Fundamentals in Nursing

Fundamentals in Nursing Set A

1. Jake is complaining of shortness of breath. The nurse assesses his

respiratory rate to be 30 breaths per minute and documents that Jake is
tachypneic. The nurse understands that tachypnea means:

A. Pulse rate greater than 100 beats per minute

B. Blood pressure of 140/90
C. Respiratory rate greater than 20 breaths per minute
D. Frequent bowel sounds
2. The nurse listens to Mrs. Sullen’s lungs and notes a hissing sound or
musical sound. The nurse documents this as:

A. Wheezes
B. Rhonchi
C. Gurgles
D. Vesicular
3. The nurse in charge measures a patient’s temperature at 101 degrees F.
What is the equivalent centigrade temperature?

A. 36.3 degrees C
B. 37.95 degrees C
C. 40.03 degrees C
D. 38.01 degrees C
4. Which approach to problem solving tests any number of solutions until one
is found that works for that particular problem?

A. Intuition
B. Routine
C. Scientific method
D. Trial and error
5. What is the order of the nursing process?

A. Assessing, diagnosing, implementing, evaluating, planning

B. Diagnosing, assessing, planning, implementing, evaluating
 C. Assessing, diagnosing, planning, implementing, evaluating
D. Planning, evaluating, diagnosing, assessing, implementing
6. During the planning phase of the nursing process, which of the following is
the outcome?

A. Nursing history
B. Nursing notes
C. Nursing care plan
D. Nursing diagnosis
7. What is an example of a subjective data?

A. Heart rate of 68 beats per minute

B. Yellowish sputum
C. Client verbalized, “I feel pain when urinating.”
D. Noisy breathing
8. Which expected outcome is correctly written?

A. “The patient will feel less nauseated in 24 hours.”

B. “The patient will eat the right amount of food daily.”
C. “The patient will identify all the high-salt food from a prepared list by
discharge.”
D. “The patient will have enough sleep.”
9. Which of the following behaviors by Nurse Jane Robles demonstrates that
she understands well th elements of effecting charting?

A. She writes in the chart using a no. 2 pencil.

B. She noted: appetite is good this afternoon.
C. She signs on the medication sheet after administering the
medication.
D. She signs her charting as follow: J.R
10. What is the disadvantage of computerized documentation of the nursing
process?

A. Accuracy
B. Legibility
C. Concern for privacy
D. Rapid communication
11. The theorist who believes that adaptation and manipulation of stressors
are related to foster change is:

A. Dorothea Orem
B. Sister Callista Roy
C. Imogene King
D. Virginia Henderson
12. Formulating a nursing diagnosis is a joint function of:

A. Patient and relatives

B. Nurse and patient
C. Doctor and family
D. Nurse and doctor
13. Mrs. Caperlac has been diagnosed to have hypertension since 10 years
ago. Since then, she had maintained low sodium, low fat diet, to control her
blood pressure. This practice is viewed as:

A. Cultural belief
B. Personal belief
C. Health belief
D. Superstitious belief
14. Becky is on NPO since midnight as preparation for blood test. Adreno-
cortical response is activated. Which of the following is an expected
response?

A. Low blood pressure

B. Warm, dry skin
C. Decreased serum sodium levels
D. Decreased urine output
15. What nursing action is appropriate when obtaining a sterile urine
specimen from an indwelling catheter to prevent infection?

A. Use sterile gloves when obtaining urine.

B. Open the drainage bag and pour out the urine.
C. Disconnect the catheter from the tubing and get urine.
D. Aspirate urine from the tubing port using a sterile syringe.
16. A client is receiving 115 ml/hr of continuous IVF. The nurse notices that
the venipuncture site is red and swollen. Which of the following interventions
would the nurse perform first?

A. Stop the infusion

B. Call the attending physician
C. Slow that infusion to 20 ml/hr
D. Place a clod towel on the site
17. The nurse enters the room to give a prescribed medication but the patient
is inside the bathroom. What should the nurse do?

A. Leave the medication at the bedside and leave the room.

B. After few minutes, return to that patient’s room and do not leave
until the patient takes the medication.
C. Instruct the patient to take the medication and leave it at the
bedside.
D. Wait for the patient to return to bed and just leave the medication at
the bedside.
18. Which of the following is inappropriate nursing action when administering
NGT feeding?

A. Place the feeding 20 inches above the pint if insertion of NGT.

B. Introduce the feeding slowly.
C. Instill 60ml of water into the NGT after feeding.
D. Assist the patient in fowler’s position.
19. A female patient is being discharged after thyroidectomy. After providing
the medication teaching. The nurse asks the patient to repeat the instructions.
The nurse is performing which professional role?

A. Manager
B. Caregiver
C. Patient advocate
D. Educator
20. Which data would be of greatest concern to the nurse when completing
the nursing assessment of a 68-year-old woman hospitalized due to
Pneumonia?
 A. Oriented to date, time and place
B. Clear breath sounds
C. Capillary refill greater than 3 seconds and buccal cyanosis
D. Hemoglobin of 13 g/dl
21. During a change-of-shift report, it would be important for the nurse
relinquishing responsibility for care of the patient to communicate. Which of
the following facts to the nurse assuming responsibility for care of the
patient?

A. That the patient verbalized, “My headache is gone.”

B. That the patient’s barium enema performed 3 days ago was
negative
C. Patient’s NGT was removed 2 hours ago
D. Patient’s family came for a visit this morning.
22. Which statement is the most appropriate goal for a nursing diagnosis of
diarrhea?

A. “The patient will experience decreased frequency of bowel

elimination.”
B. “The patient will take anti-diarrheal medication.”
C. “The patient will give a stool specimen for laboratory examinations.”
D. “The patient will save urine for inspection by the nurse.
23. Which of the following is the most important purpose of planning care
with this patient?

A. Development of a standardized NCP.

B. Expansion of the current taxonomy of nursing diagnosis
C. Making of individualized patient care
D. Incorporation of both nursing and medical diagnoses in patient care
24. Using Maslow’s hierarchy of basic human needs, which of the following
nursing diagnoses has the highest priority?

A. Ineffective breathing pattern related to pain, as evidenced by

shortness of breath.
B. Anxiety related to impending surgery, as evidenced by insomnia.
C. Risk of injury related to autoimmune dysfunction
 D. Impaired verbal communication related to tracheostomy, as
evidenced by inability to speak.
25. When performing an abdominal examination, the patient should be in a
supine position with the head of the bed at what position?

A. 30 degrees
B. 90 degrees
C. 45 degrees
D. 0 degree
Answers and Rationales
1. 1. (C) Respiratory rate greater than 20 breaths per minute. A respiratory
rate of greater than 20 breaths per minute is tachypnea. A blood
pressure of 140/90 is considered hypertension. Pulse greater than
100 beats per minute is tachycardia. Frequent bowel sounds refer to
hyper-active bowel sounds.
2. (A) Wheezes. Wheezes are indicated by continuous, lengthy, musical;
heard during inspiration or expiration. Rhonchi are usually coarse
breath sounds. Gurgles are loud gurgling, bubbling sound. Vesicular
breath sounds are low pitch, soft intensity on expiration. 

3. (B) 37.95 degrees C. To convert °F to °C use this formula, ( °F – 32 )

(0.55). While when converting °C to °F use this formula, ( °C x 1.8) +
32. Note that 0.55 is 5/9 and 1.8 is 9/5.

4. (D) Trial and error. The trial and error method of problem solving isn’t
systematic (as in the scientific method of problem solving) routine,
or based on inner prompting (as in the intuitive method of problem
solving).
5. (C) Assessing, diagnosing, planning, implementing, evaluating. The
correct order of the nursing process is assessing, diagnosing,
planning, implementing, evaluating.
6. (C) Nursing care plan. The outcome, or the product of the planning
phase of the nursing process is a Nursing care plan.
7. (C) Client verbalized, “I feel pain when urinating.”. Subjective data are
those that can be described only by the person experiencing it.
 Therefore, only the patient can describe or verify whether he is
experiencing pain or not.
8. (C) “The patient will identify all the high-salt food from a prepared list by
discharge.”. Expected outcomes are specific, measurable, realistic
statements of goal attainment. The phrases “right amount”, “less
nauseated” and “enough sleep” are vague and not measurable.
9. (C) She signs on the medication sheet after administering the medication.A
nurse should record a nursing intervention (ex. Giving medications)
after performing the nursing intervention (not before). Recording
should also be done using a pen, be complete, and signed with the
nurse’s full name and title.
10. (C) Concern for privacy. A patient’s privacy may be violated if
security measures aren’t used properly or if policies and procedures
aren’t in place that determines what type of information can be
retrieved, by whom, and for what purpose.
11. (B) Sister Callista Roy. Sister Roy’s theory is called the adaptation
theory and she viewed each person as a unified biophysical system
in constant interaction with a changing environment. Orem’s theory
is called self-care deficit theory and is based on the belief that
individual has a need for self-care actions. King’s theory is the Goal
attainment theory and described nursing as a helping profession
that assists individuals and groups in society to attain, maintain, and
restore health. Henderson introduced the nature of nursing model
and identified the 14 basic needs.
12. (B) Nurse and patient. Although diagnosing is basically the nurse’s
responsibility, input from the patient is essential to formulate the
correct nursing diagnosis.
13. (C) Health belief. Health belief of an individual influences his/her
preventive health behavior.
14. (D) Decreased urine output. Adreno-cortical response involves
release of aldosterone that leads to retention of sodium and water.
This results to decreased urine output.
15. (D) Aspirate urine from the tubing port using a sterile syringe. The
nurse should aspirate the urine from the port using a sterile syringe
to obtain a urine specimen. Opening a closed drainage system
increase the risk of urinary tract infection.
16. (A) Stop the infusion. The sign and symptoms indicate
extravasation so the IVF should be stopped immediately and put
warm not cold towel on the affected site.
17. (B) After few minutes, return to that patient’s room and do not leave
until the patient takes the medication. This is to verify or to make sure
that the medication was taken by the patient as directed.
18. (A) Place the feeding 20 inches above the pint if insertion of NGT. The
height of the feeding is above 12 inches above the point of insertion,
bot 20 inches. If the height of feeding is too high, this results to very
rapid introduction of feeding. This may trigger nausea and vomiting.
19. (D) Educator. When teaching a patient about medications before
discharge, the nurse is acting as an educator. A caregiver provides
direct care to the patient. The nurse acts as s patient advocate when
making the patient’s wishes known to the doctor.
20. (C) Capillary refill greater than 3 seconds and buccal cyanosis. Capillary
refill greater than 3 seconds and buccal cyanosis indicate decreased
oxygen to the tissues which requires immediate
attention/intervention. Oriented to date, time and place, hemoglobin
of 13 g/dl are normal data.
21. (C) Patient’s NGT was removed 2 hours ago. The change-of-shift
report should indicate significant recent changes in the patient’s
condition that the nurse assuming responsibility for care of the
patient will need to monitor. The other options are not critical
enough to include in the report.
22. (A) “The patient will experience decreased frequency of bowel
elimination.” The goal is the opposite, healthy response of the
problem statement of the nursing diagnosis. In this situation, the
problem statement is diarrhea.
23. (C) Making of individualized patient care. To be effective, the nursing
care plan developed in the planning phase of the nursing process
must reflect the individualized needs of the patient.
24. (A) Ineffective breathing pattern related to pain, as evidenced by
shortness of breath.. Physiologic needs (ex. Oxygen, fluids, nutrition)
must be met before lower needs (such as safety and security, love
and belongingness, self-esteem and self-actualization) can be met.
Therefore, physiologic needs have the highest priority.
 25. (D) 0 degree. The patient should be positioned with the head of the
bed completely flattened to perform an abdominal examination. If
the head of the bed is elevated, the abdominal muscles and organs
can be bunched up, altering the findings

Fundamentals in Nursing Set B

1. A patient is wearing a soft wrist-safety device. Which of the following

nursing assessment is considered abnormal?

A. Palpable radial pulse

B. Palpable ulnar pulse
C. Capillary refill within 3 seconds
D. Bluish fingernails, cool and pale fingers
2. Pia’s serum sodium level is 150 mEq/L. Which of the following food items
does the nurse instruct Pia to avoid?

A. broccoli
B. sardines
C. cabbage
D. tomatoes
3. Jason, 3 years old vomited. His mom stated, “He vomited 6 ounces of his
formula this morning.” This statement is an example of:

A. objective data from a secondary source

B. objective data from a primary source
C. subjective data from a primary source
D. subjective data from a secondary source
4. Which of the following is a nursing diagnosis?

A. Hypethermia
B. Diabetes Mellitus
C. Angina
D. Chronic Renal Failure
5. What is the characteristic of the nursing process?
 A. stagnant
B. inflexible
C. asystematic
D. goal-oriented
6. A skin lesion which is fluid-filled, less than 1 cm in size is called:

A. papule
B. vesicle
C. bulla
D. macule
7. During application of medication into the ear, which of the following is
inappropriate nursing action?

A. In an adult, pull the pinna upward.

B. Instill the medication directly into the tympanic membrane.
C. Warm the medication at room or body temperature.
D. Press the tragus of the ear a few times to assist flow of medication
into the ear canal.
8. Which of the following is appropriate nursing intervention for a client who is
grieving over the death of her child?

A. Tell her not to cry and it will be better.

B. Provide opportunity to the client to tell their story.
C. Encourage her to accept or to replace the lost person.
D. Discourage the client in expressing her emotions.
9. It is the gradual decrease of the body’s temperature after death.

A. livor mortis
B. rigor mortis
C. algor mortis
D. none of the above
10. When performing an admission assessment on a newly admitted patient,
the nurse percusses resonance. The nurse knows that resonance heard on
percussion is most commonly heard over which organ?

A. thigh
B. liver
 C. intestine
D. lung
11. The nurse is aware that Bell’s palsy affects which cranial nerve?

A. 2nd CN (Optic)
B. 3rd CN (Occulomotor)
C. 4th CN (Trochlear)
D. 7th CN (Facial)
12. Prolonged deficiency of Vitamin B9 leads to:

A. scurvy
B. pellagra
C. megaloblastic anemia
D. pernicious anemia
13. Nurse Cherry is teaching a 72 year old patient about a newly prescribed
medication. What could cause a geriatric patient to have difficulty retaining
knowledge about the newly prescribed medication?

A. Absence of family support

B. Decreased sensory functions
C. Patient has no interest on learning
D. Decreased plasma drug levels
14. When assessing a patient’s level of consciousness, which type of nursing
intervention is the nurse performing?

A. Independent
B. Dependent
C. Collaborative
D. Professional
15. Claire is admitted with a diagnosis of chronic shoulder pain. By definition,
the nurse understands that the patient has had pain for more than:

A. 3 months
B. 6 months
C. 9 months
D. 1 year
16. Which of the following statements regarding the nursing process is true?
 A. It is useful on outpatient settings.
B. It progresses in separate, unrelated steps.
C. It focuses on the patient, not the nurse.
D. It provides the solution to all patient health problems.
17. Which of the following is considered significant enough to require
immediate communication to another member of the health care team?

A. Weight loss of 3 lbs in a 120 lb female patient.

B. Diminished breath sounds in patient with previously normal breath
sounds
C. Patient stated, “I feel less nauseated.”
D. Change of heart rate from 70 to 83 beats per minute.
18. To assess the adequacy of food intake, which of the following
assessment parameters is best used?

A. food preferences
B. regularity of meal times
C. 3-day diet recall
D. eating style and habits
19. Van Fajardo is a 55 year old who was admitted to the hospital with newly
diagnosed hepatitis. The nurse is doing a patient teaching with Mr. Fajardo.
What kind of role does the nurse assume?

A. talker
B. teacher
C. thinker
D. doer
20. When providing a continuous enteral feeding, which of the following action
is essential for the nurse to do?

A. Place the client on the left side of the bed.

B. Attach the feeding bag to the current tubing.
C. Elevate the head of the bed.
D. Cold the formula before administering it.
21. Kussmaul’s breathing is;

A. Shallow breaths interrupted by apnea.

 B. Prolonged gasping inspiration followed by a very short, usually
inefficient expiration.
C. Marked rhythmic waxing and waning of respirations from very deep
to very shallow breathing and temporary apnea.
D. Increased rate and depth of respiration.
22. Presty has terminal cancer and she refuses to believe that loss is
happening ans she assumes artificial cheerfulness. What stage of grieving is
she in?

A. depression
B. bargaining
C. denial
D. acceptance
23. Immunization for healthy babies and preschool children is an example of
what level of preventive health care?

A. Primary
B. Secondary
C. Tertiary
D. Curative
24. Which is an example of a subjective data?

A. Temperature of 38 0C
B. Vomiting for 3 days
C. Productive cough
D. Patient stated, “My arms still hurt.”
25. The nurse is assessing the endocrine system. Which organ is part of the
endocrine system?

A. Heart
B. Sinus
C. Thyroid
D. Thymus
Answers and Rationales
1. (D) Bluish fingernails, cool and pale fingers. A safety device on the
wrist may impair blood circulation. Therefore, the nurse should
 assess the patient for signs of impaired circulation such as bluish
fingernails, cool and pale fingers. Palpable radial and ulnar pulses,
capillary refill within 3 seconds are all normal findings.
2. (B) sardines. The normal serum sodium level is 135 to 145 mEq/L,
the client is having hypernatremia. Pia should avoid food high in
sodium like processed food. Broccoli, cabbage and tomatoes are
good source of Vitamin C.
3. (A) objective data from a secondary source. Jason is the primary source;
his mother is a secondary source. The data is objective because it
can be perceived by the senses, verified by another person
observing the same patient, and tested against accepted standards
or norms.
4. (A) Hypethermia. Hyperthermia is a NANDA-approved nursing
diagnosis. Diabetes Mellitus, Angina and Chronic Renal Failure are
medical diagnoses.
5. (D) goal-oriented. The nursing process is goal-oriented. It is also
systematic, patient-centered, and dynamic.
6. (B) vesicle. Vesicle is a circumscribed circulation containing serous
fluid or blood and less than 1 cm (ex. Blister, chicken pox).
7. (B) Instill the medication directly into the tympanic membrane. During the
application of medication it is inappropriate to instill the medication
directly into the tympanic membrane. The right thing to do is instill
the medication along the lateral wall of the auditory canal.
8. (B) Provide opportunity to the client to tell their story. Providing a
grieving person an opportunity to tell their story allows the person to
express feelings. This is therapeutic in assisting the client resolve
grief.
9. (C) algor mortis. Algor mortis is the decrease of the body’s
temperature after death. Livor mortis is the discoloration of the skin
after death. Rigor mortis is the stiffening of the body that occurs
about 2-4 hours after death.
10. (D) lung. Resonance is loud, low-pitched and long duration that’s
heard most commonly over an air-filled tissue such as a normal
lung.
11. (D) 7th CN (Facial). Bells’ palsy is the paralysis of the motor
component of the 7th caranial nerve, resulting in facial sag, inability
 to close the eyelid or the mouth, drooling, flat nasolabial fold and
loss of taste on the affected side of the face.
12. (C) megaloblastic anemia. Prolonged Vitamin B9 deficiency will lead
to megaloblastic anemia while pernicious anemia results in
deficiency in Vitamin B12. Prolonged deficiency of Vitamin C leads
to scurvy and Pellagra results in deficiency in Vitamin B3.
13. (B) Decreased sensory functions. Decreased in sensory functions
could cause a geriatric patient to have difficulty retaining knowledge
about the newly prescribed medications. Absence of family support
and no interest on learning may affect compliance, not knowledge
retention. Decreased plasma levels do not alter patient’s knowledge
about the drug.
14. (A) Independent. Independent nursing interventions involve actions
that nurses initiate based on their own knowledge and skills without
the direction or supervision of another member of the health care
team.
15. (B) 6 months. Chronic pain s usually defined as pain lasting longer
than 6 months.
16. (C) It focuses on the patient, not the nurse. The nursing process is
patient-centered, not nurse-centered. It can be use in any setting,
and the steps are related. The nursing process can’t solve all patient
health problems.
17. (B) Diminished breath sounds in patient with previously normal breath
sounds. Diminished breath sound is a life threatening problem
therefore it is highly priority because they pose the greatest threat to
the patient’s well-being.
18. (C) 3-day diet recall. 3-day diet recall is an example of dietary
history. This is used to indicate the adequacy of food intake of the
client.
19. (B) teacher. The nurse will assume the role of a teacher in this
therapeutic relationship. The other roles are inappropriate in this
situation.
20. (C) Elevate the head of the bed. Elevating the head of the bed during
an enteral feeding prevents aspiration. The patient may be placed
on the right side to prevent aspiration. Enteral feedings are given at
 room temperature to lessen GI distress. The enteral tubing should
be changed every 24 hours to limit microbial growth.
21. (D) Increased rate and depth of respiration. Kussmaul breathing is
also called as hyperventilation. Seen in metabolic acidosis and renal
failure. Option A refers to Biot’s breathing. Option B is apneustic
breathing and option C is the Cheyne-stokes breathing.
22. (C) denial. The client is in denial stage because she is unready to
face the reality that loss is happening and she assumes artificial
cheerfulness.
23. (A) Primary. The primary level focuses on health promotion.
Secondary level focuses on health maintenance. Tertiary focuses on
rehabilitation. There is n Curative level of preventive health care
problems.
24. (D) Patient stated, “My arms still hurt.”. Subjective data are apparent
only to the person affected and can or verified only by that person.
25. (C) Thyroid. The thyroid is part of the endocrine system. Heart,
sinus and thymus are not.

Fundamentals in Nursing Set C