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FUNDAMENTAL OF NURSING ECXAM:BASIC PHYSICAL CARE QUESTIONS WITH CORRECT ANSWERS 2023 A+
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FUNDAMENTAL OF NURSING ECXAM:BASICPHYSICAL CARE QUESTIONS WITH CORRECT
ANSWERS 2023 A+
1001
As a nurse helps a client ambulate, the client says, "I had trouble sleeping last night." Which action
should the nurse take?
1. Recommending warm milk or a warm shower at bedtime
2. Gathering more information about the client's sleep problem
3. Determining whether the client is worried about something
4. Finding out whether the client is taking medication that may impede sleep
Correct answer: 2
RATIONALE: The nurse first should determine what the client means by "trouble sleeping." The nurse
lacks sufficient information to recommend warm milk or a warm shower or to make inferences about the
cause of the sleep problem, such as worries or medication use. CLIENT NEEDS CATEGORY: Physiological
integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: Application REFERENCE:
Weber, J., and Kelley, J. Health Assessment in Nursing, 3rd ed. Philadelphia: Lippincott Williams & Wilkins,
2007, p. 32.
1002
A client who recently immigrated to the United States from Korea is hospitalized with second- and
third-degree burns. He speaks little English and has been lying quietly in bed. Ten hours after the
client's admission, the nurse conducts a serial assessment and asks him whether he's in pain. He smiles
and shakes his head vigorously back and forth. Which nursing action is appropriate at this time?
1. Documenting that the client is resting quietly and denies pain
2. Calling a family member to obtain information about the client
3. Giving the client the ordered as-needed pain medication
4. Checking vital signs and assessing for nonverbal indications of pain
, FUNDAMENTAL OF NURSING ECXAM:BASIC
PHYSICAL CARE QUESTIONS WITH CORRECT
ANSWERS 2023 A+
Correct answer: 4
RATIONALE: The nurse should consider the possibility that the client didn't understand the question or
has been conditioned culturally not to complain openly of pain. Checking vital signs and assessing for
nonverbal indications of pain help the nurse determine whether the client is in pain. Accepting the client's
response without question or further assessment may result in inadequate intervention. Calling the family
or giving pain medication isn't warranted at this time because the client denies pain and the nurse needs
to obtain more information. CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS
SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: Application REFERENCE: Taylor, C., et al.
Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams &
Wilkins, 2008, p. 1375.
1003
When preparing a client for a diagnostic study of the colon, the nurse teaches the client how to self-
administer a prepackaged enema. Which statement by the client indicates effective teaching?
1. "I will administer the enema while sitting on the toilet."
2. "I will administer the enema while lying on my left side with my right knee flexed."
3. "I will administer the enema while lying on my right side with my left knee flexed."
4. "I will administer the enema while lying on my back with both knees flexed."
Correct answer: 2
RATIONALE: Lying on the left side allows the enema solution to flow downward by gravity into the rectum
and sigmoid colon. The other options don't accomplish this goal and, therefore, are less effective in
evacuating the lower bowel. CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS
SUBCATEGORY: Safety and infection control COGNITIVE LEVEL: Comprehension REFERENCE: Taylor, C., et
al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott
Williams & Wilkins, 2008, p. 1588.
1004
A physician orders hourly urine output measurement for a postoperative client with an indwelling
, FUNDAMENTAL OF NURSING ECXAM:BASIC
PHYSICAL CARE QUESTIONS WITH CORRECT
ANSWERS 2023 A+
catheter. The nurse records the following amounts of output for 2 consecutive hours: 8 a.m.: 50 ml; 9
a.m.: 60 ml. Based on these amounts, which action should the nurse take?
1. Continue to monitor and record hourly urine output.
2. Notify the physician.
3. Irrigate the indwelling urinary catheter.
4. Increase the I.V. fluid infusion rate.
Correct answer: 1
RATIONALE: Normal urine output for an adult with an indwelling catheter is at least 30 ml/hour.
Therefore, this client's output is normal. Beyond continued evaluation, no nursing action is warranted.
CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort
COGNITIVE LEVEL: Analysis REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human
Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p.1079.
1005
Nursing licensure and practice are regulated by:
1. nurse practice acts.
2. standards of care.
3. civil law.
4. the American Nurses Association.
Correct answer: 1
RATIONALE: Nurse practice acts regulate nursing licensure and practice. Each state has its own nurse
practice act. Standards of care offer guidelines for providing care and criteria for evaluating care. Civil law
protects an individual's rights and isn't associated with regulation of nursing licensure or practice. The
American Nurses Association, the professional organization for registered nurses in the United States,
helps make policy and establish nursing care standards. CLIENT NEEDS CATEGORY: Safe, effective care
environment CLIENT NEEDS SUBCATEGORY: Management of care COGNITIVE LEVEL: Knowledge
, FUNDAMENTAL OF NURSING ECXAM:BASIC
PHYSICAL CARE QUESTIONS WITH CORRECT
ANSWERS 2023 A+
REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed.
Philadelphia: Lippincott Williams & Wilkins, 2008, p.20.
1006
Which action should a nurse take when making a surgical bed?
1. Leave the bed in the high position when finished.
2. Place the pillow at the head of the bed.
3. Tuck the top sheet and blanket under the bottom of the bed.
4. Roll the client to the far side of the bed.
Correct answer: 1
RATIONALE: When making a surgical bed, the nurse should leave the bed in the high position when
finished. After placing the top linens on the bed without touching them, the nurse should fanfold these
linens to the side opposite the side from which the client will enter and place the pillow on the bedside
chair. All of these actions promote transfer of the postoperative client from the stretcher to the bed.
When making an occupied or unoccupied bed, the nurse should place the pillow at the head of the bed
and tuck the top sheet and blanket under the bottom of the bed. When making an occupied bed, the
nurse should roll the client to the far side of the bed. CLIENT NEEDS CATEGORY: Safe, effective care
environment CLIENT NEEDS SUBCATEGORY: Safety and infection control COGNITIVE LEVEL: Application
REFERENCE: Ellis, J.R., and Bentz, P.M. Modules for Basic Nursing Skills, 7th ed. Philadelphia: Lippincott
Williams & Wilkins, 2007, p.159.
1007
When moving a client in bed, the nurse can ensure proper body mechanics by:
1. standing with her feet apart.
2. lifting the client to the proper position.
3. straightening her knees and back.
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