1 FUNDAME NTAL OF NURSING TEST EXAM WITH COMPLETE SOLUTIONS Name: Date: 1. Which statement regarding heart sounds is correct? a. S1 and s2 sound equally loud over the entire cardiac area. b. S1 and sound fainter at the apex than at the base. c. S and 2 sound fainter at the base than at the apex. d. S1 is loudest at the apex, and S2 is loudest at the base . Rationale: The S1 sound — the “lub” sound — is loudest at the apex of the heart. It sounds longer, lower, and louder there than the S2 — the “dub” sound — is loudest at the base. It sounds shorter, sharper, higher, and louder there than the S1. 2. A client has a nursing diagnosis of Ineffective airway clearance related to poor coughing. When planning this client’s care, the nurse should include which intervention? a. Increasing fluids to 2,500 ml/day b. Teaching the client how to deep -breathe and cough c. Improving airway clearance d. Suctioning the client every 2 hours RATIONALE: Interventions should address the etiology of the client's problem — poor coughing. T eaching deep breathing and coughing addresses this etiology. Increasing fluids may improve the client’s condition, but this intervention doesn't address poor coughing. Improving airway clearance is too vague to be considered an appropriate intervention. Suctioning isn't indicated unless other measures fail to clear the airway. 3. A nurse is using the computer when a client calls for pain medication. Which action by the nurse is the best? a. Staying logged on, leaving the terminal on, and administering the medication immediately b. telling the client that he’ll have to wait 15 minutes while she completes the entry c. Asking a coworker to log out for her and administering the medicine right away d. Logging out of the computer, then administering the pain medication RATIONALE: A nurse should meet a client’s request for pain medication as quickly as possible after she logs out of the computer. A nurse shouldn' t ask a client to wait for as long as 15 minutes for requested pain medication. If the nurse leaves the terminal without logging out, others may view confidential information or use her password. Asking a coworker to log her out isn't safe computer practic e. 4. Elizabeth Kubler -Ross identified five stages of death and dying. Loss, grief, and intense sadness are symptoms of which stage? a. Denial and isolation b. Depression c. Anger d. Bargaining RATIONALE: According to Kübhler -Ross, the five stages of death and dying are denial and isolation, anger, bargaining, depression, and acceptance. In denial, the client denies aspects of the illness and death. Loss, grief, and intense sadness indicate depre ssion. In anger, the client has hostility that may be directed to family members, God, heath care workers, and others. In bargaining, the client asks God for more time, and in return promises to do something good. 5. To help minimize calcium loss from a hospitalized client's bones, the nurse should: a. reposition the client every 2 hours. b. encourage the client to walk in the hall c. provide the client daily products at frequent intervals d. provide supplemental feedings between meals. 2 RATIONALE: Calcium absorption diminishes with reduced physical activity because of decreased bone stimulation. Therefore, encouraging the client to increase physical activity such as by walking the hall, helps minimize calcium loss. Turning or repositioning the client every 2 hours wouldn’t increase activity sufficiently to minimize bone loss, Providing dairy products and supplemental feedings wouldn't lessen calcium loss - even if the dairy products and feedings contained extra calcium — becaus e the additional calcium doesn’t increase bone stimulation or osteoblast activity. 6. What is the most appropriate nursing diagnosis for the client with acute pancreatitis? a. Deficient fluid volume b. Excess fluid volume c. Decreased cardiac output d. Ineffective gastrointestinal tissue perfusion RATIONALE: Clients with acute pancreatitis often experience deficient fluid volume, which can lead to hypovolemic shock. Vomiting, hemorrhage (in hemorrhagic pancreatitis), and plasma leaking into the peritoneal cavity may cause the volume deficit. Hypovol emic shock will cause a decrease in cardiac output. Gastrointestinal tissue perfusion will be ineffective if hypovolemic shock occurs, but this wouldn't be the primary nursing diagnosis. 7. One aspect of implementation related to drug therapy is: 3 a. developing a plan of care b. documenting drugs given. c. establishing outcome criteria. d. setting realistic client goals. RATIONALE: Athough documentation isn' t a step in the nursing process, the nurse is legally required to document activities related to drug therapy, including the time of administration, the quantity, and the client's reaction. Developing a plan of care, establishing outcome criteria, and setting realistic client goals are parts of planning rather than implementation. 8. A nurse notes that a client’s I.V. insertion site is red, swollen, and warm to the touch. which action should the nurse take first? a. Discontinue the I.V. infusion. b. Apply a warm, moist compress to the I.V. site. c. Assess the I.V. infusion for patency. d. Apply an ice pack to the I.V. site. RATIONALE: Because redness, swelling, and warmth at an I.V. site are signs of infe ction, the nurse should discontinue the infusion immediately and restart at another site. After doing this, the nurse should apply warmth to the original site. Checking infusion patency isn't warranted because assessment findings suggest infection and inflammation, not infiltration. Heat, not cold is the appropriate treatment for inflammation. 9. A nurse is caring for a client with a history of falls. The nurse's first priority when caring for a client at risk for falls is: a. placing the call light for easy access. b. keeping the bed in the lowest possible position. c. instructing the client not to get out of the bed without assistance d. keeping the bedpan available so that the client doesn’t have to get out of bed. RATIONALE: Keeping the bed at the lowest possible position the first priority for clients at risk for falling. Keeping the call light easy accessible is important but isn’t a top priority. Instructing the client not to get out of bed may not effectively pr event falls — for example, if the client is confused. Even when the client needs assistance to get out of bed, the nurse should place the bed in the lowest position. The client may not require a bedpan. 10. A nurse is caring for a client who is exhibiting signs and symptoms characteristic of a myocardial infarction (MI). which statement describes priorities the nurse should establish while performing the physical assessment? a. Assess the client's level of pain and administer prescribed analgesics. b. Assess the client’s level of anxiety and provide emotional support. c. Prepare the client for pulmonary artery catheterization. d. Ensure that the client's family is kept informed of his status. RATIONALE: The cardinal symptom of MI is persistent, crushing substernal pain or pressure. The nurse should first assess the client's pain and prepare to administer nitroglycerin or morphine for pain control. The client must be medically stabilized before pulmonary artery catheterization can be used as a diagnostic procedure. Anxiety and a feeling of impending doom are characteristic of MI, but the priority is to stabilize the client medically. Although the client and his family should be kept informed at e very step of the recovery process, this action isn’t the priority when treating a client with a suspected MI. 11. A nurse is monitoring a client for adverse reactions during barbiturate therapy. What is the major disadvantage of barbiturate use? a. Prolonged half-life b. Poor absorption c. Potential for drug dependence d. Potential for hepatotoxicity RATIONALE: Clients can become dependent on barbiturates, especially with prolonged use. Because of the rapid distribution of some barbiturates, no correlation exists between duration of action and half -life. Barbiturates are absorbed well and don't cause hepatotoxicity, but because barbiturates are metabolized in the liver, existing hepatic damage does require cautious use of these drugs.
