood anyway. b. Request a psychological evaluation to ensure that the patient understands the risk. c. Request a psychological evaluation to ensure that the patient understands the risk. d. Follow the patient's wishes and do not administer a blood transfusion. - CORRECT ANSWER Follow the patient's wishes and do not administer a blood transfusion Confidentiality will be maintained by a nurse who believes in and values the ethical principle of: Select one: a. Fidelity
c. Explain to the girl and her mother that the hospital only accepts patients who can pay the hospital bill. d. Arrange for an ambulance to transport her to the nearest public hospital. - CORRECT ANSWER Examine her to determine whether her condition is stable or whether she requires immediate medical attention. An 87-year-old patient has just been diagnosed with cancer. Her durable power of attorney names her son as her surrogate decision maker. He arrives at the patient's bedside to discuss treatment options with her. The patient is alert and oriented. Her son tells you that he does not want her to receive any treatment (chemotherapy) because of the side effects and her age. The patient tells you that she wants to try the treatment. Which decision should be followed by the nurse? Select one: a. The patient b. The patient's son c. Both d. Neither - CORRECT ANSWER The patient Upon initial assessment of a 75-year-old patient, you identify bruises and scratches on the patient's arms, legs, and trunk in various stages of healing. You notify your supervisor when you suspect the patient may be a victim of physical abuse. You are complying with which of the following state laws? Select one: a. Good Samaritan Law b. Mandatory Reporting Law c. Nurse Practice Act d. Nursing Standards of Practice - CORRECT ANSWER Mandatory Reporting Law Nursing codes of ethics support which of the following? Select one: a. Patients can receive emergency treatment regardless of their ability to pay. b. Nurses will educate patients about advance directives. c. Nurses with HIV must disclose their condition to their employer. d. Patients have the right to dignity, privacy, and safety. - CORRECT ANSWER Patients have the right to dignity, privacy, and safety.
The nurse is admitting to the medical-surgical unit an older adult woman with a diagnosis of pulmonary hypertension and right-sided heart failure. The patient is complaining of shortness of breath, and the nurse observes conversational dyspnea. What is the first action the nurse should take? Select one: a. Review and implement the primary care provider's prescriptions for treatments. b. Perform a quick physical examination of breathing, circulation, and oxygenation. c. Gather a thorough medical history, including current symptoms, from the family. d. Administer oxygen to the patient through a nasal cannula. - CORRECT ANSWER Perform a quick physical examination of breathing, circulation, and oxygenation. You are caring for a young adult patient with an intracranial hemorrhage secondary to a closed head injury. During your assessment, you notice that the patient's respirations follow a cycle progressively increasing in depth, then progressively decreasing in depth, followed by a period of apnea. Which of the following appropriately describes this respiratory pattern? Select one: a. Biot's breathing b. Kussmaul's respirations c. Sleep apnea d. Cheyne-Stokes respirations - CORRECT ANSWER Cheyne-Stokes respirations A 62-year-old man with emphysema says, "My doctor wants me to quit smoking. It's too late now, though; I already have lung problems." Which of the following would be the best response to his statement? Select one: a. "You should quit so your family does not get sick from exposure to secondhand smoke." b. "You will need to use oxygen, but remember it is a fire hazard to smoke with oxygen in your home." c. "Once you stop smoking, your body will begin to repair some of the damage to your lungs."
c. Take the client's blood pressure and apical pulse readings. d. Count the client's respiratory rate for 1 minute. - CORRECT ANSWER Request the client take a deep breath and cough A 1-day postoperative client has a temperature of 98.2 F. What is the nurse's next best action? Select one: a. Contact the primary care provider for guidance. b. Document the temperature and continue with his care. c. Administer the prescribed antipyretic medication. d. Instruct the client to drink more fluids. - CORRECT ANSWER Document the temperature and continue with his care Which of the following procedure techniques has the most effect on the accuracy of an apical pulse count? Select one: a. Counting the rate for 1 full minute b. Exposing only the left side of the chest c. Determining why assessment of apical pulse is indicated d. Using your ring finger to palpate the intercostal spaces - CORRECT ANSWER Counting the rate for 1 full minute
. During a clinic interview, a client states he has been experiencing dizziness upon standing. Which nursing action is appropriate for the nurse to implement? Select one: a. Ask the client when in the day dizziness occurs. b. Help the client to assume a recumbent position. c. Measure both heart rate and blood pressure with the client standing. d. Measure vital signs with the client supine, sitting, and standing. - CORRECT ANSWER Measure vital signs with the client supine, sitting, and standing The nurse obtains a blood pressure reading of 160/90 from a cardiac patient. What is the first action by the nurse? Select one: a. Obtain the blood in lying, sitting, and standing positions. b. Contact the primary care provider for medication orders. c. Recheck the blood pressure in 30 minutes.
d. Check the patient's pattern of blood pressures over the past 3 days. - CORRECT ANSWER Check the patient's pattern of blood pressure over the past 3 days The nurse is caring for a patient with a history of postural hypotension. She obtains a blood pressure reading on her patient of 130/80 lying and 100/ standing. What is the most appropriate nursing diagnosis for this patient? Select one: a. Risk for falls b. Risk for fatigue c. Risk for dizziness d. Risk for activity intolerance - CORRECT ANSWER Risk for falls A physician orders an indwelling urinary catheter for a client who is mildly confused and has been combative. How should the nurse proceed? Select one: a. Ask a colleague for help, because the nurse cannot safely perform the procedure alone. b. Gather the equipment and prepare it before informing the client about the procedure c. Obtain an order to restrain the client before inserting the urinary catheter. d. Inform the primary provider that the nurse cannot perform the procedure because the client is confused - CORRECT ANSWER Ask a colleague for help because the nurse cannot safely perform the procedure alone A nurse is caring for a young victim of a terrorist attack. During the rehabilitative process, the nurse assists the client in bathing and dressing. The role the nurse is engaged in is: Select one: a. Caregiver b. Advocate c. Counselor d. Educator - CORRECT ANSWER Caregiver Which of the following is the best example of an outcome statement? The patient will: Select one: a. Use the incentive spirometer when awake
b. The same information is gathered in both; the difference is in who obtains the information. c. A nursing history is gathered using a specific format. d. A medical history collects more in-depth information. - CORRECT ANSWER A nursing history focuses on the patient's responses to the health problem A patient comes to the urgent care clinic because he stepped on a rusty nail. What type of assessment would the nurse perform? Select one: a. Comprehensive b. Ongoing c. Initial focused d. Special needs - CORRECT ANSWER Initial focused assessment Which of the following is an example of a problem that nurses can treat independently? Select one: a. Hemorrhage b. Nausea c. Fracture d. Infection - CORRECT ANSWER Nausea What is wrong with the following diagnostic statement? "Impaired Physical Mobility related to laziness and not having appropriate shoes." The statement is: Select one: a. Judgmental b. Too complex c. Legally questionable d. Without supportive data - CORRECT ANSWER Judgmental Which statement(s) is/are most accurate regarding values and beliefs? Select one or more: a. A value is a standard or principle that has meaning and worth to an individual. b. Values are a set of behaviors that one follows to guide health practices. c. All members of certain cultures will share the same values and beliefs. d. A belief is something one does not accepts as true. - CORRECT ANSWER Values are a set of behaviors that one follows to guide health practices
The nurse is developing a plan of care for a client with anxiety. What are appropriate nursing interventions the nurse can use for assisting the client in reducing anxiety? Select one or more: a. Assist the client to identify triggers and situations that create anxiety. b. Be vague in answering questions because you can't know how the client will react. c. Demand that the client develop coping strategies and behavior modification technique. d. Remind the patient that he must not engage in any negative thinking. - CORRECT ANSWER Assist the client to identify triggers and situations that create anxiety A 70-year-old homeless man is admitted to the emergency department with heat stroke following 3 days of overexposure to outside temperatures. The nurse is most alerted to which signs and symptoms associated with heat stroke? Select all that apply. Select one or more: a. A temperature of 103.8°F b. Throbbing headache c. Diaphoresis d. Confusion e. Pedal edema f. obesity g. hyperactive bowel sounds - CORRECT ANSWER Temperature of 103.8 F; Throbbing headache; Confusion The nurse has just completed wound care on her patient who has a large abdominal wound. What should the nurse do soon after this is completed? Select all that apply. a. Assess the patient's response to the procedure b. Teach the patient about the procedure c. Document the procedure in the nursing progress notes d. Ask the patient to assist in the wound care at the next scheduled dressing change e. Remind the patient not to look at his wound
a. Nursing diagnosis b. Assessment c. Evaluation d. Outcome identification - CORRECT ANSWER Outcome identification Which of the following is classified as a nursing diagnosis? Select one: a. Esophageal cancer b. Cholecystitis c. Grieving d. Pneumonia - CORRECT ANSWER Grieving What defines culture? Select one: a. Belief system and guiding behavior b. Altruistic grouping c. Cluster of individuals d. Consumate uniformity - CORRECT ANSWER Belief system and guiding behavior The acute experience of not comprehending a culture is termed: Select one: a. Anxiety b. Disparity c. Resolution d. Shock - CORRECT ANSWER Shock, CULTURE SHOCK! When examining values, a nurse notes that one country uses physician-assisted suicide and another country considers the practice illegal and punishable with imprisonment. How are these two views on Physician- assisted suicide affected? Select one: a. Economically b. Economically c. Ethically d. Culturally - CORRECT ANSWER Culturally For nursing students to be successful in their educational endeavors they must:
Select one: a. Come to class having memorized the material in the textbook b. be actively involved with the material in the text c. Save all questions for the end of class d. Read the material after the class for understanding - CORRECT ANSWER Be actively involved with the material in the text What is the most common client site for the development of nosocomial infections? Select one: a. Surgical wound b. Gastrointestinal c. Bloodstream d. Urinary tract - CORRECT ANSWER Urinary tract (UTIs are the most common type) The apical pulse rate is the number of pulsations felt in what period of time Select one: a. 15 seconds b. 30 seconds c. 60 seconds d. 90 seconds - CORRECT ANSWER 60 seconds When assessing a client who weighs 250 pounds and stands 5'2" tall, it would be important to: Select one: a. Assess the HDL/LDL levels b. Obtain an electrocardiogram daily c. Assist to a standing position to assess gait d. Assess blood pressure with a large cuff - CORRECT ANSWER Assess blood pressure with a large cuff A young adult woman has had orthopedic surgery on her right knee. The first time she gets out of bed, she describes weakness, dizziness, and feeling faint. She is suffering from: Select one: a. Thrombophlebitis
In assesssing breath sounds, which technique should the nurse employ? Select one: a. Ask the patient to hold his breath b. Ask the patient to repeat "99" c. Ask the patient to breath deeply through his mouth d. Ask the patient to cough deeply after each breath - CORRECT ANSWER Ask the patient to breath deeply through his mouth The nurse is assisting a client with his bed bath. The client states, "I can do it myself." The nurse's best response is: Select one: a. "I really have limited time. Let me give you a bath right now." b. "I will set up your bath for you. I will come back and help you with your back." c. You will need to sit up for your bath, and then I will change your bed." d. You will be able to take your bath by yourself tomorrow when you can get up."
- CORRECT ANSWER I will set up your bath for you. I will come back and help you with your back. The client tells the nurse during the preoperative history that he is a three-pack a day cigarette smoker. This information alerts the nurse to which potential complication? Select one: a. A decreased tolerance to pain b. A decreased clotting ability c. An increased risk for atelectasis and hypoxia d. An increased risk for excessive scar tissue formation - CORRECT ANSWER An increased risk for atelectasis and hypoxia The nurse is teaching the client how to prepare 10 units of regular insulin and 5 units of NPH insulin for injection. The nurse instructs the client to
Select one: a. Inject air into the regular insulin and then into the NPH insulin b. Withdraw the regular insulin first c. Inject air into and withdraw the NPH insulin immediately d. Inject air into both vials and withdraw the regular insulin first - CORRECT ANSWER Inject air into both vials and withdraw the regular insulin first A nurse is about to begin PEG (percutaneous endoscopic gastric) tube feedings In order to render safe care for this client, the nurse should first Select one: a. Put on sterile gloves b. Check for residual c. Irrigate with 30 cc sterile water d. Elevate head of bed 30-45 degrees - CORRECT ANSWER Elevate the head of the bed 30 - 45 degrees Which factor in a patient's medical history is most likely to prolong the half-life of certain drugs? Select one: a. Heart disease b. Liver disease c. Rheumatoid arthritis d. Tobacco use - CORRECT ANSWER Liver disease A patient who just returned from the postanesthesia care unit is complaining of severe incision pain. Which drug contained in his medication administration record will offer him the fastest relief? a. Liquid acetaminophen with codeine b. Intravenous morphine sulfate c. sub cutaneous meperidine d. Oral oxycodone tablets - CORRECT ANSWER Intravenous morphine sulfate
c. Plan d. Recover - CORRECT ANSWER Cope An example of long-term coping strategy is Select one: a. Crying to release tension after a stressful event b. Indulging in a rich desert after a stressful day c. Walking briskly three times a week for 20 minutes d. Taking a stick and banging it on a tree - CORRECT ANSWER Walking briskly three times a week for 20 minutes Which action should the nurse take immediately after administering a medication through a nasogastric tube? Select one: a. Verify correct nasogastric tube placement in the stomach b. Auscultate the abdomen for the presence of bowel sounds. c. Immediately administer the next prescribed medication. d. Flush the tube with water using a needleless syringe. - CORRECT ANSWER Flush the tube with water using a needleless syringe When the nurse enters a patient's room to administer a medication, he calls out from the bathroom telling her to leave his medication on the bedside table. He reassures her that he will take the medication as soon as he is finished. How should the nurse proceed? a. Wait outside the bathroom door until the patient is ready for the dose. b. Inform the patient that she will return when he is finished in the bathroom. c. Withhold the dose until the next administration time later in the day. d. Document that the dose was omitted in the medication administration record. - CORRECT ANSWER Inform the patient that she will return when he is finished in the bathroom Which piece or pieces of equipment or supplies is essential for you to assemble before assessing an IV? Select one:
a. Goggles b. Sterile drape c. Disposable gloves d. Blood culture set - CORRECT ANSWER disposable gloves An intravenous hypertonic solution containing dextrose, proteins, vitamins, and minerals, infusing via a central line, is known as a. Cellular hydration b. Volume expander c. Total parenteral nutrition d. Blood transfusion therapy - CORRECT ANSWER Total parenteral nutrition Nurse-client interactions are considered productive when communication is aimed toward Select one: a. Goal achievement b. Compatible realities c. Common understanding d. Sharing values - CORRECT ANSWER Common understanding In examining a peripheral IV site, you observe a red streak along the length of the vein and the vein feels hard and cordlike. What is your interpretation of these findings? Select one: a. An allergic reaction in response to the tape, cleansing agent, drug solution, or IV device b. Infiltration of drug solution into the extravascular tissues c. Phlebitis of the vein in use for IV therapy d. Local infection from bacterial contamination - CORRECT ANSWER Phlebitis of the vein in use for IV therapy A client interview consists of three phases. The nurse recognizes that those phases are: Select one:
