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BCEN CFRN FUNDAMENTALS FINAL EXAM
REVIEW EXAM QUESTIONS WITH DETAILED
VERIFIED ANSWERS (100% CORRECT
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"The nurse believes that abortion is murder, of the unborn child. While at work, the nurse is assigned a woman with septicemia following an abortion. Which concept most specifically requires the nurse to provide high-quality care for this patient? Select one: a. Ethics b. Morals c. Bioethics d. Nursing Ethics - CORRECT ANSWER=> Nursing ethics" "A pregnant 15-year-old girl presents to the emergency department (ED) of the local private hospital. She has been transported by her mother and appears to be in active labor. The girl is crying uncontrollably and says she is scared and experiencing painful contractions. Her mother states, "We don't have any money or insurance, but this hospital is closer than the public hospital, and she needs help now." What is the first step that the ED staff should take? Select one: a. Inform her mother that she will need to transport her daughter to the nearest public hospital. b. Examine her to determine whether her condition is stable or whether she requires immediate medical attention. 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."
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 100/60 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. Walk two times during day and evening shift c. Maintain oxygen saturation above 92% while performing ADLs each morning for 2 weeks d. Tolerate 10 sets of range-of-motion exercises with physical therapy - CORRECT ANSWER=> Maintain oxygen saturation above 92% while performing ADLs each morning for 2 weeks" "The nurse is individualizing Mr. Wu's plan of care by writing a plan for his nursing diagnosis of Anxiety. The nurse needs to write goals/outcomes on the plan of care because outcomes describe: Select one: a. Desirable changes in the patient's health status b. Specific patient responses to medical interventions c. Specific nursing behaviors to improve a patient's health d. Criteria to evaluate the appropriateness of a nursing diagnosis - CORRECT ANSWER=> Desirable changes in the patient's health status" "The Joint Commission requires which type of assessment to be performed on all patients? Select one: a. Functional ability b. Pain c. Wellness d. sleep - CORRECT ANSWER=> Pain" "When should the nurse make systematic observations about a patient? Select one: a. When the patient has specific complaints b. With the first assessment of the shift c. Each time the nurse gives medications to the patient
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 f. advise the patient not to request pain medication at dinner time since the nurses are very busy g. advise the patient that he can use whatever type of dressing he likes when returns home - CORRECT ANSWER=> - Assess the patient's response to the procedure
- Document the procedure in the nursing progress notes" "The need for a university-based nursing education programs was brought to light during which important historical time? Select one: a. Spanish American War b. World War 1 c. World War 2 d. Korean War - CORRECT ANSWER=> World War 2" "A nurse is caring for a 28 yr old woman who has delivered her baby by Cesarean section. She describes her pain as 9. The nurse medicates her for pain. This is an example of which of the following ethical frameworks? Select one:
a. Justice b. Fidelity c. Beneficence d. Nonmaleficence - CORRECT ANSWER=> Beneficence" "A client states, "I am having a severe headache with pain over my right eye." This statement is classified as: Select one: a. Primary source b. Objective data c. Symptom identification d. Planning care - CORRECT ANSWER=> Primary source" "The nurse writes the following on the client's chart: "The client will have complete healing of the surgical incision on the right lower quadrant of the abdomen in 3 weeks". This is a/an Select one: 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!"
c. Orthostatic hypotension d. Bradycardia - CORRECT ANSWER=> Orthostatic hypotension" "What is the most common reason people contact healthcare providers? Select one: a. Sleeplessness b. Infections c. Anxiety d. Pain - CORRECT ANSWER=> Pain" "A client is nauseated, has been vomiting with diarrhea for several hours, and needs to receive an antiemetic (antinausea) medication. The nurse recognizes that which of the following is accurate? Select one: a. An enteric-coated medication should be given b. Medication will not be absorbed as easily because of the nausea c. A parenteral route is the route of choice. d. A rectal suppository must be administered. - CORRECT ANSWER=> A parenteral route is the route of choice" "The client is assessed by the nurse as experiencing a crisis. The nurse plans to: a. Allow the client to work through independent problem- solving b. Complete an in-depth evaluation of stressors and responses to the situation c. Focus on immediate stress reduction d. Recommend ongoing therapy - CORRECT ANSWER=> Focus on immediate stress reduction" "A client who was in an automobile accident has a deep laceration in the left arm at the brachial artery. The blood pressure is 70/30, with pulse of 120 and thready. The client is suffering from Select one: a. Septic shock b. Hypovolemic shock c. Cardiogenic shock d. Anaphylactic shock - CORRECT ANSWER=> Hypovolemic shock" "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"
"A client is using prayer to assist in relieving stress. The use of prayer allows the client to Select one: a. Cope b. Understand 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: a. Introduction, assessment, conclusion b. Orientation, documentation, database c. Introduction, controlling, selection d. Orientation, working, termination - CORRECT ANSWER=> Orientation, working, termination" "The nurse decides to interview the client by using the open-ended question technique. Which of the following statements reflects this type of questioning? Select one: a. "Is your pain worse or better than it was an hour ago?" b. "Do you believe that your nausea is from the new antibiotic?" c. "Tell me what you think has been causing your depression?" d. "Have you experienced any new side effects from your medication?" - CORRECT ANSWER=> "Tell me what you think has been causing your depression?""
d. Replace the aspirate you removed and call the physician - CORRECT ANSWER=> Discontinue the feedings and call the physician" "The nurse is about to administer medications via a NGT, After ensuring correct placement of the tube, which action should the nurse take next? Select one: a. Clamp the tube for 20 minutes b. Flush the tube with water c. Administer the medication as ordered d. Crush the tablets and dissolve in sterile water - CORRECT ANSWER=> Flush the tube with water" "If the dosage given to a patient by a nurse is inappropriate, who is responsible? Select one: a. Physician b. Pharmacist c. Nurse d. Medical technician - CORRECT ANSWER=> Nurse" "A client with chronic obstructive pulmonary disease requires low flow oxygen. How will the oxygen be administered? Select one: a. Nasal cannula b. Simple oxygen mask c. Venturi mask d. Partial rebreather mask - CORRECT ANSWER=> Nasal cannula" "A surgeon prescribes potassium chloride 20 mEq by mouth for a patient with a nasogastric (NG) tube for gastric drainage. How should the nurse proceed? Select one: a. Seek clarification from the surgeon about the medication order. b. Clamp the NG tube while administering the dose by mouth. c. Instill the medication through the NG tube. d. Withhold the oral potassium chloride elixir. - CORRECT ANSWER=> Seek clarification from the surgeon about the medication order." "A patient has difficulty taking liquid medications from a cup. How should the nurse administer the medications? Select one: a. Request that the physician change the order to the IV route b. Administer the medication by the IM route.
c. Use a needleless syringe to place the medication in the back of the mouth. d. Add the dose to a small amount of food or beverage to facilitate swallowing. - CORRECT ANSWER=> Add the does to a small amount of food or beverage to facilitate swallowing (think of Aunt Missy's housemates, I think Chet had to have this... thickening of fluid to help with swallowing)" "Which of the following nursing action provides the greatest assistance in healing? Select one: a. Maintaining a restful environment b. Providing solid food in the first day c. Limiting family member visits d. Keeping the client recumbent - CORRECT ANSWER=> Maintaining a restful environment" "When the nurse administers the morning dose of a medication during the evening, which of the six rights of medication administration has she failed to follow? Select one: a. Client b. Medication c. dose d. time - CORRECT ANSWER=> Time" "After receiving diphenhydramine, a patient complains that his mouth is very dry. This is not uncommon for patients taking this medication. Which drug effect is this patient experiencing? Select one: a. Side effect b. Adverse reaction c. Toxic reaction d. Supportive effect - CORRECT ANSWER=> side effect" "When the emergency room nurse assesses the pulse oximeter on a client and it reveals 85%, the nurse determines that the most likely explanation for the value is Select one: a. Carbon monoxide poisoning b. Edema on the sensor site c. high oxygen level d. Low hematocrit levels - CORRECT ANSWER=> carbon monoxide poisoning" "When administering heparin subcutaneously, the nurse should Select one: a. Aspirate after injection
Select one: a. A client with diabetic ketoacidosis b. A postoperative appendectomy client c. A client with colitis and bloody diarrhea d. A client receiving intravenous antibiotics - CORRECT ANSWER=> A client with colitis and bloody diarrhea" "The client is to receive a medication via the buccal route. The nurse plans to implement which of the following actions? Select one: a. Place the medication inside the cheek. b. Crush the medication before administration c. Offer the client a glass of orange juice after administration d. Use sterile technique to administer the medication - CORRECT ANSWER=> Place the medication inside the cheek" "When interviewing a client, which nonverbal behavior should a nurse employ? Select one: a. Maintaining indirect eye contact with the client b. Providing space by leaning back away from the client c. Sitting squarely, facing the client d. Maintaining open posture with arms and legs crossed - CORRECT ANSWER=> sitting squarely, facing the client" "The nurse has completed an assessment of the client and identified the following nursing diagnoses. Which one of the following nursing diagnoses indicates a need to postpone teaching that was planned? Select one: a. Knowledge deficit regarding impending surgery b. Activity intolerance related to pain c. Ineffective management of treatment regimen d. Noncompliance with prescribed exercise plan - CORRECT ANSWER=> Activity intolerance related to pain" "An obese male client discusses with the nurse his plans to begin a long-term weight loss regimen. In addition to dietary changes, he plans to begin an intense aerobic exercise program 3 to 4 times a week and to take stress management classes. After praising the client for his decision, which instruction is most important for the nurse to provide? Select one: a. Be sure to have a complete physical examination before beginning your planned exercise program.
b. Be careful that the exercise program doesn't simply add to your stress level, making you want to eat more. c. Increased exercise helps to reduce stress, so you may not need to spend money on a stress management class. d. Make sure to monitor your weight loss regularly to provide a sense of accomplishment and motivation. - CORRECT ANSWER=> Be sure to have a complete physical examination before beginning your planned exercise program" "In large metropolitan areas, clients who suffer from asthma will be affected by Select one: a. Air pollution b. Noise pollution c. Radiation d. ground contamination - CORRECT ANSWER=> Air pollution" "A middle-aged woman's father has passed away, and her mother requires physical and emotional help due to disabilities. The woman is married and raising two children, along with working full time. All of the factors described are Select one: a. Stressors b. Stimuli c. Illnesses d. Demands - CORRECT ANSWER=> Stressors" "The nurse identifies the nursing diagnosis Urinary Incontinence (Total) in an older adult patient admitted after a stroke. Urinary Incontinence places the patient at risk for which complication? Select one: a. Skin breakdown b. Urinary tract infection c. Bowel incontinence d. Renal calculi - CORRECT ANSWER=> skin breakdown" "The nurse measures the urine output of a patient who requires a bedpan to void. Which action should the nurse take first? Put on gloves and: Select one: a. Have the patient void directly into the bedpan b. Pour the urine into a graduated container c. Read the volume with the container on a flat surface at eye level d. Observe the color and clarity of the urine in the bedpan - CORRECT ANSWER=> Have the patient void directly into the bedpan"
