Fundamentals of Nursing Drill #3

Test your knowledge on concepts in Fundamentals of Nursing. Get a piece of paper and a pen. Answer the following questions and check your answers. Be sure to read the rationale behind the correct answer. If you find something difficult check out of Fundamentals of Nursing Lecture Notes for quick review or browse your books.

1. The nurse is preparing to move an adult who has right-sided paralysis from the bed to the wheelchair. Which statement describes the best action for the nurse to take?
a. position the wheelchair on the left side of the bed
b. keep the head of the bed elevated at 10o
c. protect the client’s left arm with a sling during the transfer
d. bend at the waist while helping the client into a standing position


2. Which statement by the nurse best indicates a correct understanding of “log rolling” when moving a client?
a. one nurse may perform this task alone
b. pillows are needed for positioning in order to provide support
c. the legs should be moved before the head is moved
d. keeping the neck in a straight position is the primary concern


3. The nurse is caring for a client who has temperature of 105oF (40.50C). The physician orders the application of a cooling blanket. The nurse should know that which of the following statements is true about the use of a cooling blanket?
a. cold application will increase the metabolic rate
b. vital signs should be monitored every 8 hours
c. the client should remain in one position to conserve energy
d. skin hygiene and protection of body surface areas is essential


4. The nurse is preparing to administer a sponge bath to an infant with a high fever. Administration of the bath should include:
a. large amounts of alcohol to increase evaporation of heat
b. adjustment of the water temperature to 60-70 0F
c. wet clothes applied to all areas where blood circulates close to skin surfaces
d. small areas of the body sponged at a time to avoid rapid heat loss


5. The nurse is instructing the family of a homebound bedridden client in the general prevention of pressure sores. Measures to include in the teaching include:
a. promoting lifting rather than dragging when turning the client
b. massaging directly over pressure sites
c. changing the client’s position every 4 hours
d. cleaning soiled areas with hot water


6. Which of the following findings would the nurse note when assessing a client with Stage I pressure ulcer? The ulcer displays:
a. superficial skin breakdown c. subcutaneous damage or necrosis
b. deep pink, red, or mottled skin d. damage to muscle or bone


7. An adult has developed a Stage II pressure ulcer. He is scheduled to receive wet to dry dressings every shift. The nurse realizes that the purpose of receiving this type of dressing is to:
a. draw in wound exudate and decrease bacteria
b. debride slough and eschar
c. promote healing by gas exchange
d. promote a moist environment and soften exudate


8. The nurse is performing a wound irrigation and dressing change. Which action, when taken by the nurse, would be a break in the technique?
a. consistently facing the sterile field
b. washing hands before opening the sterile set
c. opening the bottle of irrigating solution and pouring directly into a container on the sterile field
d. opening the sterile set so that the initial flap is opened away from the nurse


9. Total Parenteral Nutrition (TPN) is ordered for an adult client. The nurse expects the solution will contain all of the following nutrients except:
a. dextrose 10% c. electrolytes
b. trace minerals d. amino acids


10. The nurse caring for an adult client who is receiving TPN will need to monitor him for which of the following metabolic complications:
a. hypocalcemia and hypercalcemia c. hyperglycemia and hyperkalemia
b. hyperglycemia and hypokalemia d. hyperkalemia and hypercalcemia


11. The nurse is caring for a client who is receiving IV fluids. Which observation the nurse makes best indicates the IV has infiltrated?
a. pain at the site
b. a change in flow rate
c. coldness around the insertion site


12. Within 20 minutes of the start of transfusion, the client develops a sudden fever. The most appropriate initial response by the nurse is to:
a. force fluids c. increase the flow rate of IV fluids
b. continue to monitor the vital signs d. stop the transfusion


13. The nurse is caring for a client who has had a chest tube inserted and connected to water seal drainage. The nurse determines the drainage system is functioning correctly when which of the following is observed?
a. continuous bubbling in the water seal chamber
b. fluctuation in the water seal chamber
c. suction tubing attached to a wall unit
d. vesicular breath sounds throughout the lung fields


14. The nurse is caring for a client who has just had a chest tube attached to a water seal drainage system. To ensure that the system is functioning effectively the nurse should:
a. observe for intermittent bubbling in the water seal chamber
b. flush the chest tubes with 30-60 ml of NSS every 4-6 hours
c. maintain the client in an extreme lateral position
d. strip the chest tubes in the direction of the client


15. The nurse enters the room of a client who has a chest tube attached to a water seal drainage system and notices the chest tube is dislodged from the chest. The most appropriate nursing intervention is to:
a. notify the physician
b. insert a new chest tube
c. cover the insertion site with petroleum gauze
d. instruct the client to breathe deeply until help arrives


16. A patient is ordered oxygen via nasal prongs. The nurse administering oxygen via this low-flow system recognizes that this method of delivery:
a. mixes room air with oxygen
b. delivers a precise concentration of oxygen
c. requires humidity during delivery
d. is less traumatic to the respiratory tract


17. An adult is receiving oxygen by nasal prongs. Which statement by the client indicates that the client teaching regarding oxygen therapy has been effective?
a. “I was feeling fine so I removed my nasal prongs.”
b. “I’ve increased my fluids to six glasses of water daily.”
c. “Don’t forget to come back quickly when you get me out of bed; I don’t like to be without my oxygen for too long.”
d. “My family was angry when I told them they could not smoke in my room.”


18. An adult client has a nasogastric tube in place to maintain gastric decompression. Which nursing action will relieve discomfort in the nostril with the NG tube?
a. remove any tape and loosely pin the tube to his gown
b. lubricate the NG tube with viscous xylocaine
c. loop the NG tube to avoid pressure on the nares
d. replace the NG tube with a smaller diameter tube


19. An adult client has just returned to his room following a bowel resection and end-to-end anastomosis. The nurse can expect the drainage from the NG tube in the early post-op period to be:
a. Clear        c. Scant
b. Mucoid    d. Discolored


20. The physician inserts a central venous catheter; the nurse should assist the client to assume which of the following positions?
a. supine                     c. reverse trendelenburg’s
b. trendelenburg’s        d. high fowler’s

Fundamentals Drill #2

Test your knowledge on concepts in Fundamentals of Nursing. Get a piece of paper and a pen. Answer the following questions and check your answers. Be sure to read the rationale behind the correct answer. If you find something difficult check out of Fundamentals of Nursing Lecture Notes for quick review or browse your books.

1. A nurse is reviewing the diagnostic tests prescribed for a client. The nurse notes that a lupus cell preparation (LE cell prep) has been ordered. The nurse determines that this test is used to screen primarily for which of following disorders?
a. Histoplasmosis
b. Systemic lupus erythematosus (SLE)
c. Human immunodeficiency virus (HIV)
d. Progressive systemic sclerosis

2. The nurse is caring for a hospitalized client with acquired immunodeficiency syndrome (AIDS) who is receiving didanosine (Videx). The nurse contacts the physician if which laboratory result is noted that may be an indication of potential pancreatitis?
a. Increased potassium
b. Increased serum triglycerides
c. Increased blood urea nitrogen
d. Increased creatinine

3. A client seeks treatment for a fractured radius. There is an open wound on the arm through which jagged bone edges protrude. The nurse determines that the client has a
a. Greenstick fracture
b. Comminuted fracture
c. Open fracture
d. Simple fracture

4. The client has been admitted to the hospital with a fractured pelvis sustained in a motor vehicle accident. The nurse monitors for complications and assesses the client most closely for which of the following complications in the early post-trauma period?
a. Bradycardia
b. Pain
c. Hematuria
d. Fever

5. The nurse is monitoring a client with a head injury for signs of increased intracranial pressure. Which finding indicates an early sign of increased intracranial pressure?
a. Increase in systolic blood pressure
b. Decreasing level of consciousness
c. Shallow, slow respirations
d. Decrease in pulse rate

6. The nurse is performing an assessment on a client with a diagnosis of Bell’s palsy. The nurse would expect to observe which of the following symptoms in the client?
a. Twitching on the affected side of the face
b. Ptosis of the eyelid and closure of the eye
c. Facial drooping
d. Periorbital edema

7. A client with a diagnosis of multiple myeloma is admitted to the hospital. On assessment, the nurse asks the client which question that specifically relates to a clinical manifestation of this disorder?
a. "Are you having any bone pain?"
b. "Do you have diarrhea?"
c. "Have you noticed an increase in appetite?"
d. "Do you have feelings of anxiety and nervousness, together with difficulty sleeping?"

8. The nurse is preparing to care for a client with a diagnosis of metastatic cancer and notes documentation in the client’s chart that the client is experiencing cachexia. Which of the following would the nurse expect to note on assessment of the client?
a. Sunken eyes and a hollow cheek appearance
b. Periorbital edema and swelling around the ears
c. Generalized edema and the presence of weight gain
d. Increased blood pressure and ascites

9. A nurse is caring for a client receiving hemodialysis who has an internal arteriovenous fistula. The nurse expects to note which finding if the fistula is patent?
a. White fibrin specks noted in the fistula
b. Palpation of a thrill over the site of the fistula
c. Lack of a bruit at the site of the fistula
d. Warmth and redness at the site of the fistula

10. A physician's office nurse is assessing a client who recently had a renal transplant. The nurse monitors for which signs of acute graft rejection?
a. Hypotension, graft tenderness, and anemia
b. Hypertension, oliguria, thirst, and hypothermia
c. Fever, vomiting, hypotension, and copious amounts of dilute urine
d. Fever, hypertension, graft tenderness, and malaise

11. A nurse is caring for a client with a tracheostomy tube who is receiving mechanical ventilation. The nurse is monitoring for complications related to the tracheostomy and suspects tracheoesophageal fistula when
a. Suctioning is required frequently
b. Excessive secretions are suctioned from a tracheostomy
c. The client’s skin and mucous membranes are light pink
d. Aspiration of gastric contents occurs during suctioning

12. A nurse is performing a cardiovascular assessment on a client with heart failure. Which of the following items would the nurse assess to gain the best information about the client’s left-sided heart function?
a. Breath sounds
b. Peripheral edema
c. Jugular vein distention
d. Hepatojugular reflux

13. A nurse suctioning a client through an endotracheal tube monitors the client for complications associated with the procedure. Which of the following indicates a complication?
a. A blood pressure of 138/88 mm Hg
b. An irregular heart rate
c. A reddish coloration in the client's face
d. A pulse oximetry level of 95%

14. An emergency department nurse is assessing a client who sustained a blunt chest injury and suspects the presence of flail chest. Which specific characteristic finding would the nurse note in this condition?
a. Slow deep respirations
b. Asymmetric chest movement
c. Loss of consciousness
d. Anxiety

15. A nurse is caring for a client with a tracheostomy tube and is monitoring the client for subcutaneous emphysema. The nurse identifies this complication by noting which of the following?
a. Crackling sounds heard in the upper lobes bilaterally
b. A puffy and crackling sensation on palpation of the tissues surrounding the tracheostomy site
c. Signs of respiratory distress
d. Dyspnea

16. A nurse is monitoring a client with a tracheostomy tube for complications related to the tube. The nurse suspects tracheoesophageal fistula if which of the following is noted?
a. Abdominal distention
b. Excess mucus production
c. Abnormal skin and mucous membrane color
d. Use of accessory muscles to assist with breathing
.
17. A nurse is assessing a client who was treated for an asthma attack. The nurse determines that the client's respiratory status has worsened if which of the following is noted?
a. Loud wheezing
b. Wheezing during inspiration and expiration
c. Wheezing on expiration only
d. Diminished breath sounds

18. A nurse is reviewing the assessment findings and laboratory results of a child diagnosed with new-onset glomerulonephritis. Which of the following findings would the nurse most likely expect to note?
a. Increased creatinine levels
b. Hypotension
c. Low serum potassium
d. Tea-colored urine

19. A nurse is reviewing the record of an infant admitted to the newborn nursery. The nurse notes that the physician has documented bladder exstrophy. On assessment of the infant, the nurse expects to note which of the following?
a. Undescended or hidden testes
b. The opening of the urethral meatus below the normal placement on the glans penis
c. The opening of the urethral meatus on the ventral side of the glans penis
d. The urinary bladder on the outside of the body


20. A newborn infant with a diagnosis of subdural hematoma is admitted to the newborn nursery. The nurse does which of the following to assess for the major symptom associated with subdural hematoma?
a. Checks for contractures of the extremities
b. Tests for equality of extremities when stimulating reflexes
c. Monitors the urinary output pattern
d. Monitors the urine for blood

Fundamentals of Nursing Drill #1

Test your knowledge on concepts in Fundamentals of Nursing. Get a piece of paper and a pen. Answer the following questions and check your answers. Be sure to read the rationale behind the correct answer. If you find something difficult check out of Fundamentals of Nursing Lecture Notes for quick review or browse your books.

1. A nurse is assessing the extent of pitting edema in a client with congestive heart failure. The nurse gently presses a finger on the client's ankle and notes a barely perceptible pit. The nurse interprets this finding as which measurement of pitting edema?
a. 1+
b. 2+
c. 3+
d. 4+


2. The nurse notes documentation that a client's peripheral pulses are +3. The nurse determines that the pulses are
a. Full and brisk
b. Absent
c. Normal or average
d. Palpable, but diminished


3. A nurse is reviewing a client’s record and notes that the results of the client’s vision test using a Snellen chart is 20/50. The nurse interprets this to mean that the client
a. Has normal vision
b. Has minimal visual
c. Can read at a distance of 20 feet what a client with normal vision can read at 50 feet
d. Can read at a distance of 50 feet what a client with normal vision can read at 20 feet

4. A prenatal client tells the nurse that she is really worried about knowing how to care for her first-born child. The nurse formulates which nursing diagnosis for this client?
a. Ineffective Coping
b. Dysfunctional Grieving
c. Situational Low Self-esteem
d. Deficient Knowledge

5. The nurse notes documentation that a client has the presence of cherry angiomas located on the abdomen. On assessment of the client, the nurse would expect to note which characteristic of this skin lesion?
a. Ruby red papules
b. Thickened skin areas
c. Pinpoint-sized red or purple spots
d. Areas of redness warm to touch

6. A nurse is assessing the risk factors for acquiring pneumonia during hospitalization for a group of clients. The nurse determines that which of the following clients is at lowest risk?
a. An older client with diabetes mellitus
b. A client with human immunodeficiency virus (HIV)
c. A client with a spinal cord injury who is immobile
d. A postoperative client who is ambulating

7. A nurse working in a prenatal clinic is reviewing the records of clients scheduled for prenatal visits. The nurse interprets that the client at greatest risk for abruptio placenta is the one who
a. Is 26 years old and is a primipara
b. Rides an exercise bike for 30 minutes 3 times weekly
c. Has maternal hypertension
d. Takes folic acid supplements daily

8. The nurse teaches a client with gastroesophageal reflux disease (GERD) about the measures to prevent reflux while sleeping. The nurse determines that the client needs additional instructions if the client states
a. "I shouldn't eat anything at bedtime."
b. "I should take an antacid at bedtime."
c. "I should sleep flat on my right side."
d. "Losing weight will decrease some of the stomach pressure."

9. A nurse provides instructions to a client about the measures to treat gout. The nurse determines that the client needs additional instructions if the client states that
a. The intake of red meats needs to be limited.
b. Weight loss can help prevent an attack.
c. Medication can help keep the uric acid level down.
d. Fluid intake needs to be limited.

10. A nurse provides instructions to a client who is being discharged 24 hours after undergoing a percutaneous renal biopsy. Which statement by the client indicates a need to reinforce the instructions?
a. "I need to avoid any strenuous lifting for about two weeks."
b. "I shouldn't work out at the gym for about two weeks."
c. "I will call the physician if my urine becomes bloody."
d. "A fever is normal after this procedure."

11. A clinic nurse has provided instructions to the mother of a child with a urinary tract infection. Which statement by the mother indicates a need for further instructions?
a. "I should wipe my child from front to back after urination or a bowel movement."
b. "I should increase my child's fluid intake."
c. "I should encourage my child to hold the urine and to urinate at least four times a day."
d. "I should avoid the use of bubble baths with my child."

12. A nurse provides dietary instructions to a client with hypertension. The nurse determines that the client understands the instructions if the client states that it is acceptable to eat which of the following food items?
a. Hot dogs
b. Turkey
c. Salad with blue cheese dressing
d. Corned beef hash

13. The nurse is providing dietary instructions to a client with ascites who will be discharged to home from the hospital. The nurse determines that the client understands the instructions if the client states that it is acceptable to eat which food item?
a. Canned green beans
b. Fresh plums
c. Cooked ham
d. Bologna


14. A nurse has provided instructions to a client with chronic obstructive pulmonary disease about the procedure for performing pursed lip breathing. The nurse observes the client perform the procedure and determines that he or she is performing it correctly if the client
a. Takes a deep breath and exhales quickly
b. Monitors inspiration time and ensures that expiration time is less than inspiration time
c. Lies on the side in a supine position to perform the procedure
d. Sits in an upright position, takes a deep breath, and exhales slowly


15. A nurse has completed discharge teaching with the family of a client who requires dressing changes at home. Which method of evaluation would the nurse use to best determine the family’s competence in performing the dressing changes?
a. Asking a family member to perform the dressing change and observing the procedure
b. Asking a family member to identify the supplies needed to perform the dressing change
c. Asking a family member to list the steps of the procedure for performing the dressing change
d. Asking a family member to verbalize the procedure for performing the dressing change


16. A nurse is teaching a client diagnosed with iron deficiency anemia about the foods that are high in iron. The nurse tells the client to consume which high-iron food?
a. Refined white bread
b. Egg whites
c. Mushrooms
d. Spinach

17. A clinic nurse provides instructions to a woman in the second trimester of pregnancy regarding measures to relieve backache. Which statement by the client indicates an understanding of these measures?
a. "I will sleep on a soft mattress."
b. "I will avoid doing those pelvic tilt exercises."
c. "I will avoid getting tired, and I should work at maintaining a good posture."
d. "I will wear shoes with a heel of at least 2 inches."


18. A prenatal client reports heartburn, and the nurse provides instructions to the client regarding measures to alleviate the discomfort. Which statement by the client indicates a need for further instructions?
a. "I need to eat small, frequent meals."
b. "I need to avoid fatty or spicy foods."
c. "I need to lie down after eating."
d. "I need to drink approximately 2000 mL fluid per day."


19. During the administration of a blood transfusion to a client, the nurse notes the presence of crackles in the client’s lung bases. On further assessment, the nurse notes that the client has distended neck veins and an increase in central venous pressure. The nurse suspects that the client is experiencing what complication of the blood transfusion?
a. Transfusion reaction
b. Allergic reaction
c. Sepsis
d. Circulatory overload


20. A client with type 1 diabetes mellitus has a blood glucose level of 554 mg/dL. The nurse calls the physician to report the level and monitors the client closely for which acid-base imbalance?
a. Respiratory acidosis
b. Respiratory alkalosis
c. Metabolic acidosis
d. Metabolic alkalosis