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Nursing Fundamentals I Final Exam Review
1. A patient informs the nurse that she often becomes nauseated when riding in motor vehicles. The nurse knows
that this is related to which sensory deficit?
a. Neurological deficit
b. Visual deficit
c. Hearing deficit
d. Balance deficit: Balance deficit
2. Which nursing diagnosis addresses psychological concerns for a patient with both hearing and visual
sensory impairment?
a. Self-care deficit
b. Risk for falls
c. Social isolation
d. Impaired physical mobility: Social isolation
3. Which of the following sensory changes are normal with aging?
a. Impaired night vision
b. Difficulty hearing low pitch
c. Increase in taste discrimination
d. Heightened sense of smell: impaired night vision
4. The nurse would be most concerned about the risk of malnutrition for a patient with which sensory
deficit?
a. Xerostomia
b. Disequilibrium
c. Cataracts
d. Peripheral neuropathy: Xerostomia
5. A nurse is caring for a patient with a nursing diagnosis of Hearing deficit related to presbycusis. Which
assessment of the patient would indicate an adaptation to the sensory deficit?
a. The patient frequently cleans out his ears with a cotton swab.
b. The patient turns one ear toward the nurse during conversation.
c. The patient isolates himself from social situations.
d. The patient asks the nurse to speak loudly during conversations: The patient turns one ear toward the nurse during
conversation.
6. A nurse is administering a vaccine to a 4-year-old child who is visually impaired. After the needle enters the
arm, the child says, "Ow, that was sharp!" The nurse knows that the ability to recognize and interpret stimuli is known as:
a. Sensation.
b. Reception.
c. Perception.
10. A patient has undergone an appendectomy. When discussing with the pa- tient several pain-relief
interventions, the most appropriate recommendation would be:
A. Adjunctive therapy.
B. Nonopiods
C. NSAIDs
D. PCA pain management: PCA pain management
11. A postoperative patient is using PCA. You will evaluate the effectiveness of the medication when:
A. You compare assessed pain w/baseline pain.
B. Body language is incongruent with reports of pain relief
C. Family members report that pain has subsided
D. Vital signs have returned to baseline: You compare assessed pain w/ baseline pain
12. You are caring for a patient who has diabetes complicated by kidney disease. You need to make a detailed
assessment when administering med- ications because this patient may experience problems with:
A. Absorption
B. Biotransformation
C. Distribution
D. Excretion: Excretion
13. A postoperative patient is receiving morphine sulfate via patient-con- trolled analgesia (PCA). The nurse
assesses that the patient's respirations are depressed. The effects of the morphine sulfate can be classified as:
A. Allergic
B. Idiosyncratic
C. Therapeutic
D. Toxic: Idiosyncratic
14. If a nurse experiences a problem reading a physician's medication order, the most appropriate action will
loss. Although she's familiar with her apart- ment and residence, she reports feeling a little uncertain about walking alone. There is one step into her apartment. Her children are scheduling themselves to be available to their mom for the next two weeks. Which of the following approaches will teach the children to assist ambulation: Have her grasp your arm just above the elbow and have her walk at a comfortable place; stand next to your mom at the top and the bottom of the stairs
20. A new nurse is going to help the patient walk down a corridor and sit in a chair. The patient has an
eyepatch over the left eye and poor vision in the right eye. What is the correct order of steps to help the pt safely walk down the hall and sit in a chair.: 1. Guide pt's hand to nurse's arm resting above the elbow. 2 position yourself one half step ahead of the patient. 3 Walk at a relaxed pace. 4 Tell pt when you're approaching the chair. 5 Position pt's hand on back of chair
21. Because hearing impairment is one of the most common disabilities among children, a health promotion
intervention is to teach parents and chil- dren to:: Take precautions when involved in activities associated with high- intensity noises.
22. A nurse is conducting discharge teaching for a pt with diminished tactile sensation. Which of the following
statements made by the pt indicates that additional teaching is needed: "I have right sided partial paralysis and reduced sensation so i should dress the left side of my body first"
23. Which of the following is the best nursing intervention when communicat- ing with a pt who has expressive
aphasia: Use a dry erase board or paper and pen for writing messages
24. A pt with progressive vision impairments had to surrender his deriver's license sic months ago. He comes to
the medical clinic for a routine checkup/ he is accompanied by his son. His wife died 2 years ago, and he admits to feeling lonely much of the time. Which of the following interventions reduce loneliness: Sharing info about senior transportation services; providing information about local social groups in the pt's neighborhood; recommending that the patient consider making living arrangements that will put him closer to family and friends
25. A nurse is performing an assessment on a patient admitted to the unit following treatment in the emergency
department for severe bilateral eye trauma. During pt admission the nurse's priority interventions include which of the following: Placing necessary objects such as the call light and water in front of the patient to prevent falls caused by reaching; orienting the patient to the environment to reduce anxiety and prevent further injury to the eye; placing signage on the pt's room door and over the bed to alert healthcare providers about pt's visual status
26. Which pt is most likely to experience sensory overload: A pt in the ICU whose pain is not well controlled
27. An older adult is admitted from a skilled nursing home to a medical unit with pneumonia. A review of the
medical record reveals that he had a stroke affecting the right hemisphere of the brain six months ago and was placed in the skilled nursing home because he was unable to care for himself. Which of these assessment findings does the nurse expect to find: I attention and neglect, especially to the left side; visual spatial alterations such as loss of half of a visual field
28. A nurse is performing a home care assessment on a pt with a hearing impairment. The pt reports, " i think
my hearing aid is broken. I cant hear any- thing" which of the following teaching strategies does the nurse implement- : Demonstrate hearing aid battery replacement; review method to check volume on hearing aid; discuss the importance of having wax buildup in the ear canal removed
29. When repositioning an immobile pt, the nurse notices redness over the hip bone. What is indicated when
a reddened area blanches on finger tip touch: Sensitive skin that requires special bed linen
30. Match the pressure ulcer categories/stages with the correct definition.
1. Category/stage I
2. Category/stage II
36. Which of the following describes a hydrocolloid dressing: A dressing that forms a gel that interacts with the
wound surface
37. Which of the following is an indication for a binder to be placed around a surgical pt with a new abdominal
wound: Providing support to abdominal tissues when coughing or walking; reductions of stress on the abdominal incision
38. When is an application of a warm compress to an ankle muscle sprain indicated?: To relieve edema; to
improve blood flow to an injured part
39. What is the removal of devitalized tissue from a wound called?: debride- ment
40. Name the important demensions to constantly measure to determine wound healing: Width, length and
depth
41. What does a Braden scale evaluate: Risk factors that place the patient at risk for skin breakdown
42. On assessing your pt's sacral pressure ulcer, you note that the tissue over the sacrum is dark, hard and
adherent to the wound edge. What is the correct category/stage for the patient's pressure ulcer: Unstageable
43. Which of the following are measures to reduce tissue damage from shear-
: Use a transfer device; have head of bed flat when repositioning pt; raise head of bed 30 degrees when pt positioned supine
44. Which of the following nursing actions do you take after placing a bedpan under an immobilized pt: After
position the pt on the bedpan, elevate the head of the bed to a 45 degree angle
45. *A pt has not had a bowel movement for 4 days. Now she has nausea and severe cramping throughout her
abdomen. On the basis of these findings, what do you suspect is wrong with the pt?*: An intestinal obstruction
46. During the administration of a warm tap water enema, a pt complains of cramping abdominal pain that
he rates a 6 out of 10. What is your priority nursing intervention: Stop the instillation
47. Which instruction do you include when educating a pt with constant constipation: Increase fibers and fluids
in the diet; exercise for 30 min every day; schedule time to use bathroom at same time every day
48. Which skills do you teach a patient with a new colostomy before discharge from the hospital? (Select all that
apply.): How to change the pouch, how to empty the pouch; how to open and close the pouch; how to determine if the ostomy is healing appropriately
49. Which of the following cause Clostridium Difficile infection: Contact with c diffiicile bacteria; overuse of
antibiotics
50. Place the steps of an ostomy pouch change is correct order: 1. Remove old pouch. 2 Cleanse and dry the
peristomal skin. 3 assess the stoma and skin around it. 4 measure the stoma. 5 trace the correct measurement onto back of
provider: Light pink urine
59. What is a critical step when inserting an in dwelling catheter into a male pt: Advance the catheter to the
bifurcation of the drainage and balloon ports
60. Which nursing intervention minimizes the risk for trauma and infection when applying an external
condom catheter: Washing with soap and water before applying the condom-type catheter
61. Which instructions should the nurse give the nursing assistive personal concerning a pt who has had an
indwelling urinary catheter removed that day: Report the time and amount of first voided
62. A post op pt with three way indwelling urinary catheter and continuous bladder irrigation complains of
lower abd pain and distensión. What should be the nurses initial intervention: Assess intake and output from system
63. An ambulatory elderly woman with dementia is incontinent of urine. She has poor short term memory and
has not been seen toileting independently. What is the best nursing intervention for this patient?: Start a scheduled toilet- ing program.
64. What should the nurse teach a young woman with a history of urinary tract infections about UTI
preventions: Keep the bowels regular; wear cotton underwear; cleanse the perineum from front to back
65. Which nursing assessment question would best indicate that an incon- tinent man with a history of
prostate enlargement may not be emptying his bladder adequately: Do you dribble urine constantly
66. Place the following steps of insertion of indwelling catheter in a female pt in appropriate order: 1. Drape pt
with sterile square and fenestrated drapes
2. Prepare sterile field and supplies
3. Lubricate catheter
4. Cleanse uretheral meatus with antiseptic solution
5. Insert and advance catheter
6. When urine appears advance another 2.5 to 5 centimeters
7. Inflate catheter balloon.
8. Gently pull catheter till resistance is felt
9. Attach drainage tubing
67. The nursing assistive personal reports to the nurse that a pt's catheter drainage bag has been empty for
four hours. What is the priority nursing intervention: Assess the catheter and drainage tubing for obvious occlusion
68. Which nursing interventions should a nurse implement when removing an indwelling urinary catheter in
an adult pt: Allow the balloon to drain into the syringe by gravity; initiate voiding record or bladder diary
69. What best describes measurement of post void residual: Bladder scan the pt immediately after voiding
70. Which nursing intervention decreases the risk for CAUTI: Hanging the urine drainage bag below level of the
bladder
71. There is no urine when a catheter is inserted 3 inches into a female's urethra. What should the nurse do
next?: Leave the catheter there and start over with a new catheter
72. The nurse is caring for a pt with pneumonia who has sever malnutrition. The nurse recognizes that,
because of the nutritional status, the pt is at increased risk for: Sepsis; pleural effusion; cardiac arrhythmias
73. The nurse evaluates which laboratory values to assess a pt's potential for wound healing: Nitrogen balance
action: Do not reinstall aspirate and hold the feeding until you talk to the PCP
80. The nurse would delegate which of the following to nursing assistive personnel: Performing glucose
monitoring every 6 hours on a pt; documenting PO intake on a pt who is on a calorie count for 72 hours
81. The pt's blood glucose level is 330mg/dL. What is the priority nursing intervention: Check the medical
record to see if there is a medication order for abnormal glucose levels
82. Which statement made by a pt of a 2 month old infant requires further education: I'm going to alternate
formula with whole milk starting next month
83. The nurse is teaching a program on healthy nutrition at the senior com- munity center. Which points
should be included in the program for older adults: Avoid grapefruit and grapefruit juice which impair drug absorption; take a multivitamin that includes vitamin D for bone health, cheese and eggs are good sources of protein
84. The nurse sees the nursing assistive personnel perform the following in- tervention for a pt receiving
continuous enteral feedings. Which action would require immediate attention: Placing pt supine while giving bath
85. A pt is receiving total parenteral nutrition. What is the primary intervention the nurse should follow to
prevent a central line infection: Clean the central line port through which the TPN is infusing with antiseptic
86. Which pt's are at high risk for nutritional deficits: The middle age female with celiac disease who does not follow
her gluten free diet; the 25 -year-old pt with Crohn's disease who follows a strict diet but does not take vitamins or iron supplements
87. Which of the following signs or symptoms in a pt who is opioid naive is of greatest concern to the nurse when
assessing the pt 1 hr after administering an opiod: Difficulty arousing the pt
88. A health care provider writes the following order for a pt who is opioid naive who returned from the
operating room following a total hip replacement; "fentanyl patch 100mcg, change every 3 days." On the basis of this order, the nurse takes the following action: Calls the health provider and questions the order
89. A pt is being discharged home on an around the clock opioid for chronic back pain. Because of this order, the
nurse anticipates an order for which class of medications: Stool softeners
90. A new medical resident writes an order for OxyContin SR 10 mg PO q12 hours prn. Which part of the
order does the nurse question?: time interval
91. The nurse reviews a pt's medical administration record and finds that the pt has received oxycodone/
acetaminophen, two tablets PO every 3 hours for the past 3 days. What concerns the nurse the most: The amount of daily acetaminophen
92. A pt with chronic low back pain who took an opioid around the clock for the past year decided to abruptly
stop the medication for frenar of addiction. He is now experiencing shaking, chills, abdominal cramps, and joint pain. The nurse recognizes the this pt is experiencing symptoms of: Opioid withdrawal
93. Whic of the following instructions is crucial for the nurse to give to both family members and the pt who is
about to be started on a patient controlled analgesia of morphine: Only the pt should push the button; the PCA system can set limits to prevent overdoses from occurring; do not push the button to go to sleep
94. A pt rates his pain as a 6 out of 10. The pt's wife says that he cant be in that much pain since he has been
sleeping for 30 min. Which is the most accurate resource for assessing the pain: Patient's self report
95. When using ice massage for pain relief, which of the following is correct: - Apply ice using fir pressure over
skin; apply ice for 5 min or until numbness occurs; use a slow, circular steady massage
96. When teaching a pt about transcutaneous electrical nerve stimulation, which information do you include:
TENS electrodes are applied near or directly on the site of pain
97. A post op pt is currently sleeping. Therefore the nurse knows that: The sedative administered may have helped
him sleep but it is stil necessary to assess pain
98. The nurse incorporates which priority nursing intervention into a plan of care to promote sleep for a
hospitalized patient?: Avoid awakening patient for nonessential tasks
