Fundamentals of Nursing

JEFFREY O. SUMERGIDO, B.S.N., R.N.

1. A scrub nurse in the operating room has which
responsibility?
A. positioning the client
B. assisting with gowning and gloving
C. handling surgical instrument to the surgeon
D. applying surgical drapes
2. Tachycardia can result from:
A. Vagal stimulation
B. Vomiting, anger or suctioning
C. Fear, pain or anger
D. Stress, pain or vomiting
3. While assessing the incision of a client who had a
surgery 2 weeks ago, the nurse observes that the
suture line has a shiny, light pink appearance.
Which of the following steps would the nurse take
next?
A. Notify the physician because the wound maybe
dehiscing
B. Apply normal saline solution to keep the wound moist
C. Do nothing because this is granulation tissue
D. Prepare the client for debridement of the suture line
4. To prepare for insulin administration, the nurse
disinfects the injection site. Before giving the
injection, the nurse should allow the disinfected
area to dry for:
A. 10 seconds
B. 30 seconds
C. 1 minute
D. 2 minutes
5. The physician prescribes the following preoperative
medications to be administered to a client by the IM
route: Demerol 50 mg; Vistaril, 25 mg; glycopyrrolate,
0.3 mg. the medications are dispensed as follows:
Demerol 100mg/ml; Vistaril , 100 mg/2ml ; and
glycopyrrolate, 0.2 mg/ml. How many milliliters in
total should the nurse administer?
A. 5 ml
B. 3.8 ml
C. 2.5 ml
D. 2 ml
6. During assessment, the nurse measures clients
respiratory rate at 32 breaths/minute with a
regular rhythm. When documenting this pattern,
the nurse should use which term?
A. Eupnea
B. Bradycardia
C. Apnea
D. Tachypnea
7. The nurse administers an IM injection. Afterward,
the nurse should:
A. Recap the needle and discard it in any medical waste
basket
B. Recap the needle and discard it in a puncture proof
container
C. Discard the uncap needle in a puncture proof container
D. Break the needle and discard the needle and syringe in
any medical waste container
8. A client has a nasogastric tube. Administer oral
medication to this client?
A. Heat the tablets until they liquefy, then pour the liquid
down the NG tube
B. Crush the tablets and prepare a liquid form, and then
insert the liquid into the NG tube.
C. Cut the tablet in half and wash them down the NG tube,
using a syringe filled with water.
D. Crush the tablets and wash the powder down the NG
tube, using a syringe filled with saline solution
9. The nurse is assigned to a client with a cardiac
disorder. When monitoring body temperature for
this client, the nurse should avoid which route?
A. Rectal
B. Oral
C. Axilliary
D. Tympanic
10. The nurse is calculating the proper dosage of
medication for a child. What parameters should
this calculation be based on?
A. Age
B. Body weight
C. Developmental stage in relation to age
D. Body surface area in relation to weight
11. The nurse knows that many drugs can be
administered by more than one route. Which
administration route provides the most rapid
response in a client?
A. Oral
B. I.M.
C. Sublingual
D. Subcutaneous
12. Following a fall from the horse during rodeo practice,
an 18 year old client is seen in the emergency
department. He has a large, dirty laceration on his leg.
The wound is vigorously cleaned, closed and dressed.
In the past, the client has received full immunization
regimen for tetanus toxoid. The nurse asks the client
about his tetanus immunization history and he says, I
had my last shot when I was 11 years old. The nurse
should:
A. Advise the client to get a tetanus vaccine within 3 years
B. Request the physician to order a serum tetanus titer
C. Plan on administering a dose of tetanus vaccine
D. Teach the client that he has life-long immunity to tetanus
13. When placing an indwelling urinary catheter in a
female client, the nurse should advance the
catheter how far into the urethra?
A. 2 inches (5 cm)
B. 6 inches (15 cm)
C. 8 inches (20 cm)
D. inch (1 cm)
14. Which assessment finding by the nurse
contraindicates the application of a heating pad?
A. Active bleeding
B. Reddened abscess
C. Edematous lower leg
D. Purulent wound drainage
15. The nurse may use one of many nursing theories
to guide client care. What are the four key concepts
of most nursing theories?
A. Man, health, illness, and health care
B. Health, illness, health restoration, and caring
C. Man, environment, health and nursing
D. Health, environment, disease, and treatment
16. A client is to receive a glycerin suppository. When
administering the suppository, the nurse should
insert it approximately how far into the clients
rectum?
A. 1 inch (2.5 cm)
B. 2 inches (5 cm)
C. 3 inches (7.5 cm)
D. 4 inches (10 cm)
17. The physician orders Demerol, 75 mg. IM q 4 hrs.
prn, to control a clients post operative pain. The
package insert reads: Demerol, 100 mg/ml. How
many milliliters of demerol should the client
received?
A. 0.25 ml
B. 0.5 ml
C. 0.6 ml
D. 0.75 ml
18. A nurse is assigned to care for a client with
tracheostomy tube. How can the nurse
communicate with this client?
A. By providing tracheostomy plug to use for verbal
communication
B. By placing the call button under the clients pillow
C. By supplying a magic slate or similar device
D. By suctioning the client frequently
19. A medication order reads, Demerol 1 ml I.M.
stat. The nurse responsible for administering the
drug should base the next action on which
understanding?
A. The order should specify the exact time to give the drug.
B. The ordered route is inappropriate for this drug
C. The order should be clarified with the physician
D. The order is correct and valid
20. A client who suffered CVA has a nursing
diagnosis of Ineffective Airway Clearance. The goal
of care for this client is to mobilize pulmonary
secretions. Which intervention would help meet
this goal?
A. Repositioning the client every two hours
B. Restricting fluid to 1,000ml/24 hours
C. Administering oxygen by cannula as ordered
D. Keeping the head of the bed at 30-degree angle
21. When prioritizing clients plan of care based on
Maslows hierarchy of needs, the nurses first
priority would be:
A. Allowing the family to see a newly admitted client
B. Ambulating the client in the hallway
C. Administering pain medication
D. Placing wrist restraints on the client
22. A client asks to be discharged from the hospital
against medical advice (HAMA). What should the
nurse do?
A. Prevent the client from leaving
B. Notify the physician
C. Have the client sign an AMA form
D. Call a security guard to help detain the client
23. The nurse is obtaining a sterile urine specimen
from a clients indwelling urinary catheter. To
prevent infection, the nurse should:
A. Aspirate urine from the tubing port, using a sterile
syringe and needle
B. Disconnect the catheter from the tubing and obtain
urine
C. Open the drainage bag and pour out some urine
D. Wear sterile gloves when obtaining urine
24. The client is to receive an IV infusion of 3,000 ml
of dextrose and normal saline solution over 24
hours. The nurse observes that the rate is 150
ml/hour. If the solution runs continuously at this
rate, the infusion will be completed in:
A. 12 hours
B. b. 20 hours
C. 24 hours
D. 50 hours
25. A client is admitted with acute chest pain. When
obtaining the health history, which question would
be most helpful for the nurse to ask?
A. Do you need anything now?
B. Why do you think you had a heart attack?
C. what were you doing when the pain started?
D. Has anyone in your family been sick lately?
26. The nurse is preparing to give a 9 year old client
preoperative IM injection. Which size needle
should the nurse use?
A. 22 G, 1 inch
B. 22 G, 1 inch
C. 20 G, 1 inch
D. 20 G, 1 inch
27. The maximum transfusion time for a unit of
packed RBCs is:
A. 6 hours
B. 4 hours
C. 2 hours
D. 1 hour
28. The nurse is assessing a post operative client.
Which of the following should the nurse document
as subjective data?
A. Vital signs
B. Laboratory test results
C. Client description of pain
D. ECG waveforms
29. The nurse reviews the ABG values of a client
admitted with pneumonia: pH, 7.51; Paco2, 28 mm
Hg; PaO2, 70 mmHg; HCO3, 24 mEq/L. What do
these values indicate?
A. Metabolic acidosis
B. Metabolic alkalosis
C. Respiratory acidosis
D. Respiratory alkalosis
30. A client suddenly loses consciousness. What
should the nurse do first?
A. Call for assistance
B. Assess for responsiveness
C. Palpate for carotid pulse
D. Assess for pupillary response
31. A client undergoes total abdominal hysterectomy.
When assessing the client 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
32. Following a tonsillectomy, a client returns to the
medical-surgical unit. The client is lethargic and
reports having a sore throat. Which position would
be most therapeutic for this client?
A. Semi-Fowlers
B. Supine
C. High-Fowlers
D. Side-lying
33. A client with fever, weight loss and watery
diarrhea is being admitted to the hospital. While
assessing the client, a nurse inspect the clients
abdomen and notices it is slightly concave.
Additional assessment should proceed in which
order?
A. Auscultation, percussion and palpation
B. Palpation, percussion and auscultation
C. Percussion, palpation and auscultation
D. Palpation, auscultation and percussion
34. The physician prescribes an infusion of 2,400 ml
of IV fluid over 24 hours, with half this amount to
be infused over the first 10 hours. During the first
10 hours, the client should receive how many
milliliters of IV fluid per hour?
A. 10 ml/hour
B. 100 ml/hour
C. 120 ml/hour
D. 240 ml/hour
35. When changing a sterile surgical dressing, the
nurse first must:
A. Wash the hands
B. Apply sterile gloves
C. Remove the old dressing with clean gloves
D. Open sterile packages, and moisten the dressings with
sterile saline solution
36. The physician writes the following order for a
client: Dogoxin .125 mg PO once daily. To
prevent a dosage error, how should the nurse
transcribe this order into medication
administration record?
A. Digoxin .125 mg P.O. once daily ( exactly as written by
the physician)
B. Digoxin 0.125 mg P.O. once daily
C. Digoxin 0.1250 mg P.O. once daily
D. Digoxin .1250 mg P.O. once daily.
37. Which type of medication order might read,
Vitamin K 10 mg IM daily x 3 days?
A. Single order
B. Stat order
C. Standing order
D. Standard written order
38. The nurse has an order to administer iron
dextran, 50 mg IM injection. When carrying out
this order, the nurse should:
A. Insert the needle at 45-degree angle
B. Wipe the needle immediately after injection
C. Pull the skin laterally toward the injection site
D. Use the z-track technique
39. The physician orders milk of magnesia, 2
teaspoons by mouth as needed, for a constipated
client. What is the equivalent of 1 teaspoon in the
metric system?
A. 5 mg
B. 1g
C. 5ml
D. 10 ml
40. Which finding best indicates that suctioning has
been effective?
A. Respiratory rate of 24 breaths/minute
B. Heart rate of 104 beats/minute
C. Brisk capillary refill
D. Clear breath sounds
41. A client blood test results are as follows: WBC
count 1,000/dl; hemoglobin level, 14 g/dl;
hematocrit, 42%. Which of the following goals
would be most important for this client?
A. Promote fluid balance
B. Prevent infection
C. Promote rest
D. Prevent injury
42. The physician orders a blood transfusion for a
client. The nurse should anticipate using an IV
access device of which size?
A. 23 G
B. 21 G
C. 18 G
D. 25 G
43. Which procedure or practice requires surgical
asepsis?
A. Hand washing
B. NGT irrigation
C. IV cannula insertion
D. Colostomy irrigation
44. Before administering the evening dose of a
prescribed medication, the nurse on the evening
shift finds an unlabeled, filled syringe in the
clients medication tray. What should the nurse
do?
A. Discard the syringe to avoid 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
45. The nurse is monitoring a client for adverse
reactions during barbiturate therapy. What is the
major disadvantage of a barbiturate use?
A. Prolonged half-life
B. Poor absorption
C. Potential for drug dependence
D. Potential for hepatoxicity
46. When moving a client in bed, the nurse can
ensure proper body mechanics by:
A. Standing with the feet apart
B. Lifting the client to the proper position
C. Straightening the knees and back
D. Standing several feet from the client
47. Which of the following is an example of a
primary preventive measure?
A. Participating in a cardiac rehabilitation program
B. Obtaining an annual physical examination
C. Practicing monthly breast self-examination
D. Avoiding over exposure
48. A client is placed on a low-sodium (500mg/day)
diet. Which client statement indicates that the
nurses nutrition teaching plan has been effective?
A. I can still eat a ham-and-cheese sandwich with potato
chips for lunch.
B. I chose broiled chicken with a baked potato for dinner.
C. I chose a tossed salad with sardines and oil and vinegar
dressing for lunch.
D. I am glad I can still have chicken bouillon soup.
49. A client has been receiving an IV solution. What
is an appropriate expected outcome for this
patient?
A. Monitor fluid intake and output every 4 hours
B. The client remains free of s/s of phlebitis
C. Edema and warmth are noted at IV insertion site.
D. There is a risk for infection related to IV insertion
50. Which of the following is true about crackles?
A. They are grating sounds
B. They are high-pitched, musical squeaks
C. They are low-pitched noises that sound like snoring
D. They maybe fine, medium, or coarse