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Nursing Fundamentals Exam 1 Practice Test
- A patient's surgical wound has become swollen, red, and tender.You note that the patient has a new fever and leukocytosis. What is the best immediate intervention? [28] 1. Notify the health care provider and use surgical technique to change the dressing 2. Reassure the patient and check the wound later 3. Notify the health care provider and support the patient's fluid and nutritional needs 4. Alert the patient and caregivers to the presence of an infection to ensure care after discharge Correct Answer(s) 3
- A nurse assesses a patient who comes to the pulmonary clinic. "I see that it's been over 6 months since you've been in, but your appointment was for every 2 months. Tell me about that. Also, I see from your last visit that the doctor recommended routine exercise. Can you tell me how successful you have been following his plan?" The nurse's assessment covers which of Gordon's functional health patterns? [16] 1. Value-belief pattern 2. Cognitive-perceptual pattern 3. Coping-stress-tolerance pattern 4. Health perception-health management pattern Correct Answer(s) 4
- The nurse asks a patient, "Describe for me your typical diet over a 24-hour day. What foods do you prefer? Have you noticed a change in your weight recently?" This series of questions would likely occur during which phase of a patient-centered interview? [16] 1. Setting the stage
2. Gather information about a patient's chief concerns 3. Collecting the assessment 4. Termination Correct Answer(s) 3
- What type of interview techiniques does the nurse use when asking these questions, "Do you have pain or cramping?" "Does the pain get worse when you walk?" (Select all that apply) [16]
- Active listening
- Open-ended questioning
- Closed-ended questioning
- Problem-oriented listening Correct Answer(s) 3, 4
- What technique(s) best encourage(s) a patient to tell his or her full story? (Select all that apply) [16]
- Active listening
- Back channeling
just above the IV site. The patient tells her the area is tender. The nurse checks to see if the IV line is running at the correct rate. This is an example of which type of assessment? [16]
1. Agenda setting 2. Problem-focused 3. Objective 4. Use of structured database format Correct Answer(s) 2
- A patient who visits the allergy clinic tells the nurse practitioner that he is not getting relief from shortness of breath when he uses his inhaler.The nurse decides to ask the patient to explain how he uses his inhaler, when he should take a dose of medication, and what he does when he gets no relief. On the basis of Gordon's functional health patterns, which pattern does the nurse assess? [16] 1. Health perception- health management pattern
2. Value-belief pattern 3. Cognitive-perceptual pattern 4. Coping-stress tolerance pattern Correct Answer(s) 1
- A nurse is conducting a patient-centered interview. Place the statements from the interview in the correct order. [16] 1. "You say you've lost weight. Tell me how much weight you have lost in the past month." 2. "My name is Todd. I'll be the nurse taking care of you today. I'm going to ask you a series of questions to gather your health history." 3. "I have no further questions. That you for your patience." 4. "Tell me what brought you to the hospital." 5. "So, to summarize, you've lost about 6 pounds in the last month, and your appetite has been poor - correct?" Correct Answer(s) 2, 4, 1, 5, 3
- Which of the following are examples of data validation? (Select all that apply) [16] 1. The nurse assesses the patient's heart rate and compares the value with the last value entered in the medical record 2. The nurse asks the patient if he is having pain and then asks the patient to rate the severity 3. The nurse observes a patient reading a teaching booklet and asks the patient if he has questions about its content 4. The nurse obtains a blood pressure value that is abnormal and asks the charge nurse to repeat the measurement 5. The nurse asks the patient to describe a symptom by saying "Go on." Correct Answer(s) 1, 4
- During the review of systems in a nursing history, a nurse learns that the patient has been coughing mucus. Which of the following nursing assess- ments would be best for the nurse to use to confirm a lung problem? (Select all that apply) [16] 1. Family report 2. Chest x-ray film 3. Physical examination with auscultation of the lungs 4. Medical record summary of x-ray film findings Correct Answer(s) 3, 4
- A nurse working on a medicine nursing unit is assigned to a 78-year-old patient who just entered the hosprial with symptoms of H1N1 flu. The nurse finds the patient to be short of breath with an increased respiratory rate of 30 breaths/min. He lost his wife just a month ago. The nurse's knowledge about this patient results in which of the following assessment approaches at this time? (Select all that apply) [16]
- A problem-focused approach 2. A structured comprehensive approach 3. Using multiple visits to gather a complete database 4. Focusing on the functional health pattern of the role-relationship Correct Answer(s) 1, 3
- A 58-year-old patient with nerve deafness has come to his doctor's office for a routine examination. The patient wears two hearing aids. The advanced practice nurse who is conducting the assessment uses which of the following approaches while conducting the interview with this patient? (Select all that apply) [16] 1. Maintain a neutral facial expression 2. Lean forward when interacting with the patient 3. Acknowledge the patient's answers through head nodding 4. Limit direct eye contact Correct Answer(s) 2, 3
- The nurse identified that the patient has pain on a scale of 7, he winces during movement, and he expresses discomfort over the incisional area. He guards the area by resisting movement.The incision appears to be healing, but there is natural swelling. Write a three-part nursing diagnostic statement using the PES format. [17] Correct Answer(s) Acute pain r/t incisional trauma evidenced by pain reported at 7, with guarding, and restricted turning and positioning.
- Review the following nursing diagnoses and identify the diagnoses that are correctly stated. (Select all that apply) [17] 1. Anxiety related to fear of dying 2. Fatigue related to chronic emphysema 3. need for mouth care related to inflamed mucosa 4. Risk for infection Correct Answer(s) 1, 4
The most recent nursing diagnosis is "diarrhea related to intestinal colitis." This is an incorrectly stated diagnostic statement, best described as Correct Answer(s) [17]
1. Identifying the clinical sign instead of an etiology 2. Identifying a diagnosis based on prejudicial judgment 3. Identifying the diagnostic study rather than a problem caused by the diag- nostic study 4. Identifying the medical diagnosis instead of the patient's response to the diagnosis. Correct Answer(s) 4
- A nurse is assigned to a new patient admitted to the nursing unit following admission through the emergency department. The nurse collects a nursing history and interviews the patient. Place the following steps for making a nursing diagnosis in the correct order. [17] 1. Considers context of patient's health problem and selects a related factor
2. Reviews assessment data, noting objective and subjective clinical criteria 3. Clusters clinical criteria that form a pattern 4. Chooses diagnostic label Correct Answer(s) 2, 3, 4, 1
- Review the following list of nursing diagnoses and identify those stated incorrectly. (Select all that apply) [17] 1. Acute pain related to lumbar disk repair 2. Sleep deprivation related to difficulty falling asleep 3. Constipation related to inadequate intake of fluids 4. Potential nausea related to nasogastric tube insertion Correct Answer(s) 1, 2, 4
- The nurse completed the following assessment Correct Answer(s) 63-year-old female patient has had abdominal pain for 6 days. She reports not having a bowel movement for 4 days, whereas she normally has a bowel movement every 2-3 days. She has not been hospitalized in the past. Her abdomen is distended. She reports being anxious about upcoming tests. Her temperature was 37 C, pulse 82 and regular, blood pressure 128/72. Which of the following data form a cluster, showing a relevant pattern? (Select all that apply) [17] 1. Vital sign results 2. Abdominal distension 3. Age of patient 4. Change in bowel elimination pattern 5. Abdominal pain 6. No past history of hospitalization Correct Answer(s) 2, 4, 5
- The nurse in a geriatric clinic collects the following information from an 82- year-old patient and her daughter, the family caregiver. The daughter explains that the patient is "always getting lost." The patient sits in the chair but gets
2. Hemorrhage 3. Wound infection 4. Fear Correct Answer(s) 2, 3
- Two nurses are having a discussion at the nurses' station. One nurse is a new graduate who added, "Patient needs improved bowel function related to constipation" to a patient's care plan.The nurse's colleague, the charge nurse says, "I think your diagnosis is possibly worded incorrectly. Let's go over it together." A correctly worded diagnostic statement is Correct Answer(s) [17] 1. Need for improved bowel function related to change in diet 2. Patient needs improved function related to alteration in elimination 3. Constipation related to inadequate fluid intake 4. Constipation related to hard infrequent stools Correct Answer(s) 3
- The following nursing diagnoses all apply to one patient. As the nurse adds these diagnoses to the care plan, which diagnoses will not include defining characteristics? [17] 1. Risk for aspiration 2. Acute confusion 3. Readiness for enhanced coping 4. Sedentary lifestyle Correct Answer(s) 1
- A nurse is assigned to a patient who has returned from the recovery room following surgery for a colorectal tumor. After an initial assessment the nurse anticipates the need to monitor the patient's abdominal dressing, IV infusion, and function of drainage tubes.The patient is in pain, reporting 6 on a scale of 0-10, and will not be able to eat or drink until intestinal function returns. The family has been in the waiting room for an hour, wanting to see the patient.The nurse establishes
priorities first for which of the following situations? (Select all that apply) [18]
1. The family comes to visit the patient 2. The patient expresses concern about pain control 3. The patient's vital signs change, showing a drop in blood pressure. 4. The charge nurse approaches the nurse and requests a report at end of shift. Correct Answer(s) 2, 3
- A patient signals the nurse by turning on the call light.The nurse enters the room and finds the patient's drainage tube disconnected, 100 mL of fluid in the IV line, and the patient asking to be turned. Which of the following does the nurse perform first? [18] 1. Reconnect the drainage tube 2. Inspect the condition of the IV dressing
1. Patient will explain relationship of insulin to blood glucose control 2. Patient will self-administer insulin 3. Patient will achieve glucose control 4. Patient will describe steps for preparing insulin in a syringe Correct Answer(s) 3
- A patient has been in the hospital for 2 days because of newly diagnosed diabetes. His medical condition is unstable, and the medical staff is having difficulty controlling his blood sugar. The physician expects that the patient will remain hospitalized at least 3 more days.The nurse identifies one nursing diagnosis as "deficient knowledge regarding insulin administration related to inexperience with disease management." What does the nurse need to determine before setting the goal of "patient will self-administer insulin?" (Select all that apply) [18] 1. Goal within reach of the patient
2. The nurse's own competency in teaching about insulin 3. The patient's cognitive function 4. Availability of family members to assist Correct Answer(s) 1, 3, 4
- The nurse writes an expected-outcome statement in measurable terms. An example is Correct Answer(s) [18] 1. Patient will be pain free 2. Patient will have less pain 3. Patient will take pain medication every 4 hours 4. Patient will report pain acuity less than 4 on a scale of 0 to 10. Correct Answer(s) 4
- A patient has the nursing diagnosis of "nausea."The nurse develops a care plan with the following interventions. Which are examples of collaborative interventions? [18] 1. Provide frequent mouth care 2. Maintain IV infusion at 100 mL/hr 3. administer prochlorperazine (Compazine) via rectal suppository 4. Consult with dietician on initial foods to offer patient 5. Control aversive odors or unpleasant visual stimulation that triggers nau- sea Correct Answer(s) 4
- A nurse is preparing for change-of-shift rounds with the nurse who is assuming care for his patients. Which of the following statements or actions by the nurse are characteristics of ineffective handoff communication? [18] 1. This patient is anxious about his pain after surgery; you need to review the information I gave him about how to use a patient-controlled analgesia (PCA) pump this evening 2. The nurse refers to the electronic care plan in the electronic health record (EHR) to
- A nurse from home health is talking with a nurse who works on an acute medical division within a hospital. The home health nurse is making a con- sultation. Which of the following statements describes the unique difference between a nursing care plan from a hospital verses one for home care? [18] 1. The goals of care will always be more long term 2. The patient and family need to be able to independently provide most of the health care 3. The patient's goals need to be mutually set with family members who will care for him or her 4. The expected outcomes need to address what can be influenced by inter- ventions Correct Answer(s) 2
- Which outcome allows you to measure a patient's response to care more precisely? [18] 1. The patient's wound will appear normal within 3 days 2. The patient's wound will have less drainage within 72 hours 3. The patient's wound will reduce in size to less than 4 cm (1 1/2 inches) by day 4. 4. The patient's wound will heal without redness or drainage by day 4. Correct Answer(s) 3
- A nurse identifies several interventions to resolve a patient's nursing diagnosis of "impaired skin integrity." Which of the following are written in error? (Select all that apply) [18] 1. Turn the patient regularly from side to back to side. 2. Provide perineal care, using Dove soap and water, every shift and after each episode of urinary incontinence 3. Apply a pressure-relief device to bed
4. Apply transparent dressing to sacral pressure ulcer Correct Answer(s) 1, 3
- The nurse enters a patient's room and finds that the patient was inconti- nent of liquid stool.The patient has recurrent redness in the perineal area, and there is concern that he is developing a pressure ulcer.The nurse cleanses the patient, inspects the skin, and applies a skin barrier ointment to the perineal area. She calls the ostomy and wound care specialist and asks that he visit the patient to recommend skin care measures.Which of the following describe the nurse's actions? (Select all that apply) [19] 1. The application of the skin barrier is a dependent measure 2. The call to the ostomy and wound care specialist is an indirect care mea- sure 3. The cleansing of the skin is a direct care measure 4. The application of the skin barrier is a direct care measure Correct Answer(s) 2, 3, 4
