Fundamentals of Nursing
1. The nurse has made an error in a narrative documentation of an assessment finding on a client and obtains
the client’s record to correct the error. The nurse should take which action to correct the error?
A. Documenting a late entry into the client’s record.
B. Trying to erase for space to write in the correct data.
C. Using whiteout to delete the error to write in the correct data.
D. Drawing one line through the error, initiating and dating, and then documenting the correct information.
Answer D. If the nurse makes an error in narrative documentation in the client’s record, the nurse should
follow agency policies to correct the error. This includes drawing one line through the error, initiating and dating
the line, and then document additional information not remembered at the initial time of documentation.
Erasing data from the client’s record and the use of whiteout is prohibited.
2. Which identifies accurate nursing documentation notations? Select all apply.
A. The slept through the night.
B. Abdominal wound dressing is dry and intact without drainage.
C. The client seem angry when awakened for vital sign measurement.
D. The client appears to become anxious when it is time for respiratory treatments.
E. The client’s left lower medial leg wound is 3cm in length without redness drainage, or edema.
Answer A. B, E. Factual documentation containsdescriptive, objective information about what the nurse sees,
hears, feels, or smells. The use of inferences without supporting factial data is not acceptable because it can
be misunderstood. The use of vague terms, such as seemed or appears is not acceptable because these
words suggest that the nurse is stating an opinion.
3. An 87-year-old woman I brought to the emergency department for treatment of fractured arm. On physical
assessment, the nurse notes old and new ecchymotic areas on the client’s chest and legs and asks the client
how the bruises were sustained. The client, although reluctant, tells the nurse in confidence that her son
frequently hits her if supper is not prepared on time when he arrives home from work. Which is the most
appropriate nursing response?
A. “Oh, really. I will disscuss this situation with your son.”
B. “Let’s talk about the ways you can manage your time to prevent this from happening.”
C. “Do you have any friends that can help you out until you you reolve these important issues with your son?”
D. As a nurse, I am legally bound to report abuse. I will stay with you while you give the report and help find a
safe place for you to stay.”
Answer D. The nurse must report situations related to child or elder abuse, gunshot wounds, and other
criminal acts, and certain infectious diseases. Confidential issues are not to be discussed with nonmedical
personnel or the client’s family or friends without the client’s permission. Clients should be assured that
information is kept confidential, unless it places the nurse under a legal obligation.
4. The nurse calls the health care provider (HCP) regarding a new medication prescription because the dosage
prescribed is higher than the recommended dosage. The nurse is unable to locate the HCP, and the
medication is due to be administered. Which action should the nurse take?
A. Contact the nursing supervisor.
B. Administer the dose as prescribed.
C. Hold the medication until the HCP can be contacted.
D. Administer the recommended dose until the HCP can be located.
Answer A. If the HCP writes a prescription that requires clarification, the nurses responsibility is to contact the
HCP. If there is no resolution regarding the prescription because the HCP cannot be located or because the
prescription remains as it was written after talking with the HCP, the nurse should contact the nurse manager
or nursing supervisor for further clarification as to what next step should be. Under no circumstances should
the nurse proceed to carry out the prescription until obtain clarification.
5. Nurse Brenda is teaching a patient about a newly prescribed drug. What could cause a geriatric patient to
have difficulty retaining knowledge about prescribed medications?
a.
Decreased plasma drug levels
b.
Sensory deficits
c.
Lack of family support
d.
History of Tourette syndrome
Answer B. Sensory deficits could cause a geriatric patient to have difficulty retaining knowledge about
prescribed medications. Decreased plasma drug levels do not alter the patient’s knowledge about the drug. A
lack of family support may affect compliance, not knowledge retention. Toilette syndrome is unrelated to
knowledge retention.
6.
When examining a patient with abdominal pain the nurse in charge should assess:
a.
Any quadrant first
b.
The symptomatic quadrant first
c.
The symptomatic quadrant last
d.
The symptomatic quadrant either second or third
Answer C. The nurse should systematically assess all areas of the abdomen, if time and the patient’s
condition permit, concluding with the symptomatic area. Otherwise, the nurse may elicit pain in the
symptomatic area, causing the muscles in other areas to tighten. This would interfere with further assessment.
7.
The nurse is assessing a postoperative adult patient. Which of the following should thenurse document as
subjective data?
a.
Vital signs
b.
Laboratory test result
c.
Patient’s description of pain
d.
Electrocardiographic (ECG) waveforms
Answer C. Subjective data come directly from the patient and usually are recorded as direct quotations that
reflect the patient’s opinions or feelings about a situation. Vital signs, laboratory test result, and ECG
waveforms are examples of objective data.
8.
A male patient has a soft wrist-safety device. Which assessment finding should the nurse consider
abnormal?
a.
A palpable radial pulse
b.
A palpable ulnar pulse
c.
Cool, pale fingers
d.
Pink nail beds
Answer C. A safety device on the wrist may impair circulation and restrict blood supply to body tissues.
Therefore, the nurse should assess the patient for signs of impaired circulation, such as cool, pale fingers. A
palpable radial or lunar pulse and pink nail beds are normal findings.
9.
Which of the following planes divides the body longitudinally into anterior and posterior regions?
a.
Frontal plane
b.
Sagittal plane
c.
Midsagittal plane
d. Transverse plane
Answer A. Frontal or coronal plane runs longitudinally at a right angle to a sagittal plane dividing the body in
anterior and posterior regions. A sagittal plane runs longitudinally dividing the body into right and left regions; if
exactly midline, it is called a midsagittal plane. A transverse plane runs horizontally at a right angle to the
vertical axis, dividing the structure into superior and inferior regions.
10.
A female patient with a terminal illness is in denial. Indicators of denial include:
a.
Shock dismay
b.
Numbness
c.
Stoicism
d.
Preparatory grief
Answer A. Shock and dismay are early signs of denial-the first stage of grief. The other options are associated
with depression—a later stage of grief.
11.
The nurse in charge is transferring a patient from the bed to a chair. Which action does the nurse take
during this patient transfer?
a.
Position the head of the bed flat
b.
Helps the patient dangle the legs
c.
Stands behind the patient
d.
Places the chair facing away from the bed
Answer B. After placing the patient in high Fowler’s position and moving the patient to the side of the bed, the
nurse helps the patient sit on the edge of the bed and dangle the legs; the nurse then faces the patient and
places the chair next to and facing the head of the bed.
12.
A female patient who speaks a little English has emergency gallbladder surgery, during discharge
preparation, which nursing action would best help this patient understand wound care instruction?
a.
Asking frequently if the patient understands the instruction
b.
Asking an interpreter to replay the instructions to the patient.
c.
Writing out the instructions and having a family member read them to the patient
d.
Demonstrating the procedure and having the patient return the demonstration
Answer D. Demonstrating by the nurse with a return demonstration by the patient ensures that the patient can
perform wound care correctly. Patients may claim to understand discharge instruction when they do not. An
interpreter of family member may communicate verbal or written instructions inaccurately.
13.
Before administering the evening dose of a prescribed medication, the nurse on the evening shift finds an
unlabeled, filled syringe in the patient’s medication drawer. What should the nurse in charge do?
a.
Discard the syringe to avoid a medication error
b.
Obtain a label for the syringe from the pharmacy
c.
Use the syringe because it looks like it contains the same medication the nurse was prepared to give
d.
Call the day nurse to verify the contents of the syringe
Answer A. As a safety precaution, the nurse should discard an unlabeled syringe that contains medication.
The other options are considered unsafe because they promote error.
14.
When administering drug therapy to a male geriatric patient, the nurse must stay especially alert for
adverse effects. Which factor makes geriatric patients to adverse drug effects?
a.
Faster drug clearance
b.
Aging-related physiological changes
c.
Increased amount of neurons
d.
Enhanced blood flow to the GI tract
Answer B. Aging-related physiological changes account for the increased frequency of adverse drug reactions
in geriatric patients. Renal and hepatic changes cause drugs to clear more slowly in these patients. With
increasing age, neurons are lost and blood flow to the GI tract decreases.
15.
A female patient is being discharged after cataract surgery. After providing medication teaching,
the nurse asks the patient to repeat the instructions. The nurse is performing which professional role?
a.
Manager
b.
Educator
c.
Caregiver
d.
Patient advocate
Answer B. When teaching a patient about medications before discharge, the nurse is acting as an educator.
The nurse acts as a manager when performing such activities as scheduling and making patient care
assignments. The nurse performs the care giving role when providing direct care, including bathing patients
and administering medications and prescribed treatments. The nurse acts as a patient advocate when making
the patient’s wishes known to the doctor.
16.
A female patient exhibits signs of heightened anxiety. Which response by the nurse is most likely to
reduce the patient’s anxiety?
a.
“Everything will be fine. Don’t worry.”
b.
“Read this manual and then ask me any questions you may have.”
c.
“Why don’t you listen to the radio?”
d.
“Let’s talk about what’s bothering you.”
Answer D. Anxiety may result from feeling of helplessness, isolation, or insecurity. This response helps reduce
anxiety by encouraging the patient to express feelings. The nurse should be supportive and develop goals
together with the patient to give the patient some control over an anxiety-inducing situation. Because the other
options ignore the patient’s feeling and block communication, they would not reduce anxiety.
17.
A scrub nurse in the operating room has which responsibility?
a.
Positioning the patient
b.
Assisting with gowning and gloving
c.
Handling surgical instruments to the surgeon
d.
Applying surgical drapes
Answer C. The scrub nurse assist the surgeon by providing appropriate surgical instruments and supplies,
maintaining strict surgical asepsis and, with the circulating nurse, accounting for all gauze, sponges, needles,
and instruments. The circulating nurse assists the surgeon and scrub nurse, positions the patient, applies
appropriate equipment and surgical drapes, assists with gowning and gloving, and provides the surgeon and
scrub nurse with supplies.
18.
A patient is in the bathroom when the nurse enters to give a prescribed medication. What should
the nurse in charge do?
a.
Leave the medication at the patient’s bedside
b.
Tell the patient to be sure to take the medication. And then leave it at the bedside
c.
Return shortly to the patient’s room and remain there until the patient takes the medication
d.
Wait for the patient to return to bed, and then leave the medication at the bedside
Answer C. The nurse should return shortly to the patient’s room and remain there until the patient takes the
medication to verify that it was taken as directed. The nurse should never leave medication at the patient’s
bedside unless specifically requested to do so.
19.
A male patient undergoes a total abdominal hysterectomy. When assessing the patient 10 hours later,
the nurse identifies which finding as an early sign of shock?
a.
Restlessness
b.
Pale, warm, dry skin
c.
Heart rate of 110 beats/minute
d.
Urine output of 30 ml/hour
Answer A. Early in shock, hyperactivity of the sympathetic nervous system causes increased epinephrine
secretion, which typically makes the patient restless, anxious, nervous, and irritable. It also decreases tissue
perfusion to the skin, causing pale, cool clammy skin. An above-normal heart rate is a late sign of shock. A
urine output of 30 ml/hour is within normal limits
20.
Which pulse should the nurse palpate during rapid assessment of an unconscious male adult?
a.
Radial
b.
Brachial
c.
Femoral
d.
Carotid
Answer D. During a rapid assessment, the nurse’s first priority is to check the patient’s vital functions by
assessing his airway, breathing, and circulation. To check a patient’s circulation, the nurse must assess his
heart and vascular network function. This is done by checking his skin color, temperature, mental status and,
most importantly, his pulse. The nurse should use the carotid artery to check a patient’s circulation. In a patient
with a circulatory problems or a history of compromised circulation, the radial pulse may not be palpable. The
brachial pulse is palpated during rapid assessment of an infant.
Source: Saunders Comprehensive Review for the NCLEX-RN EXAMINATION