FUNDAMENTALS OF NURSING b.

Mashed potatoes and broiled chicken

1. The most appropriate nursing order for a c. A tossed salad with oil and vinegar and
patient who develops dyspnea and shortness of olives
breath would be…
d. Chicken bouillon
a. Maintain the patient on strict bed rest at
5. The physician orders a maintenance dose
all times
of 5,000 units of subcutaneous heparin (an
b. Maintain the patient in an orthopneic anticoagulant) daily. Nursing responsibilities for
position as needed Mrs. Mitchell now include:

c. Administer oxygen by Venturi mask at a. Reviewing daily activated partial

24%, as needed thromboplastin time (APTT) and prothrombin
time.
d. Allow a 1 hour rest period between
activities b. Reporting an APTT above 45 seconds to
the physician
2.The nurse observes that Mr. Adams begins to
have increased difficulty breathing. She elevates c. Assessing the patient for signs and
the head of the bed to the high Fowler position, symptoms of frank and occult bleeding
which decreases his respiratory distress. The
d. All of the above
nurse documents this breathing as:
6. The four main concepts common to nursing
a. Tachypnea
that appear in each of the current conceptual
b. Eupnca models are:

c. Orthopnea a. Person, nursing, environment, medicine

d. Hyperventilation b. Person, health, nursing, support systems

3. The physician orders a platelet count to be c. Person, health, psychology, nursing

performed on Mrs. Smith after breakfast. The
d. Person, environment, health, nursing
nurse is responsible for:
7. In Maslow’s hierarchy of physiologic needs,
a. Instructing the patient about this
the human need of greatest priority is:
diagnostic test
a. Love
b. Writing the order for this test
b. Elimination
c. Giving the patient breakfast
c. Nutrition
d. All of the above
d. Oxygen
4. Mrs. Mitchell has been given a copy of her
diet. The nurse discusses the foods allowed on a 8. The family of an accident victim who has
500-mg low sodium diet. These include: been declared brain-dead seems amenable to
organ donation. What should the nurse do?
a. A ham and Swiss cheese sandwich on
whole wheat bread a. Discourage them from making a decision
until their grief has eased
b. Listen to their concerns and answer their 12. If patient asks the nurse her opinion
questions honestly about a particular physicians and the nurse
replies that the physician is incompetent, the
c. Encourage them to sign the consent form
nurse could be held liable for:
right away
a. Slander
d. Tell them the body will not be available
for a wake or funeral b. Libel

9. A new head nurse on a unit is distressed c. Assault

about the poor staffing on the 11 p.m. to 7 a.m.
d. Respondent superior
shift. What should she do?
13. A registered nurse reaches to answer the
a. Complain to her fellow nurses
telephone on a busy pediatric unit, momentarily
b. Wait until she knows more about the unit turning away from a 3 month-old infant she has
been weighing. The infant falls off the scale,
c. Discuss the problem with her supervisor
suffering a skull fracture. The nurse could be
d. Inform the staff that they must volunteer charged with:
to rotate
a. Defamation
10. Which of the following principles of
b. Assault
primary nursing has proven the most satisfying
to the patient and nurse? c. Battery

a. Continuity of patient care promotes d. Malpractice

efficient, cost-effective nursing care
b. Autonomy and authority for planning are
best delegated to a nurse who knows the
patient well
c. Accountability is clearest when one nurse
is responsible for the overall plan and its
implementation.
14. Which of the following is an example of
nursing malpractice?
a. The nurse administers penicillin to a
patient with a documented history of allergy to
the drug. The patient experiences an allergic
reaction and has cerebral damage resulting
from anoxia.

d. The holistic approach provides for a b. The nurse applies a hot water bottle or a
therapeutic relationship, continuity, and heating pad to the abdomen of a patient with
efficient nursing care. abdominal cramping.

11. If nurse administers an injection to a c. The nurse assists a patient out of bed with
patient who refuses that injection, she has the bed locked in position; the patient slips and
committed: fractures his right humerus.

a. Assault and battery d. The nurse administers the wrong

medication to a patient and the patient vomits.
b. Negligence
This information is documented and reported to
c. Malpractice the physician and the nursing supervisor.

d. None of the above

15. Which of the following signs and 19. A patient about to undergo abdominal
symptoms would the nurse expect to find when inspection is best placed in which of the
assessing an Asian patient for postoperative following positions?
pain following abdominal surgery?
a. Prone
a. Decreased blood pressure and heart rate
b. Trendelenburg
and shallow respirations
c. Supine
b. Quiet crying
d. Side-lying
c. Immobility, diaphoresis, and avoidance of
deep breathing or coughing 20. For a rectal examination, the patient can
be directed to assume which of the following
d. Changing position every 2 hours
positions?
16. A patient is admitted to the hospital with
a. Genupecteral
complaints of nausea, vomiting, diarrhea, and
severe abdominal pain. Which of the following b. Sims
would immediately alert the nurse that the
patient has bleeding from the GI tract? c. Horizontal recumbent

a. Complete blood count d. All of the above

b. Guaiac test 21. During a Romberg test, the nurse asks the
patient to assume which position?
c. Vital signs
a. Sitting
d. Abdominal girth
b. Standing
17. The correct sequence for assessing the
abdomen is: c. Genupectoral

a. Tympanic percussion, measurement of d. Trendelenburg

abdominal girth, and inspection 22. If a patient’s blood pressure is 150/96, his
b. Assessment for distention, tenderness, pulse pressure is:
and discoloration around the umbilicus. a. 54
c. Percussions, palpation, and auscultation b. 96
d. Auscultation, percussion, and palpation c. 150
18. High-pitched gurgles head over the right d. 246
lower quadrant are:
23. A patient is kept off food and fluids for 10
a. A sign of increased bowel motility hours before surgery. His oral temperature at 8
b. A sign of decreased bowel motility a.m. is 99.8 F (37.7 C) This temperature reading
probably indicates:
c. Normal bowel sounds
a. Infection
d. A sign of abdominal cramping
b. Hypothermia
c. Anxiety a. Apical

d. Dehydration b. Radial

24. Which of the following parameters should c. Pedal

be checked when assessing respirations?
d. Femoral
a. Rate
29. Which of the following patients is at
b. Rhythm greatest risk for developing pressure ulcers?

c. Symmetry a. An alert, chronic arthritic patient treated

with steroids and aspirin
d. All of the above
b. An 88-year old incontinent patient with
25. A 38-year old patient’s vital signs at 8 a.m.
gastric cancer who is confined to his bed at
are axillary temperature 99.6 F (37.6 C); pulse
home
rate, 88; respiratory rate, 30. Which findings
should be reported? c. An apathetic 63-year old COPD patient
receiving nasal oxygen via cannula
a. Respiratory rate only
d. A confused 78-year old patient with
b. Temperature only
congestive heart failure (CHF) who requires
c. Pulse rate and temperature assistance to get out of bed.

d. Temperature and respiratory rate 30. The physician orders the administration of
high-humidity oxygen by face mask and
26. All of the following can cause tachycardia placement of the patient in a high Fowler’s
except: position. After assessing Mrs. Paul, the nurse
a. Fever writes the following nursing diagnosis: Impaired
gas exchange related to increased secretions.
b. Exercise Which of the following nursing interventions
c. Sympathetic nervous system stimulation has the greatest potential for improving this
situation?
d. Parasympathetic nervous system
stimulation a. Encourage the patient to increase her
fluid intake to 200 ml every 2 hours
27. Palpating the midclavicular line is the
correct technique for assessing b. Place a humidifier in the patient’s room.

a. Baseline vital signs c. Continue administering oxygen by high

humidity face mask
b. Systolic blood pressure
d. Perform chest physiotheraphy on a
c. Respiratory rate regular schedule
d. Apical pulse 31. The most common deficiency seen in
alcoholics is:
28. The absence of which pulse may not be a
significant finding when a patient is admitted to a. Thiamine
the hospital?
b. Riboflavin surgery. Which of the following nursing
interventions would be appropriate?
c. Pyridoxine
a. Encourage the patient to walk in the hall
d. Pantothenic acid
alone
32. Which of the following statement is
b. Discourage the patient from walking in
incorrect about a patient with dysphagia?
the hall for a few more days
a. The patient will find pureed or soft foods,
c. Accompany the patient for his walk.
such as custards, easier to swallow than water
d. Consuit a physical therapist before
b. Fowler’s or semi Fowler’s position reduces
allowing the patient to ambulate
the risk of aspiration during swallowing
36. A patient has exacerbation of chronic
c. The patient should always feed himself
obstructive pulmonary disease (COPD)
d. The nurse should perform oral hygiene manifested by shortness of breath; orthopnea:
before assisting with feeding. thick, tenacious secretions; and a dry hacking
cough. An appropriate nursing diagnosis would
33. To assess the kidney function of a patient be:
with an indwelling urinary (Foley) catheter, the
nurse measures his hourly urine output. She a. Ineffective airway clearance related to
should notify the physician if the urine output thick, tenacious secretions.
is:
b. Ineffective airway clearance related to
a. Less than 30 ml/hour dry, hacking cough.

b. 64 ml in 2 hours c. Ineffective individual coping to COPD.

c. 90 ml in 3 hours d. Pain related to immobilization of affected

leg.
d. 125 ml in 4 hours
37. Mrs. Lim begins to cry as the nurse
34. Certain substances increase the amount discusses hair loss. The best response would be:
of urine produced. These include:
a. “Don’t worry. It’s only temporary”
a. Caffeine-containing drinks, such as coffee
and cola. b. “Why are you crying? I didn’t get to the
bad news yet”
b. Beets
c. “Your hair is really pretty”
c. Urinary analgesics
d. “I know this will be difficult for you, but
d. Kaolin with pectin (Kaopectate) your hair will grow back after the completion of
35. A male patient who had surgery 2 days chemotheraphy”
ago for head and neck cancer is about to make 38. An additional Vitamin C is required during
his first attempt to ambulate outside his room. all of the following periods except:
The nurse notes that he is steady on his feet
and that his vision was unaffected by the a. Infancy

b. Young adulthood
c. Childhood c. Side rails are a deterrent that prevent a
patient from falling out of bed.
d. Pregnancy
d. Side rails are a reminder to a patient not
39. A prescribed amount of oxygen s needed
to get out of bed
for a patient with COPD to prevent:
43. Examples of patients suffering from
a. Cardiac arrest related to increased partial
impaired awareness include all of the following
pressure of carbon dioxide in arterial blood
except:
(PaCO2)
a. A semiconscious or over fatigued patient
b. Circulatory overload due to hypervolemia
b. A disoriented or confused patient
c. Respiratory excitement
c. A patient who cannot care for himself at
d. Inhibition of the respiratory hypoxic
home
stimulus
d. A patient demonstrating symptoms of
40. After 1 week of hospitalization, Mr. Gray
drugs or alcohol withdrawal
develops hypokalemia. Which of the following is
the most significant symptom of his disorder? 44. The most common injury among elderly
persons is:
a. Lethargy
a. Atherosclerotic changes in the blood
b. Increased pulse rate and blood pressure
vessels
c. Muscle weakness
b. Increased incidence of gallbladder disease
d. Muscle irritability
c. Urinary Tract Infection
41. Which of the following nursing
d. Hip fracture
interventions promotes patient safety?
45. The most common psychogenic disorder
a. Asses the patient’s ability to ambulate and
among elderly person is:
transfer from a bed to a chair
a. Depression
b. Demonstrate the signal system to the
patient b. Sleep disturbances (such as bizarre
dreams)
c. Check to see that the patient is wearing
his identification band c. Inability to concentrate

d. All of the above d. Decreased appetite

42. Studies have shown that about 40% of 46. Which of the following vascular system
patients fall out of bed despite the use of side changes results from aging?
rails; this has led to which of the following
a. Increased peripheral resistance of the
conclusions?
blood vessels
a. Side rails are ineffective
b. Decreased blood flow
b. Side rails should not be used
c. Increased work load of the left ventricle
d. All of the above

47. Which of the following is the most

common cause of dementia among elderly
persons?

a. Parkinson’s disease

b. Multiple sclerosis

c. Amyotrophic lateral sclerosis (Lou Gerhig’s

disease)

d. Alzheimer’s disease

48. The nurse’s most important legal

responsibility after a patient’s death in a
hospital is:

a. Obtaining a consent of an autopsy

b. Notifying the coroner or medical examiner

c. Labeling the corpse appropriately

d. Ensuring that the attending physician

issues the death certification

49. Before rigor mortis occurs, the nurse is

responsible for:

a. Providing a complete bath and dressing

change

b. Placing one pillow under the body’s head

and shoulders

c. Removing the body’s clothing and

wrapping the body in a shroud

d. Allowing the body to relax normally

50. When a patient in the terminal stages of

lung cancer begins to exhibit loss of
consciousness, a major nursing priority is to:

a. Protect the patient from injury

b. Insert an airway

c. Elevate the head of the bed

d. Withdraw all pain medications