PART 1

1. The most important nursing

intervention to correct skin dryness
is:
A. Avoid bathing the patient until the
condition is remedied, and notify the
physician
B. Ask the physician to refer the patient
to a dermatologist, and suggest that the
patient wear home-laundered sleepwear
C. Consult the dietitian about increasing
the patients fat intake, and take
necessary measures to prevent infection
D. Encourage the patient to increase his
fluid intake, use non-irritating soap when
bathing the patient, and apply lotion to
the involved areas
2. When bathing a patients
extremities, the nurse should use
long, firm strokes from the distal to
the proximal areas. This technique:
A. Provides an opportunity for skin
assessment
B. Avoids undue strain on the nurse
C. Increases venous blood return
D. Causes vasoconstriction and increases
circulation
3. Vivid dreaming occurs in which
stage of sleep?
A. Stage I non-REM
B. Rapid eye movement (REM) stage
C. Stage II non-REM
D. Delta stage
4. The natural sedative in meat and
milk products (especially warm milk)
that can help induce sleep is:
A. Flurazepam
B. Temazepam
C. Tryptophan
D. Methotrimeprazine
5. Nursing interventions that can
help the patient to relax and sleep
restfully include all of the following
except:
A. Have the patient take a 30- to 60minute nap in the afternoon
B. Turn on the television in the patients
room
C. Provide quiet music and interesting
reading material
D. Massage the patients back with long
strokes

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Page 1

6. Restraints can be used for all of

the following purposes except to:
A. Prevent a confused patient from
removing tubes, such as feeding tubes,
I.V. lines, and urinary catheters
B. Prevent a patient from falling out of
bed or a chair
C. Discourage a patient from attempting
to ambulate alone when he requires
assistance for his safety
D. Prevent a patient from becoming
confused or disoriented
7. Which of the following is the
nurses legal responsibility when
applying restraints?
A. Document the patients behavior
B. Document the type of restraint used
C. Obtain a written order from the
physician except in an emergency, when
the patient must be protected from injury
to himself or others
D. All of the above
8. Kubler-Rosss five successive
stages of death and dying are:
A. Anger, bargaining, denial, depression,
acceptance
B. Denial, anger, depression, bargaining,
acceptance
C. Denial, anger, bargaining, depression
acceptance
D. Bargaining, denial, anger, depression,
acceptance
9. A terminally ill patient usually
experiences all of the following
feelings during the anger stage
except:
A. Rage
B. Envy
C. Numbness
D. Resentment
10. Nurses and other health care
provides often have difficulty helping
a terminally ill patient through the
necessary stages leading to
acceptance of death. Which of the
following strategies is most helpful
to the nurse in achieving this goal?
A. Taking psychology courses related to
gerontology
B. Reading books and other literature on
the subject of thanatology
C. Reflecting on the significance of death

D. Reviewing varying cultural beliefs and

practices related to death
11. Which of the following symptoms
is the best indicator of imminent
death?
A. A weak, slow pulse
B. Increased muscle tone
C. Fixed, dilated pupils
D. Slow, shallow respirations
12. A nurse caring for a patient with
an infectious disease who requires
isolation should refers to guidelines
published by the:
A. National League for Nursing (NLN)
B. Centers for Disease Control (CDC)
C. American Medical Association (AMA)
D. American Nurses Association (ANA)
13. To institute appropriate isolation
precautions, the nurse must first
know the:
A. Organisms mode of transmission
B. Organisms Gram-staining
characteristics
C. Organisms susceptibility to antibiotics
D. Patients susceptibility to the organism
14. Which is the correct procedure
for collecting a sputum specimen for
culture and sensitivity testing?
A. Have the patient place the specimen in
a container and enclose the container in a
plastic bag
B. Have the patient expectorate the
sputum while the nurse holds the
container
C. Have the patient expectorate the
sputum into a sterile container
D. Offer the patient an antiseptic
mouthwash just before he expectorate
the sputum
15. An autoclave is used to sterilize
hospital supplies because:
A. More articles can be sterilized at a time
B. Steam causes less damage to the
materials
C. A lower temperature can be obtained
D. Pressurized steam penetrates the
supplies better
16. The best way to decrease the risk
of transferring pathogens to a
patient when removing contaminated
gloves is to:
A. Wash the gloves before removing them
B. Gently pull on the fingers of the gloves
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Page 2

when removing them

C. Gently pull just below the cuff and
invert the gloves when removing them
D. Remove the gloves and then turn them
inside out
17. After having an I.V. line in place
for 72 hours, a patient complains of
tenderness, burning, and swelling.
Assessment of the I.V. site reveals
that it is warm and erythematous.
This usually indicates:
A. Infection
B. Infiltration
C. Phlebitis
D. Bleeding
18. To ensure homogenization when
diluting powdered medication in a
vial, the nurse should:
A. Shake the vial vigorously
B. Roll the vial gently between the palms
C. Invert the vial and let it stand for 1
minute
D. Do nothing after adding the solution to
the vial
19. The nurse is teaching a patient to
prepare a syringe with 40 units of U100 NPH insulin for self-injection.
The patients first priority concerning
self-injection in this situation is to:
A. Assess the injection site
B. Select the appropriate injection site
C. Check the syringe to verify that the
nurse has removed the prescribed insulin
dose
D. Clean the injection site in a circular
manner with alcohol sponge
20. The physicians order reads
Administer 1 g cefazolin sodium
(Ancef) in 150 ml of normal saline
solution in 60 minutes. What is the
flow rate if the drop factor is 10 gtt =
1 ml?
A. 25 gtt/minute
B. 37 gtt/minute
C. 50 gtt/minute
D. 60 gtt/minute
21. A patient must receive 50 units
of Humulin regular insulin. The label
reads 100 units = 1 ml. How many
milliliters should the nurse
administer?
A. 0.5 ml
B. 0.75 ml

C. 1 ml
D. 2 ml
22. How should the nurse prepare an
injection for a patient who takes
both regular and NPH insulin?
A. Draw up the NPH insulin, then the
regular insulin, in the same syringe
B. Draw up the regular insulin, then the
NPH insulin, in the same syringe
C. Use two separate syringe
D. Check with the physician
23. A patient has just received 30 mg
of codeine by mouth for pain. Five
minutes later he vomits. What should
the nurse do first?
A. Call the physician
B. Remedicate the patient
C. Observe the emesis
D. Explain to the patient that she can do
nothing to help him
24. A patient is characterized with a
#16 indwelling urinary (Foley)
catheter to determine if:
A. Trauma has occurred
B. His 24-hour output is adequate
C. He has a urinary tract infection
D. Residual urine remains in the bladder
after voiding
25. A staff nurse who is promoted to
assistant nurse manager may feel
uncomfortable initially when
supervising her former peers. She
can best decrease this discomfort by:
A. Writing down all assignments
B. Making changes after evaluating the
situation and having discussions with the
staff.
C. Telling the staff nurses that she is
making changes to benefit their
performance
D. Evaluating the clinical performance of
each staff nurse in a private conference

Answers and Rationale

1. Answer: D. Encourage the patient
to increase his fluid intake, use nonirritating soap when bathing the
patient, and apply lotion to the
involved areas

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Page 3

Dry skin will eventually crack, ranking the

patient more prone to infection. To
prevent this, the nurse should provide
adequate hydration through fluid intake,
use nonirritating soaps or no soap when
bathing the patient, and lubricate the
patients skin with lotion. Bathing may be
limited but need not be avoided entirely.
The attending physician and dietitian may
be consulted for treatment, but homelaundered items usually are not
necessary.
2. Answer: C. Increases venous blood
return
Washing from distal to proximal areas
stimulates venous blood flow, thereby
preventing venous stasis. It improves
circulation but does not result in
vasoconstriction. The nurse can assess
the patients condition throughout the
bath, regardless of washing technique,
and should feel no strain while bathing
the patient.
3. Answer: B. Rapid eye movement
(REM) stage
Other characteristics of rapid eye
movement (REM) sleep are deep sleep
(the patient cannot be awakened easily),
depressed muscle tone, and possibly
irregular heart and respiratory rates. NonREM sleep is a deep, restful sleep without
dreaming. Delta stage, or slow-wave
sleep, occurs during non-REM Stages III
and IV and is often equated with quiet
sleep.
4. Answer: C. Tryptophan
Tryptophan is a natural sedative;
flurazepam (Dalmane), temazepam
(Restoril), and methotrimeprazine
(Levoprome) are hypnotic sedatives.
5. Answer: A. Have the patient take a
30- to 60-minute nap in the
afternoon
Napping in the afternoon is not
conductive to nighttime sleeping. Quiet
music, watching television, reading, and
massage usually will relax the patient,
helping him to fall asleep.
6. Answer: D. Prevent a patient from
becoming confused or disoriented
By restricting a patients movements,
restraints may increase stress and lead to
confusion, rather than prevent it. The

other choices are valid reasons for using

restraints.
7. Answer: D. All of the above
When applying restraints, the nurse must
document the type of behavior that
prompted her to use them, document the
type of restraints used, and obtain a
physicians written order for the
restraints.
8. Answer: C. Denial, anger,
bargaining, depression acceptance
Kubler-Rosss five successive stages of
death and dying are denial, anger,
bargaining, depression, and acceptance.
The patient may move back and forth
through the different stages as he and his
family members react to the process of
dying, but he usually goes through all of
these stages to reach acceptance.
9. Answer: C. Numbness
Numbness is typical of the depression
stage, when the patient feels a great
sense of loss. The anger stage includes
such feelings as rage, envy, resentment,
and the patients questioning Why me?
10. Answer: C. Reflecting on the
significance of death
According to thanatologists, reflecting on
the significance of death helps to reduce
the fear of death and enables the health
care provider to better understand the
terminally ill patients feelings. It also
helps to overcome the belief that medical
and nursing measures have failed, when
a patient cannot be cured.
11. Answer: C. Fixed, dilated pupils
Fixed, dilated pupils are sign of imminent
death. Pulse becomes weak but rapid,
muscles become weak and atonic, and
periods of apnea occur during respiration.
12. Answer: B. Centers for Disease
Control (CDC)
The Center of Disease Control (CDC)
publishes and frequently updates
guidelines on caring for patients who
require isolation. The National League of
Nursings (NLNs) major function is
accrediting nursing education programs in
the United States. The American Medical
Association (AMA) is a national
organization of physicians. The American
Nurses Association (ANA) is a national
organization of registered nurses.
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Page 4

13. Answer: A. Organisms mode of

transmission
Before instituting isolation precaution, the
nurse must first determine the organisms
mode of transmission. For example, an
organism transmitted through nasal
secretions requires that the patient be
kept in respiratory isolation, which
involves keeping the patient in a private
room with the door closed and wearing a
mask, a gown, and gloves when coming
in direct contact with the patient. The
organisms Gram-straining characteristics
reveal whether the organism is gramnegative or gram-positive, an important
criterion in the physicians choice for drug
therapy and the nurses development of
an effective plan of care. The nurse also
needs to know whether the organism is
susceptible to antibiotics, but this could
take several days to determine; if she
waits for the results before instituting
isolation precautions, the organism could
be transmitted in the meantime. The
patients susceptibility to the organism
has already been established. The nurse
would not be instituting isolation
precautions for a non-infected patient.
14. Answer: C. Have the patient
expectorate the sputum into a sterile
container
Placing the specimen in a sterile
container ensures that it will not become
contaminated. The other answers are
incorrect because they do not mention
sterility and because antiseptic
mouthwash could destroy the organism to
be cultured (before sputum collection, the
patient may use only tap water for
nursing the mouth).
15. Answer: D. Pressurized steam
penetrates the supplies better
An autoclave, an apparatus that sterilizes
equipment by means of high-temperature
pressurized steam, is used because it can
destroy all forms of microorganisms,
including spores.
16. Answer: C. Gently pull just below
the cuff and invert the gloves when
removing them
Turning the gloves inside out while
removing them keeps all contaminants
inside the gloves. They should than be

placed in a plastic bag with soiled

dressings and discarded in a soiled utility
room garbage pail (double bagged). The
other choices can spread pathogens
within the environment.
17. Answer: C. Phlebitis
Tenderness, warmth, swelling, and, in
some instances, a burning sensation are
signs and symptoms of phlebitis. Infection
is less likely because no drainage or fever
is present. Infiltration would result in
swelling and pallor, not erythema, near
the insertion site. The patient has no
evidence of bleeding.
18. Answer: B. Roll the vial gently
between the palms
Gently rolling a sealed vial between the
palms produces sufficient heat to
enhance dissolution of a powdered
medication. Shaking the vial vigorously
can break down the medication and alter
its pharmacologic action. Inverting the
vial or leaving it alone does not ensure
thorough homogenization of the powder
and the solvent.
19. Answer: C. Check the syringe to
verify that the nurse has removed
the prescribed insulin dose
When the nurse teaches the patient to
prepare an insulin injection, the patients
first priority is to validate the dose
accuracy. The next steps are to select the
site, assess the site, and clean the site
with alcohol before injecting the insulin.
20. Answer: A. 25 gtt/minute
21. Answer: A. 0.5 ml
22. Answer: B. Draw up the regular
insulin, then the NPH insulin, in the
same syringe
Drugs that are compatible may be mixed
together in one syringe. In the case of
insulin, the shorter-acting, clear insulin
(regular) should be drawn up before the
longer-acting, cloudy insulin (NPH) to
ensure accurate measurements.
23. Answer: C. Observe the emesis
After a patient has vomited, the nurse
must inspect the emesis to document
color, consistency, and amount. In this
situation, the patient recently ingested
medication, so the nurse needs to check
for remnants of the medication to help
determine whether the patient retained
Fundamentals of Nursing

Page 5

enough of it to be effective. The nurse

must then notify the physician, who will
decide whether to repeat the dose or
prescribe an antiemetic.
24. Answer: B. His 24-hour output is
adequate
A 24-hour urine output of less than 500
ml in an adult is considered inadequate
and may indicate kidney failure. This
must be corrected while the patient is in
the acute state so that appropriate fluids,
electrolytes, and medications can be
administered and excreted. Indwelling
catheterization is not needed to diagnose
trauma, urinary tract infection, or residual
urine.
25. Answer: B. Making changes after
evaluating the situation and having
discussions with the staff.
A new assistant nurse manager should
not make changes until she has had a
chance to evaluate staff members,
patients, and physicians. Changes must
be planned thoroughly and should be
based on a need to improve conditions,
not just for the sake of change. Written
assignments allow all staff members to
know their own and others responsibilities
and serve as a checklist for the manager,
enabling her to gauge whether the unit is
being run effectively and whether
patients are receiving appropriate care.
Telling the staff nurses that she is making
changes to benefit their performance
should occur only after the nurse has
made a thorough evaluation. Evaluations
are usually done on a yearly basis or as
needed.

PART 2
1. Nurse Clarisse 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

A. Shock dismay
B. Numbness
C. Stoicism
D. Preparatory grief

2. When examining a patient with

abdominal pain the nurse in charge
should assess:

7. 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. Any quadrant first

B. The symptomatic quadrant first
C. The symptomatic quadrant last
D. The symptomatic quadrant either
second or third

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

3. The nurse is assessing a

postoperative adult patient. Which of
the following should the nurse
document as subjective data?
A. Vital signs
B. Laboratory test result
C. Patients description of pain
D. Electrocardiographic (ECG) waveforms
4. A male patient has a soft wristsafety 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
5. 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
6. A female patient with a terminal
illness is in denial. Indicators of
denial include:
Fundamentals of Nursing

Page 6

8. 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
9. Before administering the evening
dose of a prescribed medication, the
nurse on the evening shift finds an
unlabeled, filled syringe in the
patients 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
10. 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
11. 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
12. A female patient exhibits signs of
heightened anxiety. Which response
by the nurse is most likely to reduce
the patients anxiety?
A. Everything will be fine. Dont worry.
B. Read this manual and then ask me
any questions you may have.
C. Why dont you listen to the radio?
D. Lets talk about whats bothering
you.
13. A scrub nurse in the operating
room has which responsibility?

A. Leave the medication at the patients

bedside
B. Tell the patient to be sure to take the
medication. And then leave it at the
bedside
C. Return shortly to the patients 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
15. The physician orders heparin,
7,500 units, to be administered
subcutaneously every 6 hours. The
vial reads 10,000 units per milliliter.
The nurse should anticipate giving
how much heparin for each dose?
A. ml
B. ml
C. ml
D. 1 ml
16. The nurse in charge measures a
patients temperature at 102
degrees F. what is the equivalent
Centigrade temperature?
A. 39 degrees C
B. 47 degrees C
C. 38.9 degrees C
D. 40.1 degrees C
17. To evaluate a patient for hypoxia,
the physician is most likely to order
which laboratory test?

A. Positioning the patient

B. Assisting with gowning and gloving
C. Handling surgical instruments to the
surgeon
D. Applying surgical drapes
Fundamentals of Nursing

14. A patient is in the bathroom

when the nurse enters to give a
prescribed medication. What should
the nurse in charge do?

Page 7

A. Red blood cell count

B. Sputum culture
C. Total hemoglobin
D. Arterial blood gas (ABG) analysis

18. The nurse uses a stethoscope to

auscultate a male patients chest.
Which statement about a
stethoscope with a bell and
diaphragm is true?

C. Tertiary prevention
D. Passive prevention

A. The bell detects high-pitched sounds

best
B. The diaphragm detects high-pitched
sounds best
C. The bell detects thrills best
D. The diaphragm detects low-pitched
sounds best

A. Leaves the bed in the high position

when finished
B. Places the pillow at the head of the bed
C. Rolls the patient to the far side of the
bed
D. Tucks the top sheet and blanket under
the bottom of the bed

19. A male patient is to be

discharged with a prescription for an
analgesic that is a controlled
substance. During discharge
teaching, the nurse should explain
that the patient must fill this
prescription how soon after the date
on which it was written?

23. The physician prescribes 250 mg

of a drug. The drug vial reads 500
mg/ml. how much of the drug should
the nurse give?

A. Within 1 month
B. Within 3 months
C. Within 6 months
D. Within 12 months

A. 2 ml
B. 1 ml
C. ml
D. ml
24. Nurse Mackey is monitoring a
patient for adverse reactions during
barbiturate therapy. What is the
major disadvantage of barbiturate
use?

20. Which human element

considered by the nurse in charge
during assessment can affect drug
administration?

A. Prolonged half-life
B. Poor absorption
C. Potential for drug dependence
D. Potential for hepatotoxicity

A. The patients ability to recover

B. The patients occupational hazards
C. The patients socioeconomic status
D. The patients cognitive abilities

25. Which nursing action is essential

when providing continuous enteral
feeding?

21. An employer establishes a

physical exercise area in the
workplace and encourages all
employees to use it. This is an
example of which level of health
promotion?

A. Elevating the head of the bed

B. Positioning the patient on the left side
C. Warming the formula before
administering it
D. Hanging a full days worth of formula
at one time

A. Primary prevention
B. Secondary prevention
Fundamentals of Nursing

22. What does the nurse in charge do

when making a surgical bed?

Page 8

26. When teaching a female patient

how to take a sublingual tablet, the
nurse should instruct the patient to
place the table on the:

A. Radial
B. Brachial
C. Femoral
D. Carotid

A. Top of the tongue

B. Roof of the mouth
C. Floor of the mouth
D. Inside of the cheek
27. Which action by the nurse in
charge is essential when cleaning
the area around a Jackson-Pratt
wound drain?
A. Cleaning from the center outward in a
circular motion
B. Removing the drain before cleaning the
skin
C. Cleaning briskly around the site with
alcohol
D. Wearing sterile gloves and a mask
28. The doctor orders dextrose 5% in
water, 1,000 ml to be infused over 8
hours. The I.V. tubing delivers 15
drops per milliliter. The nurse in
charge should run the I.V. infusion at
a rate of:
A. 15 drop per minute
B. 21 drop per minute
C. 32 drop per minute
D. 125 drops per minute
29. A female 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

Fundamentals of Nursing

30. Which pulse should the nurse

palpate during rapid assessment of
an unconscious male adult?

Page 9

Fundamentals of Nursing

Page 10

The nurse should systematically assess all

areas of the abdomen, if time and the
patients 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.
3. Answer: C. Patients description of
pain
Subjective data come directly from the
patient and usually are recorded as direct
quotations that reflect the patients
opinions or feelings about a situation.
Vital signs, laboratory test result, and ECG
waveforms are examples of objective
data.
4. Answer: C. Cool, pale fingers
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.
Answers and Rationale

5. Answer: A. Frontal plane

1. Answer: B. Sensory deficits

Sensory deficits could cause a geriatric
patient to have difficulty retaining
knowledge about prescribed medications.
Decreased plasma drug levels do not
alter the patients knowledge about the
drug. A lack of family support may affect
compliance, not knowledge retention.
Toilette syndrome is unrelated to
knowledge retention.

6. Answer: A. Shock dismay

2. Answer: C. The symptomatic

quadrant last

Fundamentals of Nursing

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.

Shock and dismay are early signs of

denial-the first stage of grief. The other
Page 11

options are associated with depressiona

later stage of grief.
7. Answer: B. Helps the patient
dangle the legs
After placing the patient in high Fowlers
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.
8. Answer: D. Demonstrating the
procedure and having the patient
return the demonstration

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 patients wishes known to the doctor.
12. Answer: D. Lets talk about
whats bothering you.

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.
9. Answer: A. Discard the syringe to
avoid a medication error
As a safety precaution, the nurse should
discard an unlabeled syringe that
contains medication. The other options
are considered unsafe because they
promote error.
10. Answer: B. Aging-related
physiological changes
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.
Fundamentals of Nursing

11. Answer: B. Educator

Page 12

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
patients feeling and block
communication, they would not reduce
anxiety.
13. Answer: C. Handling surgical
instruments to the surgeon
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.

14. Answer: C. Return shortly to the

patients room and remain there
until the patient takes the
medication

low pitched sounds best. Palpation

detects thrills best.

The nurse should return shortly to the

patients 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 patients
bedside unless specifically requested to
do so.

In most cases, an outpatient must fill a

prescription for a controlled substance
within 6 months of the date on which the
prescription was written.

15. Answer: C. ml

The nurse must consider the patients

cognitive abilities to understand drug
instructions. If not, the nurse must find a
family member or significant other to take
on the responsibility of administering
medications in the home setting. The
patients ability to recover, occupational
hazards, and socioeconomic status do not
affect drug administration.

The nurse solves the problem as follows:

10,000 units/7,500 units = 1 ml/X
10,000 X = 7,500
X= 7,500/10,000 or ml
16. Answer: C. 38.9 degrees C
To convert Fahrenheit degrees to
centigrade, use this formula:

20. Answer: D. The patients

cognitive abilities

21. Answer: A. Primary prevention

Primary prevention precedes disease and
applies to health patients. Secondary
prevention focuses on patients who have
health problems and are at risk for
developing complications. Tertiary
prevention enables patients to gain
health from others activities without
doing anything themselves.

C degrees = (F degrees 32) x 5/9

C degrees = (102 32) 5/9
+ 70 x 5/9
38.9 degrees C
17. Answer: D. Arterial blood gas
(ABG) analysis
All of these test help evaluate a patient
with respiratory problems. However, ABG
analysis is the only test evaluates gas
exchange in the lungs, providing
information about patients oxygenation
status.
18. Answer: B. The diaphragm
detects high-pitched sounds best
The diaphragm of a stethoscope detects
high-pitched sound best; the bell detects

Fundamentals of Nursing

19. Answer: C. Within 6 months

Page 13

22. Answer: A. Leaves the bed in the

high position when finished
When making a surgical bed, the nurse
leaves the bed in the high position when
finished. After placing the top linens on
the bed without pouching them, the nurse
fanfolds these linens to the side opposite
from where the patient will enter and
places the pillow on the bedside chair. All
these actions promote transfer of the
postoperative patient from the stretcher
to the bed. When making an occupied

bed or unoccupied bed, the nurse places

the pillow at the head of the bed and
tucks the top sheet and blanket under the
bottom of the bed. When making an
occupied bed, the nurse rolls the patient
to the far side of the bed.
23. Answer: C. ml
The nurse should give ml of the drug.
The dosage is calculated as follows:
250 mg/X=500 mg/1 ml
500x=250
X=1/2 ml

27. Answer: A. Cleaning from the

center outward in a circular motion

24. Answer: C. Potential for drug

dependence
Patients 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 do not
cause hepatotoxicity, although existing
hepatic damage does require cautions
use of the drug because barbiturates are
metabolized in the liver.
25. Answer: A. Elevating the head of
the bed
Elevating the head of the bed during
enteral feeding minimizes the risk of
aspiration and allows the formula to flow
in the patients intestines. When such
elevation is contraindicated, the patient
should be positioned on the right side.
The nurse should give enteral feeding at
room temperature to minimize GI
distress. To limit microbial growth, the
nurse should hang only the amount of
formula that can be infused in 3 hours.
26. Answer: C. Floor of the mouth
Fundamentals of Nursing

The nurse should instruct the patient to

touch the tip of the tongue to the roof of
the mouth and then place the sublingual
tablet on the floor of the mouth.
Sublingual medications are absorbed
directly into the bloodstream form the
oral mucosa, bypassing the GI and
hepatic systems. No drug is administered
on top of the tongue or on the roof of the
mouth. With the buccal route, the tablet
is placed between the gum and the
cheek.

The nurse always should clean around a

wound drain, moving from center outward
in ever-larger circles, because the skin
near the drain site is more contaminated
than the site itself. The nurse should
never remove the drain before cleaning
the skin. Alcohol should never be used to
clean around a drain; it may irritate the
skin and has no lasting effect on bacteria
because it evaporates. The nurse should
wear sterile gloves to prevent
contamination, but a mask is not
necessary.
28. Answer: C. 32 drop per minute
Giving 1,000 ml over 8 hours is the same
as giving 125 ml over 1 hour (60 minutes)
to find the number of milliliters per
minute:
125/60 min = X/1 minute
60X = 125X = 2.1 ml/minute
To find the number of drops/minute:
2.1 ml/X gtts = 1 ml/15 gtts
X = 32 gtts/minute, or 32 drops/minute
29. Answer: A. Restlessness

Page 14

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.
30. Answer: D. Carotid
During a rapid assessment, the nurses
first priority is to check the patients vital
functions by assessing his airway,
breathing, and circulation. To check a
patients 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
patients 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.

PART 3
1. Which intervention is an example
of primary prevention?
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Page 15

A. Administering digoxin (Lanoxicaps) to a

patient with heart failure
B. Administering a measles, mumps, and
rubella immunization to an infant
C. Obtaining a Papanicolaou smear to
screen for cervical cancer
D. Using occupational therapy to help a
patient cope with arthritis

C. Lean red meat

D. Creamed corn

2. The nurse in charge is assessing a

patients abdomen. Which
examination technique should the
nurse use first?

A. Lethal arrhythmias
B. Malignant hypertension
C. Status epilepticus
D. Bone marrow suppression

A. Auscultation
B. Inspection
C. Percussion
D. Palpation

7. A female patient is diagnosed with

deep-vein thrombosis. Which nursing
diagnosis should receive highest
priority at this time?

3. Which statement regarding heart

sounds is correct?

A. Impaired gas exchanges related to

increased blood flow
B. Fluid volume excess related to
peripheral vascular disease
C. Risk for injury related to edema
D. Altered peripheral tissue perfusion
related to venous congestion

A. S1 and S2 sound equally loud over the

entire cardiac area.
B. S1 and S2 sound fainter at the apex
C. S1 and S2 sound fainter at the base
D. S1 is loudest at the apex, and S2 is
loudest at the base
4. The nurse in charge identifies a
patients responses to actual or
potential health problems during
which step of the nursing process?
A. Assessment
B. Nursing diagnosis
C. Planning
D. Evaluation
5. A female patient is receiving
furosemide (Lasix), 40 mg P.O. b.i.D.
in the plan of care, the nurse should
emphasize teaching the patient
about the importance of consuming:
A. Fresh, green vegetables
B. Bananas and oranges
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Page 16

6. The nurse in charge must monitor

a patient receiving chloramphenicol
for adverse drug reaction. What is
the most toxic reaction to
chloramphenicol?

8. When positioned properly, the tip

of a central venous catheter should
lie in the:
A. Superior vena cava
B. Basilica vein
C. Jugular vein
D. Subclavian vein
9. Nurse Nikki is revising a clients
care plan. During which step of the
nursing process does such revision
take place?
A. Assessment
B. Planning
C. Implementation
D. Evaluation

10. A 65-year-old female who has

diabetes mellitus and has sustained
a large laceration on her left wrist
asks the nurse, How long will it take
for my scars to disappear? which
statement would be the nurses best
response?
A. The contraction phase of wound
healing can take 2 to 3 years.
B. Wound healing is very individual but
within 4 months the scar should fade.
C. With your history and the type of
location of the injury, its hard to say.
D. If you dont develop an infection, the
wound should heal any time between 1
and 3 years from now.
11. One aspect of implementation
related to drug therapy is:
A. Developing a content outline
B. Documenting drugs given
C. Establishing outcome criteria
D. Setting realistic client goals
12. A female client is readmitted to
the facility with a warm, tender,
reddened area on her right calf.
Which contributing factor would the
nurse recognize as most important?
A. A history of increased aspirin use
B. Recent pelvic surgery
C. An active daily walking program
D. A history of diabetes
13. Which intervention should the
nurse in charge try first for a client
that exhibits signs of sleep
disturbance?
A. Administer sleeping medication before
bedtime
B. Ask the client each morning to describe
the quantity of sleep during the previous
night
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Page 17

C. Teach the client relaxation techniques,

such as guided imagery, medication, and
progressive muscle relaxation
D. Provide the client with normal sleep
aids, such as pillows, back rubs, and
snacks
14. While examining a clients leg,
the nurse notes an open ulceration
with visible granulation tissue in the
wound. Until a wound specialist can
be contacted, which type of
dressings is most appropriate for the
nurse in charge to apply?
A. Dry sterile dressing
B. Sterile petroleum gauze
C. Moist, sterile saline gauze
D. Povidone-iodine-soaked gauze
15. A male client in a behavioralhealth facility receives a 30-minute
psychotherapy session, and provider
uses a current procedure
terminology (CPT) code that bills for
a 50-minute session. Under the False
Claims Act, such illegal behavior is
known as:
A. Unbundling
B. Overbilling
C. Upcoding
D. Misrepresentation
16. A nurse assigned to care for a
postoperative male client who has
diabetes mellitus. During the
assessment interview, the client
reports that hes impotent and says
that hes concerned about its effect
on his marriage. In planning this
clients care, the most appropriate
intervention would be to:
A. Encourage the client to ask questions
about personal sexuality
B. Provide time for privacy

C. Provide support for the spouse or

significant other
D. Suggest referral to a sex counselor or
other appropriate professional

A. Extravasation
B. Osteomalacia
C. Petechiae
D. Uremia

17. Using Abraham Maslows

hierarchy of human needs, a nurse
assigns highest priority to which
client need?

21. Which document addresses the

clients right to information,
informed consent, and treatment
refusal?

A. Security
B. Elimination
C. Safety
D. Belonging

A. Standard of Nursing Practice

B. Patients Bill of Rights
C. Nurse Practice Act
D. Code for Nurses

18. A male client is on prolonged bed

rest has developed a pressure ulcer.
The wound shows no signs of healing
even though the client has received
skin care and has been turned every
2 hours. Which factor is most likely
responsible for the failure to heal?

22. If a blood pressure cuff is too

small for a client, blood pressure
readings taken with such a cuff may
do which of the following?

A. Inadequate vitamin D intake

B. Inadequate protein intake
C. Inadequate massaging of the affected
area
D. Low calcium level
19. A female client who received
general anesthesia returns from
surgery. Postoperatively, which
nursing diagnosis takes highest
priority for this client?
A. Acute pain related to surgery
B. Deficient fluid volume related to blood
and fluid loss from surgery
C. Impaired physical mobility related to
surgery
D. Risk for aspiration related to
anesthesia
20. The nurse inspects a clients
back and notices small hemorrhagic
spots. The nurse documents that the
client has:
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Page 18

A. Fail to show changes in blood pressure

B. Produce a false-high measurement
C. Cause sciatic nerve damage
D. Produce a false-low measurement
23. Nurse Elijah has been teaching a
client about a high-protein diet. The
teaching is successful if the client
identifies which meal as high in
protein?
A. Baked beans, hamburger, and milk
B. Spaghetti with cream sauce, broccoli,
and tea
C. Bouillon, spinach, and soda
D. Chicken cutlet, spinach, and soda
24. A male client is admitted to the
hospital with blunt chest trauma
after a motor vehicle accident. The
first nursing priority for this client
would be to:
A. Assess the clients airway
B. Provide pain relief
C. Encourage deep breathing and

coughing
D. Splint the chest wall with a pillow

mm in the left eye and 3 mm in the

right eye. Unequal pupils are known
as:

25. A newly hired charge nurse

assesses the staff nurses as
competent individually but
ineffective and nonproductive as a
team. In addressing her concern, the
charge nurse should understand that
the usual reason for such a situation
is:
A. Unhappiness about the charge in
leadership
B. Unexpected feeling and emotions
among the staff
C. Fatigue from overwork and
understaffing
D. Failure to incorporate staff in decision
making
26. A male client blood test results
are as follows: white blood cell
(WBC) count, 100ul; hemoglobin (Hb)
level, 14 g/dl; hematocrit (HCT), 40%.
Which goal would be most important
for this client?
A. Promote fluid balance
B. Prevent infection
C. Promote rest
D. Prevent injury
27. Following a tonsillectomy, a
female client returns to the medicalsurgical 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
28. The nurse inspects a clients
pupil size and determines that its 2
Fundamentals of Nursing

Page 19

A. Anisocoria
B. Ataxia
C. Cataract
D. Diplopia
29. The nurse in charge is caring for
an Italian client. Hes complaining of
pain, but he falls asleep right after
his complaint and before the nurse
can assess his pain. The nurse
concludes that:
A. He may have a low threshold for pain
B. He was faking pain
C. Someone else gave him medication
D. The pain went away
30. A female client is admitted to the
emergency department with
complaints of chest pain shortness of
breath. The nurses assessment
reveals jugular vein distention. The
nurse knows that when a client has
jugular vein distension, its typically
due to:
A. A neck tumor
B. An electrolyte imbalance
C. Dehydration
D. Fluid overload

Fundamentals of Nursing

Page 20

nurse systematically collects data about

the patient or family. During the planning
step, the nurse develops strategies to
resolve or decrease the patients
problem. During the evaluation step, the
nurse determines the effectiveness of the
plan of care.

Answers and Rationale

1. Answer: B. Administering a
measles, mumps, and rubella
immunization to an infant
Immunizing an infant is an example of
primary prevention, which aims to
prevent health problems.
Administering digoxin to treat heart
failure and obtaining a smear for a
screening test are examples for
secondary prevention, which promotes
early detection and treatment of disease.
Using occupational therapy to help a
patient cope with arthritis is an example
of tertiary prevention, which aims to help
a patient deal with the residual
consequences of a problem or to prevent
the problem from recurring.
2. Answer: B. Inspection
Inspection always comes first when
performing a physical examination.
Percussion and palpation of the abdomen
may affect bowel motility and therefore
should follow auscultation.
3. Answer: D. S1 is loudest at the
apex, and S2 is loudest at the base
The S1 soundthe lub soundis
loudest at the apex of the heart. It sounds
longer, lower, and louder there than the
S2 sounds. The S2the dub soundis
loudest at the base. It sounds shorter,
sharper, higher, and louder there than S1.
4. Answer: B. Nursing diagnosis
The nurse identifies human responses to
actual or potential health problems during
the nursing diagnosis step of the nursing
process. During the assessment step, the
Fundamentals of Nursing

Page 21

5. Answer: B. Bananas and oranges

Because furosemide is a potassiumwasting diuretic, the nurse should plan to
teach the patient to increase intake of
potassium-rich foods, such as bananas
and oranges. Fresh, green vegetables;
lean red meat; and creamed corn are not
good sources of potassium.
6. Answer: D. Bone marrow
suppression
The most toxic reaction to
chloramphenicol is bone marrow
suppression. Chloramphenicol is not
known to cause lethal arrhythmias,
malignant hypertension, or status
epilepticus.
7. Answer: D. Altered peripheral
tissue perfusion related to venous
congestion
Altered peripheral tissue perfusion related
to venous congestion takes highest
priority because venous inflammation and
clot formation impede blood flow in a
patient with deep-vein thrombosis. Option
A is incorrect because impaired gas
exchange is related to decreased, not
increased, blood flow. Option B is
inappropriate because no evidence
suggest that this patient has a fluid
volume excess. Option C may be
warranted but is secondary to altered
tissue perfusion.
8. Answer: A. Superior vena cava

When the central venous catheter is

positioned correctly, its tip lies in the
superior vena cava, inferior vena cava, or
the right atriumthat is, in central
venous circulation. Blood flows
unimpeded around the tip, allowing the
rapid infusion of large amounts of fluid
directly into circulation. The basilica,
jugular, and subclavian veins are common
insertion sites for central venous
catheters.

12. Answer: B. Recent pelvic surgery

The client shows signs of deep vein
thrombosis (DVT). The pelvic area is rich
in blood supply, and thrombophlebitis of
the deep vein is associated with pelvic
surgery. Aspirin, an antiplatelet agent,
and an active walking program help
decrease the clients risk of DVT. In
general, diabetes is a contributing factor
associated with peripheral vascular
disease.

9. Answer: D. Evaluation
During the evaluation step of the nursing
process the nurse determines whether
the goals established in the care plan
have been achieved, and evaluates the
success of the plan. If a goal is unmet or
partially met the nurse reexamines the
data and revises the plan. Assessment
involves data collection. Planning involves
setting priorities, establishing goals, and
selecting appropriate interventions.
10. Answer: C. With your history
and the type of location of the injury,
its hard to say.
Wound healing in a client with diabetes
will be delayed. Providing the client with a
time frame could give the client false
information.
11. Answer: B. Documenting drugs
given
Although documentation isnt 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
clients reaction. Developing a content
outline, establishing outcome criteria, and
setting realistic client goals are part of
planning rather than implementation.
Fundamentals of Nursing

Page 22

13. Answer: D. Provide the client

with normal sleep aids, such as
pillows, back rubs, and snacks
The nurse should begin with the simplest
interventions, such as pillows or snacks,
before interventions that require greater
skill such as relaxation techniques. Sleep
medication should be avoided whenever
possible. At some point, the nurse should
do a thorough sleep assessment,
especially if common sense interventions
fail.
14. Answer: C. Moist, sterile saline
gauze
Moist, sterile saline dressings support
would heal and are cost-effective. Dry
sterile dressings adhere to the wound and
debride the tissue when removed.
Petroleum supports healing but is
expensive. Povidone-iodine can irritate
epithelial cells, so it shouldnt be left on
an open wound.
15. Answer: C. Upcoding
Upcoding is the practice of using a CPT
code thats reimbursed at a higher rate
than the code for the service actually
provided. Unbundling, overbilling, and
misrepresentation arent the terms used
for this illegal practice.

16. Answer: D. Suggest referral to a

sex counselor or other appropriate
professional
The nurse should refer this client to a sex
counselor or other professional. Making
appropriate referrals is a valid part of
planning the clients care. The nurse
doesnt normally provide sex counseling.
Therefore, providing time for privacy and
providing support for the spouse or
significant other are important, but not as
important as referring the client to a sex
counselor.
17. Answer: B. Elimination
According to Maslow, elimination is a firstlevel or physiological need, and therefore
takes priority over all other needs.
Security and safety are second-level
needs; belonging is a third-level need.
Second- and third-level needs can be met
only after a clients first-level needs have
been satisfied.
18. Answer: B. Inadequate protein
intake
A client on bed rest suffers from a lack of
movement and a negative nitrogen
balance. Therefore, inadequate protein
intake impairs wound healing. Inadequate
vitamin D intake and low calcium levels
arent factors in poor healing for this
client. A pressure ulcer should never be
massaged.
19. Answer: D. Risk for aspiration
related to anesthesia
Risk for aspiration related to anesthesia
takes priority for this client because
general anesthesia may impair the gag
and swallowing reflexes, possibly leading
to aspiration. The other options, although
important, are secondary.
Fundamentals of Nursing

Page 23

20. Answer: C. Petechiae

Petechiae are small hemorrhagic spots.
Extravasation is the leakage of fluid in the
interstitial space. Osteomalacia is the
softening of bone tissue. Uremia is an
excess of urea and other nitrogen
products in the blood.
21. Answer: B. Patients Bill of Rights
The Patients Bill of Rights addresses the
clients right to information, informed
consent, timely responses to requests for
services, and treatment refusal. A legal
document, it serves as a guideline for the
nurses decision making. Standards of
Nursing Practice, the Nurse Practice Act,
and the Code for Nurses contain nursing
practice parameters and primarily
describe the use of the nursing process in
providing care.
22. Answer: B. Produce a false-high
measurement
Using an undersized blood pressure cuff
produces a falsely elevated blood
pressure because the cuff cant record
brachial artery measurements unless its
excessively inflated. The sciatic nerve
wouldnt be damaged by hyperinflation of
the blood pressure cuff because the
sciatic nerve is located in the lower
extremity.
23. Answer: A. Baked beans,
hamburger, and milk
Baked beans, hamburger, and milk are all
excellent sources of protein. The
spaghetti-broccoli-tea choice is high in
carbohydrates. The bouillon-spinach-soda
choice provides liquid and sodium as well
as some iron, vitamins, and
carbohydrates. Chicken provides protein
but the chicken-spinach-soda combination

provides less protein than the baked

beans-hamburger-milk selection.

position dont allow for adequate oral

drainage in a lethargic post tonsillectomy
client, and increase the risk of blood
aspiration.

24. Answer: A. Assess the clients

airway

28. Answer: A. Anisocoria

The first priority is to evaluate airway
patency before assessing for signs of
obstruction, sternal retraction, stridor, or
wheezing. Airway management is always
the nurses first priority. Pain
management and splinting are important
for the clients comfort, but would come
after airway assessment. Coughing and
deep breathing may be contraindicated if
the client has internal bleeding and other
injuries.
25. Answer: B. Unexpected feeling
and emotions among the staff
The usual or most prevalent reason for
lack of productivity in a group of
competent nurses is inadequate
communication or a situation in which the
nurses have unexpected feeling and
emotions. Although the other options
could be contributing to the problematic
situation, theyre less likely to be the
cause.
26. Answer: B. Prevent infection
The client is at risk for infection because
WBC count is dangerously low. Hb level
and HCT are within normal limits;
therefore, fluid balance, rest, and
prevention of injury are inappropriate.
27. Answer: D. Side-lying
Because of lethargy, the post
tonsillectomy client is at risk for
aspirating blood from the surgical wound.
Therefore, placing the client in the sidelying position until he awake is best. The
semi-Fowlers, supine, and high-Fowlers
Fundamentals of Nursing

Page 24

Unequal pupils are called anisocoria.

Ataxia is uncoordinated actions of
involuntary muscle use. A cataract is an
opacity of the eyes lens. Diplopia is
double vision.
29. Answer: A. He may have a low
threshold for pain
People of Italian heritage tend to
verbalize discomfort and pain. The pain
was real to the client, and he may need
medication when he wakes up.
30. Answer: D. Fluid overload
Fluid overload causes the volume of blood
within the vascular system to increase.
This increase causes the vein to distend,
which can be seen most obviously in the
neck veins. A neck tumor doesnt typically
cause jugular vein distention. An
electrolyte imbalance may result in fluid
overload, but it doesnt directly contribute
to jugular vein distention.

PART 4
1. Critical thinking and the nursing
process have which of the following
in common? Both:
A. Are important to use in nursing
practice
B. Use an ordered series of steps
C. Are patient-specific processes
D. Were developed specifically for nursing
2. In which step of the nursing
process does the nurse analyze data
and identify client problems?
A. Assessment
B. Diagnosis
C. Planning outcomes
D. Evaluation
3. In which phase of the nursing
process does the nurse decide
whether her actions have
successfully treated the clients
health problem?
A. Assessment
B. Diagnosis
C. Planning outcomes
D. Evaluation
4. What is the most basic reason that
self-knowledge is important for
nurses? Because it helps the nurse
to:

Fundamentals of Nursing

Page 25

A. Identify personal biases that may affect

his thinking and actions
B. Identify the most effective
interventions for a patient
C. Communicate more efficiently with
colleagues, patients, and families
D. Learn and remember new procedures
and techniques

tobacco, especially when they have a

serious lung condition; I figure if I
can stop smoking, they should be
able to. I must remember how
physically and psychologically
difficult that is, and be very careful
not to let be judgmental of this
patient. This best illustrates:

5. Arrange the steps of the nursing

process in the sequence in which
they generally occur.

A. Theoretical knowledge
B. Self-knowledge
C. Using reliable resources
D. Use of the nursing process

A. Assessment
B. Evaluation
C. Planning outcomes
D. Planning interventions
E. Diagnosis

8. Which organizations standards

require that all patients be assessed
specifically for pain?

A. E, B, A, D, C
B. A, B, C, D, E
C. A, E, C, D, B
D. D, A, B, E, C

A. American Nurses Association (ANA)

B. State nurse practice acts
C. National Council of State Boards of
Nursing (NCSBN)
D. The Joint Commission

6. How are critical thinking skills and

critical thinking attitudes similar?
Both are:

9. Which of the following is an

example of data that should be
validated?

A. Influences on the nurses problem

solving and decision making
B. Like feelings rather than cognitive
activities
C. Cognitive activities rather than feelings
D. Applicable in all aspects of a persons
life

A. The urinalysis report indicates there

are white blood cells in the urine.
B. The client states she feels feverish; you
measure the oral temperature at 98F.
C. The client has clear breath sounds; you
count a respiratory rate of 18.
D. The chest x-ray report indicates the
client has pneumonia in the right lower
lobe.

7. The nurse is preparing to admit a

patient from the emergency
department. The transferring nurse
reports that the patient with chronic
lung disease has a 30+ year history
of tobacco use. The nurse used to
smoke a pack of cigarettes a day at
one time and worked very hard to
quit smoking. She immediately
thinks to herself, I know I tend to
feel negatively about people who use
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Page 26

10. Which of the following is an

example of appropriate behavior
when conducting a client interview?
A. Recording all the information on the
agency-approved form during the
interview
B. Asking the client, Why did you think it
was necessary to seek health care at this

time?
C. Using precise medical terminology
when asking the client questions
D. Sitting, facing the client in a chair at
the clients bedside, using active listening
11. The nurse wishes to identify
nursing diagnoses for a patient. She
can best do this by using a data
collection form organized according
to: Select all that apply.
A. A body systems model
B. A head-to-toe framework
C. Maslows hierarchy of needs
D. Gordons functional health patterns
12. The nurse is recording
assessment data. She writes, The
patient seems worried about his
surgery. Other than that, he had a
good night. Which errors did the
nurse make? Select all that apply.
A. Used a vague generality
B. Did not use the patients exact words
C. Used a waffle word (e.g., appears)
D. Recorded an inference rather than a
cue
13. A patient is admitted with
shortness of breath, so the nurse
immediately listens to his breath
sounds. Which type of assessment is
the nurse performing?
A. Ongoing assessment
B. Comprehensive physical assessment
C. Focused physical assessment
D. Psychosocial assessment
14. The nurse is assessing vital signs
for a patient just admitted to the
hospital. Ideally, and if there are no
contraindications, how should the
nurse position the patient for this
Fundamentals of Nursing

Page 27

portion of the admission

assessment?
A. Sitting upright
B. Lying flat on the back with knees flexed
C. Lying flat on the back with arms and
legs fully extended
D. Side-lying with the knees flexed
15. For all body systems except the
abdomen, what is the preferred
order for the nurse to perform the
following examination techniques?
A. Palpation
B. Auscultation
C. Inspection
D. Percussion
A. D, B, A, C
B. C, A, D, B
C. B, C, D, A
D. A, B, C, D
16. The nurse is assessing a patient
admitted to the hospital with rectal
bleeding. The patient had a hip
replacement 2 weeks ago. Which
position should the nurse avoid when
examining this patients rectal area?
A. Sims
B. Supine
C. Dorsal recumbent
D. Semi-Fowlers
17. How should the nurse modify the
examination for a 7-year-old child?
A. Ask the parents to leave the room
before the examination.
B. Demonstrate equipment before using
it.
C. Allow the child to help with the
examination.
D. Perform invasive procedures (e.g.,
otoscopic) last.

18. The nurse must examine a

patient who is weak and unable to sit
unaided or to get out of bed. How
should she position the patient to
begin and perform most of the
physical examination?
A. Dorsal recumbent
B. Semi-Fowlers
C. Lithotomy
D. Sims
19. The nurse should use the
diaphragm of the stethoscope to
auscultate which of the following?
A. Heart murmurs
B. Jugular venous hums
C. Bowel sounds
D. Carotid bruits
20. The nurse calculates a body mass
index (BMI) of 18 for a young adult
woman who comes to the physicians
office for a college physical. This
patient is considered:
A. Obese
B. Overweight
C. Average
D. Underweight

Answers and Rationale

Fundamentals of Nursing

Page 28

1. Answer: A. Are important to use in

nursing practice
Nurses make many decisions: some
require using the nursing process,
whereas others are not client related but
require critical thinking. The nursing
process has specific steps; critical
thinking does not. Neither is linear.
Critical thinking applies to any discipline.
2. Answer: B. Diagnosis
In the assessment phase, the nurse
gathers data from many sources for
analysis in the diagnosis phase. In the
diagnosis phase, the nurse identifies the
clients health status. In the planning
outcomes phase, the nurse formulates
goals and outcomes. In the evaluation
phase, which occurs after implementing
interventions, the nurse gathers data
about the clients responses to nursing
care to determine whether client
outcomes were met.

4. Answer: A. Identify personal

biases that may affect his thinking
and actions
The most basic reason is that selfknowledge directly affects the nurses
thinking and the actions he chooses.
Indirectly, thinking is involved in
identifying effective interventions,
communicating, and learning procedures.
However, because identifying personal
biases affects all the other nursing
actions, it is the most basic reason.
5. Answer: C. A, E, C, D, B
Logically, the steps are assessment,
diagnosis, planning outcomes, planning
interventions, and evaluation. Keep in
mind that steps are not always performed
in this order, depending on the patients
needs, and that steps overlap.
6. Answer: A. Influences on the
nurses problem solving and decision
making

3. Answer: D. Evaluation
In the assessment phase, the nurse
gathers data from many sources for
analysis in the diagnosis phase. In the
diagnosis phase, the nurse identifies the
clients health status. In the planning
outcomes phase, the nurse and client
decide on goals they want to achieve. In
the intervention planning phase, the
nurse identifies specific interventions to
help achieve the identified goal. During
the implementation phase, the nurse
carries out the interventions or delegates
them to other health care team members.
During the evaluation phase, the nurse
judges whether her actions have been
successful in treating or preventing the
identified client health problem.

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Page 29

Cognitive skills are used in complex

thinking processes, such as problem
solving and decision making. Critical
thinking attitudes determine how a
person uses her cognitive skills. Critical
thinking attitudes are traits of the mind,
such as independent thinking, intellectual
curiosity, intellectual humility, and fairmindedness, to name a few. Critical
thinking skills refer to the cognitive
activities used in complex thinking
processes. A few examples of these skills
involve recognizing the need for more
information, recognizing gaps in ones
own knowledge, and separating relevant
from irrelevant data. Critical thinking,
which consists of intellectual skills and
attitudes, can be used in all aspects of
life.

7. Answer: B. Self-knowledge

usually necessary for laboratory test

results.

Personal knowledge is self-understanding

awareness of ones beliefs, values,
biases, and so on. That best describes the
nurses awareness that her bias can
affect her patient care. Theoretical
knowledge consists of information, facts,
principles, and theories in nursing and
related disciplines; it consists of research
findings and rationally constructed
explanations of phenomena. Using
reliable resources is a critical thinking
skill. The nursing process is a problemsolving process consisting of the steps of
assessing, diagnosing, planning
outcomes, planning interventions,
implementing, and evaluating. The nurse
has not yet met this patient, so she could
not have begun the nursing process.
8. Answer: D. The Joint Commission
The Joint Commission has developed
assessment standards, including that all
clients be assessed for pain. The ANA has
developed standards for clinical practice,
including those for assessment, but not
specifically for pain. State nurse practice
acts regulate nursing practice in
individual states. The NCSBN asserts that
the scope of nursing includes a
comprehensive assessment but does not
specifically include pain.
9. Answer: B. The client states she
feels feverish; you measure the oral
temperature at 98F.
Validation should be done when
subjective and objective data do not
make sense. For instance, it is
inconsistent data when the patient feels
feverish and you obtain a normal
temperature. The other distractors do not
offer conflicting data. Validation is not
Fundamentals of Nursing

Page 30

10. Answer: D. Sitting, facing the

client in a chair at the clients
bedside, using active listening
Active listening should be used during an
interview. The nurse should face the
patient, have relaxed posture, and keep
eye contact. Asking why may make the
client defensive. Note-taking interferes
with eye contact. The client may not
understand medical terminology or health
care jargon.
11. Answers: C, D
Nursing models produce a holistic
database that is useful in identifying
nursing rather than medical diagnoses.
Body systems and head-to-toe are not
nursing models, and they are not holistic;
they focus on identifying physiological
needs or disease. Maslows hierarchy is
not a nursing model, but it is holistic, so it
is acceptable for identifying nursing
diagnoses. Gordons functional health
patterns are a nursing model.
12. Answer: A, C, D
The nurse recorded a vague generality:
he has had a good night. The nurse did
not use the patients exact words, but she
did not quote the patient at all, so that is
not one of her errors. The nurse used the
waffle word, seems worried instead of
documenting what the patient said or did
to lead her to that conclusion. The nurse
recorded these inferences: worried and
had a good night.
13. Answer: C. Focused physical
assessment

The nurse is performing a focused

physical assessment, which is done to
obtain data about an identified problem,
in this case shortness of breath. An
ongoing assessment is performed as
needed, after the initial data are
collected, preferably with each patient
contact. A comprehensive physical
assessment includes an interview and a
complete examination of each body
system. A psychosocial assessment
examines both psychological and social
factors affecting the patient. The nurse
conducting a psychosocial assessment
would gather information about stressors,
lifestyle, emotional health, social
influences, coping patterns,
communication, and personal responses
to health and illness, to name a few
aspects.
14. Answer: A. Sitting upright
If the patient is able, the nurse should
have the patient sit upright to obtain vital
signs in order to allow the nurse to easily
access the anterior and posterior chest
for auscultation of heart and breath
sounds. It allows for full lung expansion
and is the preferred position for
measuring blood pressure. Additionally,
patients might be more comfortable and
feel less vulnerable when sitting upright
(rather than lying down on the back) and
can have direct eye contact with the
examiner. However, other positions can
be suitable when the patients physical
condition restricts the comfort or ability of
the patient to sit upright.
15. Answer: B. C, A, D, B
Inspection begins immediately as the
nurse meets the patient, as she observes
the patients appearance and behavior.
Observational data are not intrusive to
the patient. When performing assessment
Fundamentals of Nursing

Page 31

techniques involving physical touch, the

behavior, posture, demeanor, and
responses might be altered. Palpation,
percussion, and auscultation should be
performed in that order, except when
performing an abdominal assessment.
During abdominal assessment,
auscultation should be performed before
palpation and percussion to prevent
altering bowel sounds.
16. Answer: A. Sims
Sims position is typically used to
examine the rectal area. However, the
position should be avoided if the patient
has undergone hip replacement surgery
The patient with a hip replacement can
assume the supine, dorsal recumbent, or
semi-Fowlers positions without causing
harm to the joint. Supine position is lying
on the back facing upward. The patient in
dorsal recumbent is on his back with
knees flexed and soles of feet flat on the
bed. In semi-Fowlers position, the patient
is supine with the head of the bed
elevated and legs slightly elevated.
17. Answer: B. Demonstrate
equipment before using it.
The nurse should modify his examination
by demonstrating equipment before using
it to examine a school-age child. The
nurse should make sure parents are not
present during the physical examination
of an adolescent, but they usually help
younger children feel more secure. The
nurse should allow a preschooler to help
with the examination when possible, but
not usually a school-age child. Toddlers
are often fearful of invasive procedures,
so those should be performed last in this
age group. It is best to perform invasive
procedures last for all age groups;
therefore, this does not represent a
modification.

18. Answer: B. Semi-Fowlers

If a patient is unable to sit up, the nurse
should place him lying flat on his back,
with the head of the bed elevated. Dorsal
recumbent position is used for abdominal
assessment if the patient has abdominal
or pelvic pain. The patient in dorsal
recumbent is on his back with knees
flexed and soles of feet flat on the bed.
Lithotomy position is used for female
pelvic examination. It is similar to dorsal
recumbent position, except that the
patients legs are well separated and
thighs are acutely flexed. Feet are usually
placed in stirrups. Fold sheet or bath
blanket crosswise over thighs and legs so
that genital area is easily exposed. Keep
patient covered as much as possible. The
patient in Sims position is on left side
with right knee flexed against abdomen
and left knee slightly flexed. Left arm is
behind body; right arm is placed
comfortably. Sims position is used to
examine the rectal area. In semi-Fowlers
position, the patient is supine with the
head of the bed elevated and legs slightly
elevated.
19. Answer: C. Bowel sounds
The bell of the stethoscope should be
used to hear low-pitched sounds, such as
murmurs, bruits, and jugular hums. The
diaphragm should be used to hear highpitched sounds that normally occur in the
heart, lungs, and abdomen.
20. Answer: D. Underweight
For adults, BMI should range between 20
and 25; BMI less than 20 is considered
underweight; BMI 25 to 29.9 is
overweight; and BMI greater than 30 is
considered obese.

Fundamentals of Nursing

Page 32

2. For a morbidly obese patient,

which intervention should the nurse
choose to counteract the pressure
created by the skin folds?
A. Cover the mattress with a sheepskin.
B. Keep the linens wrinkle free.
C. Separate the skin folds with towels.
D. Apply petrolatum barrier creams.
3. A client exhibits all of the
following during a physical
assessment. Which of these is
considered a primary defense
against infection?
A. Fever
B. Intact skin
C. Inflammation
D. Lethargy
4. A client with a stage 2 pressure
ulcer has methicillin-resistant
Staphylococcus aureus (MRSA)
cultured from the wound. Contact
precautions are initiated. Which rule
must be observed to follow contact
precautions?
PART 5
1. The charge nurse asks the nursing
assistive personnel (NAP) to give a
bag bath to a patient with end-stage
chronic obstructive pulmonary
disease. How should the NAP
proceed?
A. Bathe the patients entire body using 8
to 10 washcloths.
B. Assist the patient to a chair and
provide bathing supplies.
C. Saturate a towel and blanket in a
plastic bag, and then bathe the patient.
D. Assist the patient to the bathtub and
provide a bath chair.
Fundamentals of Nursing

Page 33

A. A clean gown and gloves must be worn

when in contact with the client.
B. Everyone who enters the room must
wear a N-95 respirator mask.
C. All linen and trash must be marked as
contaminated and send to biohazard
waste.
D. Place the client in a room with a client
with an upper respiratory infection.
5. A client requires protective
isolation. Which client can be safely
paired with this client in a client-care
assignment? One:
A. admitted with unstable diabetes
mellitus.
B. who underwent surgical repair of a

perforated bowel.
C. with a stage 3 sacral pressure ulcer.
D. admitted with a urinary tract infection.

IV infusion pump
D. Prescription without the route of
administration

6. A newly hired at Nurseslabs

Medical Center is assigned in the OR
Department. Which action
demonstrates a break in sterile
technique?

10. The nurse is orienting a new

nurse to the unit and reviews sourceoriented charting. Which statement
by the nurse best describes sourceoriented charting? Source-oriented
charting:

A. Remaining 1 foot away from nonsterile

areas
B. Placing sterile items on the sterile field
C. Avoiding the border of the sterile drape
D. Reaching 1 foot over the sterile field
7. Nurse Berta is facilitating a
monthly mothers class at a small
village. As a knowledgeable nurse,
she must know that a mother who
breastfeeds her child passes on
which antibody through breast milk?
A. IgA
B. IgE
C. IgG
D. IgM
8. The clinical instructor asks her
students the rationale for
handwashing. The students are
correct if they answered that
handwashing is expected to remove:

11. When the nurse completes the

patients admission nursing
database, the patient reports that he
does not have any allergies. Which
acceptable medical abbreviation can
the nurse use to document this
finding?
A. NA
B. NDA
C. NKA
D. NPO
12. The nurse is working on a unit
that uses nursing assessment flow
sheets. Which statement best
describes this form of charting?
Nursing assessment flow sheets:

A. transient flora from the skin.

B. resident flora from the skin.
C. all microorganisms from the skin.
D. media for bacterial growth.
9. Which of the following incidents
requires the nurse to complete an
occurrence report?
A. Medication given 30 minutes after
scheduled dose time
B. Patients dentures lost after transfer
C. Worn electrical cord discovered on an
Fundamentals of Nursing

A. Separates the health record according

to discipline
B. Organizes documentation around the
patients problems
C. Highlights the patients concerns,
problems, and strengths
D. Is designed to streamline
documentation

Page 34

A. Are comprehensive charting forms that

integrate assessments and nursing
actions
B. Contain only graphic information, such
as I&O, vital signs, and medication
administration
C. Are used to record routine aspects of
care; they do not contain assessment

data
D. Contain vital data collected upon
admission, which can be compared with
newly collected data
13. At the end of the shift, the nurse
realizes that she forgot to document
a dressing change that she
performed for a patient. Which
action should the nurse take?
A. Complete an occurrence report before
leaving.
B. Do nothing; the next nurse will
document it was done.
C. Write the note of the dressing change
into an earlier note.
D. Make a late entry as an addition to the
narrative notes.
14. Patient Z asks Nurse Toni why an
electronic health record (EHR)
system is being used. Which
response by the nurse indicates an
understanding of the rationale for an
EHR system?
A. It includes organizational reports of
unusual occurrences that are not part of
the clients record.
B. This type of system consists of
combined documentation and daily care
plans.
C. It improves interdisciplinary
collaboration that improves efficiency in
procedures.
D. This type of system tracks medication
administration and usage over 24 hours.
15. In the United States, the first
programs for training nurses were
affiliated with:
A. The military
B. General hospitals
C. Civil service
D. Religious orders
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Page 35

16. Which of the following is/are an

example(s) of a health restoration
activity? Select all that apply.
A. Administering an antibiotic every day
B. Teaching the importance of
handwashing
C. Assessing a clients surgical incision
D. Advising a woman to get an annual
mammogram after age 50 years
17. Which of the following aspects of
nursing is essential to defining it as
both a profession and a discipline?
A. Established standards of care
B. Professional organizations
C. Practice supported by scientific
research
D. Activities determined by a scope of
practice
18. The charge nurse on the medical
surgical floor assigns vital signs to
the nursing assistive personnel
(NAP) and medication administration
to the licensed vocational nurse
(LVN). Which nursing model of care is
this floor following?
A. Team nursing
B. Case method nursing
C. Functional nursing
D. Primary nursing
19. Paul Jake suffered a stroke and
has difficulty swallowing. Which
healthcare team member should be
consulted to assess the patients risk
for aspiration?
A. Respiratory therapist
B. Occupational therapist
C. Dentist
D. Speech therapist

20. Which of the following is/are an

example(s) of theoretical
knowledge? Select all that apply.
A. Antibiotics are ineffective in treating
viral infections.
B. When you take a patients blood
pressure, the patients arm should be at
heart level.
C. In Maslows framework, physical needs
are most basic.
D. When drawing medication out of a vial,
inject air into the vial first.

Answers and Rationale

1. Answer: A. Bathe the patients
entire body using 8 to 10 washcloths.
A towel bath is a modification of the bed
bath in which the NAP places a large
towel and a bath blanket into a plastic
bag, saturates them with a commercially
prepared mixture of moisturizer, non rinse
cleaning agent, and water; warms in them
in a microwave, and then uses them to
bathe the patient. A bag bath is a
modification of the towel bath, in which
the NAP uses 8 to 10 washcloths instead
of a towel or blanket. Each part of the
patients body is bathed with a fresh
cloth. A bag bath is not given in a chair or
in the tub.
2. Answer: B. Keep the linens wrinkle
free.
Separating the skin folds with towels
relieves the pressure of skin rubbing on
Fundamentals of Nursing

Page 36

skin. Sheepskins are not recommended

for use at all. Petrolatum barrier creams
are used to minimize moisture caused by
incontinence.
3 Answer: B. Intact skin
Intact skin is considered a primary
defense against infection. Fever, the
inflammatory response, and phagocytosis
(a process of killing pathogens) are
considered secondary defenses against
infection.
4. Answer: A. A clean gown and
gloves must be worn when in contact
with the client.
A clean gown and gloves must be worn
when any contact is anticipated with the
client or with contaminated items in the
room. A respirator mask is required only
with airborne precautions, not contact
precautions. All linen must be doublebagged and clearly marked as
contaminated. The client should be
placed in a private room or in a room with
a client with an active infection caused by
the same organism and no other
infections.
5. Answer: A. admitted with unstable
diabetes mellitus.
The client with unstable diabetes mellitus
can safely be paired in a client-care
assignment because the client is free
from infection. Perforation of the bowel
exposes the client to infection requiring
antibiotic therapy during the
postoperative period. Therefore, this
client should not be paired with a client in
protective isolation. A client in protective
isolation should not be paired with a
client who has an open wound, such as a
stage 3 pressure ulcer, or with a client
who has a urinary tract infection.
Fundamentals of Nursing

Page 37

6. Answer: D. Reaching 1 foot over

the sterile field
Reaching over the sterile field while
wearing sterile garb breaks sterile
technique. While observing sterile
technique, healthcare workers should
remain 1 foot away from nonsterile areas
while wearing sterile garb, place sterile
items needed for the procedure on the
sterile drape, and avoid coming in contact
with the 1-inch border of the sterile
drape.
7. Answer: C. IgG
The antibody IgG is passed to the child
through the mothers breast milk during
breastfeeding. IgA, IgE, and IgM are
produced by the childs body after
exposure to an antigen.
8. Answer: A. transient flora from the
skin.
There are two types of normal flora:
transient and resident. Transient flora are
normal flora that a person picks up by
coming in contact with objects or another
person (e.g., when you touch a soiled
dressing). You can remove these with
hand washing. Resident flora live deep in
skin layers where they live and multiply
harmlessly. They are permanent
inhabitants of the skin and cannot usually
be removed with routine hand washing.
Removing all microorganisms from the
skin (sterilization) is not possible without
damaging the skin tissues. To live and
thrive in humans, microbes must be able
to use the bodys precise balance of food,
moisture, nutrients, electrolytes, pH,
temperature, and light. Food, water, and
soil that provide these conditions may
serve as nonliving reservoirs. Hand
washing does little to make the skin
uninhabitable for microorganisms, except

perhaps briefly when an antiseptic agent

is used for cleansing.
9. Answer: B. Patients dentures lost
after transfer
You would need to complete an
occurrence report if you suspect your
patients personal items to be lost or
stolen. A medication can be administered
within a half-hour of the administration
time without an error in administration;
therefore, an occurrence report is not
necessary. The worn electrical cord should
be taken out of use and reported to the
biomedical department. The nurse should
seek clarification if the providers order is
missing information; an occurrence report
is not necessary.
10. Answer: A. Separates the health
record according to discipline
In source-oriented charting, each
discipline documents findings in a
separately labeled section of the chart.
Problem-oriented charting organizes
notes around the patients problems.
Focus charting highlights the patients
concerns, problems, and strengths.
Charting by exception is a unique
charting system designed to streamline
documentation.
11. Answer: C. NKA
The nurse can use the medical
abbreviation NKA, which means no known
allergies, to document this finding. NA is
an abbreviation for not applicable. NDA is
an abbreviation for no known drug
allergies. NPO is an abbreviation that
means nothing by mouth.
12. Answer: A. Are comprehensive
charting forms that integrate
assessments and nursing actions
Fundamentals of Nursing

Page 38

Nursing assessment flow sheets are

organized by body systems. The nurse
checks the box corresponding to the
current assessment findings. Nursing
actions, such as wound care, treatments,
or IV fluid administration, are also
included. Graphic information, such as
vital signs, I&O, and routine care, may be
found on the graphic record. The
admission form contains baseline
information.
13. Answer: D. Make a late entry as
an addition to the narrative notes.
If the nurse fails to make an important
entry while charting, she should make a
late entry as an addition to the narrative
notes. An occurrence report is not
necessary in this case. If documentation
is omitted, there is no legal verification
that the procedure was performed. It is
illegal to add to a chart entry that was
previously documented. The nurse can
only document care directly performed or
observed. Therefore, the nurse on the
incoming shift would not record the
wound change as performed.
14. Answer: C. It improves
interdisciplinary collaboration that
improves efficiency in procedures.
The EHR has several benefits for use,
including improving interdisciplinary
collaboration and making procedures
more accurate and efficient. An
occurrence report is an organizational
record of an unusual occurrence or
accident that is not a part of the clients
record. Integrated plans of care (IPOC) are
a combined charting and care plan
format. A medication administration
record (MAR) is used to document
medications administered and their
usage.

15. Answer: D. Religious orders

18. Answer: C. Functional nursing

When the Civil War broke out, the Army

used nurses who had already been
trained in religious orders. Although the
Army did provide some training, it
occurred later than in the religious orders.
Although nurses were trained in hospitals,
the training and the hospitals were
affiliated with religious orders. Civil
service was not mentioned in Chapter 1
and was not a factor in the early 1800s.
Nursing started with religious orders. The
Hindu faith was the first to write about
nursing. In the United States, all training
for nurses was affiliated with religious
orders until after the Civil War.

With team nursing, an RN or LVN is paired

with a NAP. The pair is then assigned to
render care for a group of patients. In
case method nursing, one nurse cares for
one patient during her entire shift. Private
duty nursing is an example of this care
model. This medical surgical floor is
following the functional nursing model of
care, in which care is partitioned and
assigned to a staff member with the
appropriate skills. For example, the NAP is
assigned vital signs, and the LVN is
assigned medication administration.
When the primary nursing model is
utilized, one nurse manages care for a
group of patients 24 hours a day, even
though others provide care during part of
the day.

16. Answer: A, C
Health restoration activities help an ill
client return to health. This would include
taking an antibiotic every day and
assessing a clients surgical incision.
Hand washing and mammograms both
involve healthy people who are trying to
prevent illness.
17. Answer: C. Practice supported by
scientific research
The American Nurses Association (ANA)
has developed standards of care, but they
are unrelated to defining nursing as a
profession or discipline. Having
professional organizations is not included
in accepted characteristics of either a
profession or a discipline. A profession
must have knowledge that is based on
technical and scientific knowledge. The
theoretical knowledge of a discipline must
be based on research, so both are
scientifically based. Having a scope of
practice is not included in accepted
characteristics of either a profession or a
discipline.
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19. Answer: D. Speech therapist

Respiratory therapists provide care for
patients with respiratory disorders.
Occupational therapists help patients
regain function and independence.
Dentists diagnose and treat dental
disorders. Speech and language
therapists provide assistance to clients
experiencing swallowing and speech
disturbances. They assess the risk for
aspiration and recommend a treatment
plan to reduce the risk.
20. Answer: A, C
Theoretical knowledge consists of
research findings, facts (e.g., Antibiotics
are ineffective . . . is a fact), principles,
and theories (e.g., In Maslows
framework . . . is a statement from a
theory). Instructions for taking a blood
pressure and withdrawing medications
are examples of practical knowledge
what to do and how to do it.

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