FUNDAMENTALS IN NURSING (LEC)
REVIEWER during the hospitalization
The nurse assesses that a client is experiencing
spiritual distress. What should be the nurse’s
primary intervention?
Answer: Establish a trusting nurse client
relationship
A client who is facing a final life saving
surgery asks the nurse to stay and pray until
the surgery begins. In which ways should the
nurse demonstrate presencing with this client?
(Select all that apply) 1. Adjusting the
intravenous infusion 2. Talking with the client
about holding area 3. Sitting next to the client
in the holding are. 4. Praying with the client
for divine intervention 5. Focusing on the
client and fulfilling his needs
Answer: Praying with the client for divine
intervention and Focusing on the client and
fulfilling his needs (4 and 5)
The client being prepared for a procedure asks
to be allowed to wear a religious medal. The
client states, " | have worn this medal and have
not removed it since I was a teenager". What
action should the nurse take? Remove the
medal and place it on head of the bed where
the client will be able to see it during the
procedure?
Answer: Tell the client that the nurse will
explain to the procedure staff about the
medal and will request that they allow the
client to wear it.
The nurse is determining whether
interventions to address the diagnosis of
Spiritual Distress for a client newly diagnosed
with chronic illness have been effective. What
outcome would indicate that interventions
have been effective for this client? The client
states that there is nothing that can be done
spiritually to improve her current outlook on
life
Answer: The client thanks the nurse for
trying to help improve her feelings client
has talked with the church priest twice
The nurse is caring for the family of a
terminally ill client. The family members have
been tearful and sad since the diagnosis was
given. What is the best nursing diagnosis
problem statement for this family?
Answer: Anticipatory grieving
A client who was having an affair is upset and
can't sleep since learning of her partner's
death. The nurse recognizes that the sleeping
difficulty is most likely a result of which type
of grief?
Answer: Disenfranchised
The nurse determines that a terminally ill
client is nearing death. What did the nurse
assess to make this clinical decision? (Select
all that apply) 1.Diarrhea 2.Muscle spasm
3.Slow,weak pulse 4.Decreased bp 5.Cyanosis
of the extremities
Answer: Slow weak pulse, Decreased BP
and Cyanosis of the extremities 3,4,5
A client recovering from back surgery is upset
after learning of the future inability to perform
certain sports, activities, and employment
types because of the surgery. The nurse
interprets this client reaction as a response to
which type of loss?
Answer: Situational loss
The nurse is providing postmortem care for a
client whose family would like to view the
body before it is transported to the morgue.
What interventions are necessary for this
preparation? (Select all that apply) 1.Provide a
total bed bath 2.Place absorbent pads beneath
the body 3.Remove dentures 4.Dress the client
in street clothes 5.Place a pillow under the
head 6.Tape the eyelids closed
Answer: Place absorbent pads beneath the
body and Place a pillow under the head (2
and 5)
The nurse determines that a client, after
learning of the death of a close family
member, is demonstrating normal signs of
grief. What did the nurse assess in this client?
(Select all that apply) 1.Crying 2.Weakness
3.Inability to sleep 4.No appetite 5.Inability to
concentrate on conversations
Answer: Crying, Inability to sleep, No
appetite and Inability to concentrate on
conversations (1,3,4,5
The nurse is considering using the NANDA
nursing diagnosis Impaired Physical Mobility
in the care plan of a newly admitted client. In
order to make this problem statement more
individual, the nurse should take which
action?
Answer: Include what mobility is impaired
The nurse is caring for a client experiencing
dyspnea. In which position should the nurse
place this client?
Answer: Orthopneic position across the
overbed table
A client with sleep apnea reports falling asleep
while driving, almost being involved in an
accident, and frequent episodes of
sleepwalking. What nursing diagnosis should
be a priority for this client?
Answer: Risk for injury related to
somnambulism
A 5 year old client has recurrent night terrors.
What nursing intervention should the nurse
use to help alleviate this problem?
Answer: Have the child empty the bladder
prior to going to bed
A hospitalized client is being awakened every
hour during the night for care and procedures.
The nurse realizes that the lack of NREM
sleep can have a physiological effect?
Answer: Increase susceptibility to infection
A client recovering from surgery is turned and
repositioned in bed. Which should the nurse
document about positioning? (Select of that
apply) 1.Skin status 2.Type of surgery 3.Time
of position change 4.Use of supportive devices
5.Client response to the move
Answer: Type of surgery, Time of position
change, Use of supportive devices and
Client response to the move (2 3,4,5)
The nurse is working on a hospital committee
focused on preventing back injury in nurses.
Which recommendation by this committee is
most likely to result in a decrease in back
injuries if followed?
Answer: No solo lifting of clients is
permitted in the facility
At what age does an average child begin to
walk indepently?
Answer: 12 months
The nurse observes a client walking the hall.
Which element of the body movement should
the nurse assess in this client? (Select all that
apply) 1.Posture 2.Balance 3.Joint mobility
4.Range of motion 5.Coordinated movement
Answer: Posture, Balance, Joint mobility
and Coordinated movement (1,2,3,5)
Crawling is considered normal developmental
milestone on what age?
Answer: 6 months
Which statement made by the client would
indicate a "me centered" self concept?
Answer: "My future is based on my
decisions I made today"
During an assessment, the nurse notes that a
client frequently refers to his cultural heritage.
In which way should the nurse identify the
impact of the client's heritage? 
Answer: Personal identity
An adolescent client with a rare malignancy
would prefer to die to have a leg amputated.
What information should the nurse use to plan
future interventions for this client?
Answer: The knowledge that adolescents
are very concerned about body image
 The nurse suspects that a client is having
difficulty with specific self esteem. Which
client statements caused the nurse to have this
concern? (Select all that apply)
1. I hate my hair
2. Life is wonderful
3. My hips are too big
4. I wish i had that nose job 2years ago
5. It is awesome that i got that promotion at
work
Answer: I hate my hair, My hips are too big
and I wish I had that nose job (1,3,4)
Which nursing intervention would be helpful
when caring for client who has negative self
esteem?
Answer: Design a series of "small
successes" for the client
The 45year old married client reports having
no interest in sex and has not had intercourse
in 16years. How should the nurse interpret this
assessment data?  
Answer: The lack of sexual desire has
adversely affected the spouse
Client Dee who engages in collegiate sports
asks why sexual activity must be avoided for
two days before a sport event? Which
response should the nurse make?
Answer: As long as intercourse is not
involved, there is no reason to avoid sexual
activity.
The nurse enters the room and finds the adult
client masturbating. What action should the
nurse take?
Answer: Say "excuse me" and leave the
room
After an assessment, the nurse determines that
a client has strong sexual health. What did the
nurse assess in the client? (Select all that
apply)
1. Knowledge about sexual behavior 
2. Reluctance to discuss sexual history
3. Utilization of birth control method that fits
lifestyle
4. Statement that there are no issues with
sexuality
5. Discussing sexual problems with healthcare
provider
Answer: Knowledge about sexual behavior,
Utilization of birth control method that fits
lifestyle and Discussing sexual problems
with healthcare provider (1,3,5)
When discussing the orgasmic phase of the
sexual response cycle, what should the nurse
include as physiological changes that affect
both sexes? (Select all that apply)
1. The respiratory rate can increase up to 40
breaths per minute
2. Involuntary muscle spasms occur
throughout the body
3. The heart rate decreases to 20 beats below
normal
4. Systolic bp can increase 20 to 30 mmHg
above normal
5. Diastolic bp can decrease 20 to 50 mmHg
below normal
Answer: The respiratory rate can increase
up to 40 breaths per minute, Involuntary
muscle spasms occur throughout the body
and Systolic BP can increase 20-30 mmHg
above normal (1,2,4)
 A client who has been treated for diabetes
mellitus since childhood has a blood glucose
reading of 180 mg/dL. For which sensory
disturbance should the nurse assess in this
client? 
 Answer: Vision loss
The nurse is assisting a visually impaired
client with ambulation. In which way should
the nurse proceed with this intervention ?
Answer: Walk 1 foot in front of the client
The nurse is concerned that a client is
experiencing sensory deprivation. What did
the nurse assess to make this clinical decision?
(Select all that apply)
1. Excessive sleeping, 2. Confusion at night, 3.
Anger over minor issues, 4. Easily distracted
and 5. Sitting quietly reading a book
Answer: Excessive sleeping, Confusion at
night, Anger over minor issues and Easily
distracted (1,2,3,4)
The family of a client in the hospital is
concerned about the constant noise in the care
area. Which healthcare professionals have the
greatest control over the level of sensory input
in the hospital?  that teaching was effective?
Answer: Nurse
A client can be aroused only with extreme or
repeated stimuli. How should the nurse
document this client's behavior?
Answer: Semicomatose
A client experiences pallor, diaphoresis,
tachycardia, and dizziness when moving from
a lying to sitting position. For which health
problem should the nurse plan care for
this client?
Answer: Orthostatic hypotension
The family is being instructed to turn and
reposition a client. Which action should the
nurse take to ensure the family's
comprehension of the procedure?
Answer: Ask the family to demonstrate the
procedure.
The nurse assesses a client who engages in
athletic activities. Which fluid replacement
should the nurse suggest to maintain metabolic
processes?
Answer: Osteoporosis
A client experiences chronic pain with
mobility. For which health problem should the
nurse assess this client?  of adenosine.
Answer: Altered self-esteem
A client is prone to developing pressure
injuries of the heels. Which equipment should
the nurse use for this client?
Answer: Suspension boots
A client with chronic fatigue syndrome reports
being too tired to exercise. Which suggestion
should the nurse make?
Answer: Intersperse rest periods with
activity periods.
The nurse teaches a client the importance of
aerobic exercise in maintaining cardiovascular
health. Which client statement should indicate
Answer: Engage in daily exercise.
A client is prescribed isotonic exercises.
Which client activity should the nurse
encourage?
Answer: Use a trapeze to lift the body off of
the bed
A client reports going for a long run every
night after dinner. Which assessment finding
should the nurse expect?
Answer: Insomnia
A client is being treated for diabetic
ketoacidosis. For which potential health
problem should the nurse plan care for this
client?
Answer: Hypersomnia
A preschool-age client has a history of night
terrors. Which action should the nurse take to
help this client?
Answer: Toilet the client before bedtime.
The nurse prepares teaching about the
restorative aspects of sleep. Which
information should the nurse include?
Answer; During sleep the body clears itself
An older client reports a sleep disturbance. For
which health problem should the nurse assess
the client?
Answer: Gastric reflux disease
The nurse has worked 24 hours to help staff
the hospital after a major community disaster.
Which action should the nurse take?
Answer: Ask a friend for a ride home.
 
An adolescent client experiences a sleep
disturbance. Which suggestion should the
nurse make?
Answer: Do not sleep with the smartphone
in the bedroom.
A parent reports having a toddler who
constantly refuses to go to sleep. Which
suggestion should the nurse make?
Answer: Implement a regular sleep routine.
A client is diagnosed with hyperthyroidism.
Which should the nurse expect when assessing
this client?
Answer: Lengthened presleep cycle
A client reports having difficulty stimulating
the micturition reflex. Which suggestion
should the nurse make?
Answer: Turn on running water.
A 3-year-old client is not completely toilet
trained which causes the parent concern.
Which information should the nurse provide to
the parent?
 
Answer: Full urinary control occurs at age
4 or 5
An older client is experiencing nocturia.
Which factor should the nurse expect is the
cause of this client's symptom?
Answer: Diminished bladder muscle tone
An adolescent's daily urine output is 1500 mL.
Which action should the nurse take?
Answer: Document the finding in the
client's medical record.
A client reports drinking several caffeinated
drinks each day. Which should the nurse
expect when assessing this client?
Answer: Polyuria
A female client experiences incontinence
because of chronic urinary tract infections.
Which advice should the nurse provide this
client?
Answer: Perform pelvic floor muscle
exercises.
 
The nurse is planning care for a client with
dementia. Which toileting schedule should the
nurse implement for the client?
Answer: Every 2 hours
The nurse prepares to irrigate a client's
bladder. Which action should the nurse take
first?
Answer: Review the client record for recent
fluid intake and output (I&O).
 
A client who has been treated for diabetes
mellitus since childhood has a blood glucose
reading of 180 mg/dl. For which sensory
disturbance should the nurse assess in this
client?
Answer: Vision loss
 
The nurse is assigning support personnel to
assist the families of clients who have died in
dealing with the stress related to the loss of
their family members. For which client should
the nurse screen the family as being at the
highest risk for complicated grief?
Answer: Client was killed in the robbery of
a bank.
The nurse is caring for the family of a
terminally ill client. The family members have
been tearful and sad since the diagnosis was
given. What is the best nursing diagnosis
problem statement for this family?
Answer: Anticipatory Grieving
How should the nurse document the clients
behavior?
Answer: Semi-Comatose
The nurse concern that the hospitalized client
is experiencing sensory overload. What is the
nurse assess to come to this conclusion?
(select all that apply)
Answer: -, Anxiety, and Raising thoughts
(1,2, and 4)
The nurse suspect that the client having
difficulty with specific self-esteem. Which
client treatment cause the nurse to have this
concern? (Select all that apply)
Answer: I hate my hair, My hips are too
big, and I wish I had that nose job 2 years
ago. (1,3, and 4)
The nurse is preparing an educational session
on the sexual response cycle. What should be
included when discussing the psychological or
the physiological changes during the
excitement phase? (Select all that apply)
Answer: Erection of the clitoris, the breasts
enlarge, and the uterus elevates. (3,4 and 5)
A client speaks about an adult son who is a
practicing homosexual and expresses concern
by stating: I am so worried about him and I
know he is going to hell. What is the most
important fact for the nurse to consider in
formulating a response to this clients concern?
Answer: What constitutes normal sexual
expression varies among cultures and
religions.
The nurse is developing strategies for the
relief of menstrual cramping to teach a group
of young clients. What should be the focus of
these strategies?
Answer: Increase of blood flow to the
uterine muscle
Which statement, made by a postmenopausal
client, would the nurse evaluate as indicating
the need for further assessment?
Answer: I am so glad that I dont need to
worry about sex anymore.
The nurse who is teaching a client breast self-
examination describes inspection of the
breasts before a mirror. Which findings should
the nurse tell the client should be evaluated by
a healthcare provider?
Answer: Puckering of the skin, flattening of
the breast from the side view, and change in
shape. (1,2, and 5)
The nurse uses the PLISSIT format in helping
clients who have sexual dysfunction. Which
action by the nurse best reflects the SS section
of this format?
Answer: Use the nurses knowledge about
how disease affects sexuality to offer
specific suggestions for the client.
In discussion with teenagers, the nurse
chooses to use the term sexually transmitted
infection rather than sexually transmitted
disease. What is the rationale for this choice?
Answer: The word disease may elicit guilt,
shame, and fear in the client.
The nurse uses the PLISSIT format in helping
clients who have sexual dysfunction. Which
action by the nurse best reflects the LI section
of this format?
Answer: Give the client accurate but
concise information in regard to any sexual
questions that might be asked.
The nurse uses the PLISSIT format in helping
clients who have sexual dysfunction. Which
action by the nurse best reflects the P section
of this format?
Answer: Acknowledge the clients spoken
and unspoken sexual concerns when
providing care.
The nurse enters the room and finds the adult
client masturbating. What action should the
nurse take?
Answer: Say excuse me and leave the room.
The female client has experienced recurrent
candidiasis with intense vaginal itching and
excoriation. After treatment the client is
reexamined, and the nurse practitioner finds
presence of a white, cheesy discharge. What
recommendation is necessary?
Answer: Examination and treatment of
sexual partner
After an assessment, the nurse determines that
a client has strong sexual health. What did the
nurse assess in the client?
Answer: Knowledge about sexual behavior,
utilization of birth control method that fits
lifestyle, and discussing sexual problems
with healthcare provider. (1,3, and 5)
The nurse is preparing to assess a clients
sexual health. What will the nurse include in
this assessment?
Answer: Sexual self-concept, body image,
and gender identity. (1,2, and 3)
During an assessment, a client tells the nurse
of a desire to wear clothing that is typically
associated with the opposite sex. The nurse
realizes this client is describing which gender
identity?
Answer: Cross-dressing.
During a sexual assessment, a client tells the
nurse about a preference for oralgenital sex.
How should the nurse instruct this client?
Answer: The need to follow safe sex
practices.
The mother of a 5-year-old tells the nurse that
her daughter has always been closer to her
than to her husband. The mother expresses
concern that, over the last 2 months, the little
girl wants to spend all of her time with her
father instead of with the mother. The nurse
recognizes that this behavior:
Answer: Is a normal expectation of a
preschooler developing sexuality.
When discussing the orgasmic phase of the
sexual response cycle, which of the following
will the nurse include as physiological changes
that affect both sexes?
Answer: The respiratory rate can increase
up to 40 breaths per minute, involuntary
muscle spasms throughout the body, and
systolic blood pressure can increase 2030
mm Hg above normal (1,2, and 4)
The nurse is conducting a health history with
an older client with arthritis and heart disease.
When gathering the sexual history for this
client, what question should the nurse ask?
Answer: Have there been any changes in
your sexual functioning that might be
related to your illness or the medications
you take?
The 45-year-old client reports that she has no
interest in sex and that she and her husband
have not had intercourse in 16 years. How
does the nurse interpret these assessment data?
Answer: If both partners share the same
lack of desire, there is often not a problem.
The nurse is conducting a sexual health history
with a client. What questions should the nurse
ask during this history?
Answer: Are you currently sexually active?,
do you experience any pain with sexual
interaction?, and do you have difficulty
with sexual desire? (2,3, and 4)
The nurse is preparing educational materials to
be used when instructing clients on testicular
and breast self-examination. What would be
applicable for both sets of instructions?
Answer: Perform palpation in the shower.
The nurse is conducting a health history with
an older client with arthritis and heart disease.
When gathering the sexual history for this
client, what question should the nurse ask?
Answer:
The nurse attends a continuing education
program to learn about the latest cardiac
catheterization care. Which type of credential
should the nurse expect to earn after attending
this program?
Answer: Certificate of completion
The nurse wants to earn a master's degree in
nursing. On which content should the nurse
expect the program's curriculum to focus?
Answer: Advanced leadership roles
The nurse coordinates the care and consults
with interdisciplinary team members about the
needs of a client receiving hemodialysis. In
which way should this  nurse's role be
described?
Answer: Specialist

A group of nurses are discussing the changes

in nursing education curricula. Which societal
factor should be identified that has influenced
nursing education curricula? (Select all that
apply.)
Answer: Political climate, new scientific
knowledge, cultural changes, and
technological advances. (1,2,4, and 5)

The nurse learns of receiving licensure as a

practical nurse. To which setting should the
nurse apply for  employment? (Select all that
apply.)
Answer: Hospice, home health agency,
nursing home and hospital. (2,3,4 and 5)
 FUNDAMENTALS IN NURSING
(SKILLS) REVIEWER
Which of the following actions would the nurse
expect it to perform when instilling eardrops
correctly?
Answer: Strengthen the auditory canal by
pulling the cartilaginous portion of the pinna
up and back in an adult and down and back
in an infant or child under 3 years
Which of the following actions would the nurse
expect it to perform when instilling eardrops
correctly?
Answer: Place the thumb near the margin of
the lower eyelid and exert pressure upward
over the bony prominence of the cheek.
Which of the following sites is recommended
for adults as a safe site for the majority of
intramuscular injections
Answer: ventrogluteal site
When giving an intramuscular injection using
the z-track technique the nurse should consider
which of the following?
Answer: do not massage the site because it
may cause irritation
A patient weighs 110 LB. what is the correct
kilograms I’m on a nurse should calculate if he
or she understand how to convert pounds to
kilograms?
Answer: 50 kg
Which means of drug administration would be
used in an emergency to achieve rapid
absorption, and quicker results
Answer: injection
Mr. Harris is a 78 year old women admitted to
your unit after experiencing symptoms of stroke
when administering the medication prescribed
OK the nurse should be aware that this patient
has an increase possibility of drug toxicity due
to which of the following age related factors?
Answer: decline in liver function in
production of enzymes needed for drug
metabolism
A patient tells the nurse this field is different
color than the other that I usually play at home
which is the best response by the nurse?
Answer: I will recheck your medication
orders
Most drugs are excreted through which of the
following organs?
Answer: kidneys
Which of the following types of medication
orders with a position prescribe for “as needed”
pain medication?
Answer: PRN order
Before administering a drug for a patient, the
nurse should identify the patient by doing which
of the following?
Answer: check the patient’s ID bracelet
The nurse is experiencing a Compazine
injection to be given to a client. Which of the
following statements is correct?
Answer: when handling a syringe, the nurse
may touch the outside of the barrel, and the
handle of the plunger
A client in the emergency department is to
receive a rectal suppository which of the
following nursing action is not correct for
administering a rectal suppository?
Answer:
A nurse is evaluating a nursing student’s
transdermal patch application to a comatose
client. Which of the following options
demonstrate a need for further teaching? The
student:
Answer: holes the patch by touching the
adhesive edges.
Erythromycin 500 mg is ordering it is supplied
in a liquid form containing 250 mg in 5 mL.
How many milliliters would the nurse
administer?
Answer: 10