Nursing.Criminology.LET.CSE.

NAPOLCOM
4th Floor Insular Life Bldg. Rizal St. Legazpi City
Take Home Exam: Fundamentals of Nursing 2
Instructions:
1. Choose the best answer and encircle the corresponding letter on the questionnaire.
2. Show your duly accomplished output to iMind Staff at the next meeting.
NURSING PROCESS
1. In developing a plan of care for a client with a chronic hypertension, which nursing activity would
be most important?
a. Set incremental goals for blood pressure reduction.
b. Instruct the client to make dietary changes by reducing sodium intake.
c. Include the client and family when setting goals and for emulating the plan care.
d. Assess past compliance to medication regimens.
2. Which nurse is demonstrating the assessment phase of the nursing process?
a. The nurse who observes that the client`s pain was relieved with pain medication.
b. The nurse who turn the client to a more comfortable position.
c. The nurse who asks the client how much lunch he or she ate.
d. The nurse who works with the client to set desired outcome goals.
3. The client states, ”My chest hurts and my left arm feels numb.” The nurse interprets that this
data is of which type and source?
a. Subjective data from a primary source.
b. Subjective data from secondary source.
c. Objective data from a primary source.
d. Objective data from secondary source
4. The nurse feels a client is at risk for skin breakdown because he has only had clear liquids for the
last 10 days (essentially no protein intake). The nurse would formulate which diagnostic statement
that would be best reflects this problem?
a. Risk for malnutrition related to clear liquid.
b. Impaired skin integrity related to no protein intake.
c. Risk for impaired skin integrity related to malnutrition.
d. Impaired nutrition related to current illness.
5. The nurse would place which correctly written nursing diagnostic statement into the clients care
plan?
a. Cancer related to cigarette smoking.
b. Impaired gas exchange related to aspiration of foreign matter as evidenced by oxygen
saturation of 91 %.
c. Imbalanced nutrition: more than body requirements related to overweight status.
d. Impaired physical mobility related to generalized weakness and pain.
6. Which of the following outcome goals has the nurse designed correctly for the postoperative
client`s plan of care? Select all that apply.
a. Client will state pain is less than equal to a 3 on a zero to ten pain scale.
b. Client will have no pain.
c. Client will state pain is less than or equal to a 3 on a zero to ten pain scale within 24
hours.
d. Client will state pain is less than or equal to a 5 on a zero to ten pain scale by time of
discharge.
e. Client will be medicated every 4 hours by the nurse.
7. The nurse questions if the dosage of the medication is unsafe for the client because of the clients
weight and age. The nurse should take which of the following actions?
a. Administer the medication as ordered by the prescriber.
b. Call the prescriber to discuss the order and the nurse`s concern.
c. Administer the medication, but chart the nurse`s concern about the dosage.
d. Give the client half of the dosage, and document accordingly.
8. Which activity would be appropriate for the nurse to delegate to an unlicensed assistive person
(UAP) or nursing aide?
a. Taking vital signs of clients on the nursing unit.
b. Assisting the physician with an invasive procedure.
c. Adjusting the rate on an infusion pump.
d. Evaluating achievement of client outcome goals.
9. In giving a change-of-shift report, which type of client information communicated by the nurse is
most appropriate?
a. Vital signs are stable.
b. Client is pleasant, alert, and oriented to time, place and person.
c. The chest x-ray results were negative.
d. Client voided 250 mL of urine 2 hours after urinary catheter removal.
10. Twenty minutes after administering pain medication to the client, the nurse returns to ask if the
client`s level of pain has decreased. The nurse documents the client`s response as part of which
phase of the nursing process?
a. Diagnosis c. Implementation
b. Planning d. Evaluation
HEALTH ASSESSMENT
11. Prior to taking the health history, the nurse should first do which of the following?
a. Establish a rapport with the client.
b. Offer the client a beverage of choice.
c. Establish that insurance coverage exist.
d. Ask the client to disrobe and put on a gown.
12. The nurse would use which technique first when examining the abdomen to a client?
a. Palpation c. Percussion
b. Auscultation d. Inspection

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13. When assessing a client`s mental status which of the following would be key areas to include?
Select all that apply.
a. The clients level of attained education.
b. The client’s appearance, facial expressions, mood, and affect.
c. The clients gait and balance.
d. The client’s judgment and recent (short-term) memory.
e. The presence or absence of suicidal thoughts/ideations.
14. When taking health history, the first action the nurse should perform after the clients describes
the chief complaint is to:
a. Document verbatim what the client has said about the problem.
b. Paraphrase in the nurse`s own words that the problem is.
c. Refrain from note taking to appear focused.
d. Ask the client to repeat the data to ensure reliability.
15. The nurse selects which of the following pieces of equipment to test for a cremasteric reflex?
a. Blood pressure cuff. c. Sharp end of the needle
b. Cotton applicator d. Percussion hammer
16. The nurse preparing to assess for jugular venous distention (JVD) places the client into which
position?
a. Supine with the head of bed elevated 30 degrees.
b. Supine with neck placed downward on chest.
c. High Fowler`s with head elevated upward
d. Side-lying with no pillows under the head
17. The nurse select which of the following as the highest priority nursing diagnosis for a 70-year-old
male client with an absence of hair on the lower left leg?
a. Imbalanced nutrition :less than body requirements
b. Risk for infection
c. Deficient fluid volume
d. Impaired peripheral tissue perfusion
18. The nurse is preparing to assess for the first time the pulse of the client who has heart disease
and a history of cardiac dysrhythiams. What would be the best technique for the nurse to use?
a. Auscultate the apical pulse for one full minute while another nurse palpates the radical
pulse.
b. Auscultate the apical pulse for 30 seconds and multiply the rate by 2 to obtain an accurate
heart rate.
c. Ausculate the apical pulse over the 2nd intercostals space at the midclavicular line.
d. Auscultate the apical pulse for one full minute and then palpate the radial pulse during the
next minute.
19. In which position should the nurse place the client to best inspect and palpate the Batholin glands?
a. Semi-Fowlers c. Lithotomy
b. Sim`s d. Prone
20. To adequately inspect the external ear canal of an adult client, the nurse should do which of the
following to inserting the otoscope?
a. Require that all earings be removed safety purposes.
b. Pull the pinna up and back
c. Use a cotton-tipped applicator to remove cerumen.
d. Have the client lie down to promote comfort.
COMMUNICATION
21. A nurse observes a client pacing the halls, and it appears as if the client has been crying. What is
the most appropriate action by nurse?
a. Consider the behavior as a normal reaction to illness.
b. Validate perceptions with the client.
c. Discuss the client`s action with another nurse for verification.
d. Discuss the morning schedule with the client to decrease apprehension.
22. What would be the best approach for the nurse to use when a client conveys anxiety immediately
prior to surgery? Select all the apply.
a. Reassure the client of the surgeon`s competency.
b. Provide teaching about the surgical procedure.
c. Explore the client`s feelings with him or her.
d. Relate the nurse`s personal experience of having a similar surgery.
e. Check on the client frequently until the client is transported to the operating room.
23. A nurse is preparing to complete an admission assessment on a client who is partially hearing
impaired. What would be the best approach for the nurse to use?
a. Request that a family member is present.
b. Prepare written questions that cover the assessment criteria.
c. Speak slowly in a low-pitched voice while facing the client.
d. Perform only the physical assessment at this time.
24. A client states,” I am so sick, I know I am going to die.” The best way for the nurse to document
this data would be to write:
a. Client is depressed today.
b. Client thinks he is going to die.
c. Client is frustrated with being sick.
d. Client states, “I am so sick, I know I am going to die.”
25. A 68-year-old female client needs to learn how to take her pulse before taking prescribed heart
medication. Before beginning the client teaching, the nurse should evaluate which of the following
about the client?
a. Cardiac status d. Motivation to attain optimal
b. Reading ability wellness
c. Psychomotor abilities
26. A nurse can best evaluate a client’s ability to self-administer insulin by using which of the following
methods?
a. Have the client write the procedure.
b. Demonstrate the technique on a mannequin.

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 c. Have the client tell the nurse the steps to take when administering insulin.
d. Observed the client self-administrating an insulin dose.
27. Which of the following behaviors by a client indicates to the nurse that learning in the cognitive
domain has taken place?
a. Explaining the rationale for taking a new medication
b. Actively demonstrating the new skills.
c. Telling the nurse he has accepted the illness and its effects on lifestyle.
d. Physically demonstrating insulin injections.
28. Which of the following options would be typical outcome criteria likely to appear on a critical
pathway for a postoperative appendectomy client?
a. Morphine sulfate 6 mg IM Q 4 hour’s prn for pain.
b. Limit visitors at the bedside to immediate family.
c. Client will be febrile within 24 hours after surgery.
d. Encourage ambulation and self-care after breakfast.
29. In order to provide care to clients, the nurse would give high priority to which information received
in inter shift report?
a. Physical assessment data and client response to care
b. Client`s list of active and resolved problems and associated medical treatments.
c. Physician visit and new orders
d. Intake/output data and vital signs
30. Charting by exception is used by a hospital for documentation. Using this format, how would the
nurse document routine morning care in the narrative nets?
a. Morning care completed
b. Morning care completed, client tolerated well
c. Morning care completed by client
d. Not necessary to document morning care if uneventful
PROFESSIONAL STANDARDS
31. Because a nurse caring for a surgical clients fails to monitor the clients adequately du ring the
postoperative period according to the standard of care, the clients experiences surgical
complications. The nurse concludes that this action is consistent with which of the following?
a. Practicing medicine without a license
b. Negligence
c. A misdemeanor
d. Failure to follow the good Samaritan Law
32. A nurse accidentally administers a dug to the wrong client reacts adversely to that drug. The nurse
anticipates that this event could lead to which of the following reasons?
a. A tort c. Fraud
b. Malpractice d. Assault
33. A 45-year old male Hispanic client who speaks very little English is scheduled for surgery
tomorrow. The nurse is concerned that the informed consent signed by the client on admission
may not be valid for which of the following reason?
a. The surgical consent form was not notarized
b. It was witnessed by unlicensed personnel
c. The client may not be able to understand the document he signed, which outlines
treatment and associated risks.
d. The client may be undocumented immigrant.
34. The new graduate nurse asks the nursing unit manger to share strategies aimed at risk
management. The manager correctly recommends which of the following? Select all that apply.
a. Treat every client with kindness and respect.
b. Seek help when facing new situation if unsure about which course of action is best.
c. Observe and report suspicious behavior of colleagues.
d. Be aware of the provisions of the state’s nurse practice act and function within those
provisions.
e. Refuse to assist in the area of clients assigned to other nurses.
35. The clinic managers want nurses working in the unit to administer moderate sedation. To legally
include this procedure in their practice, the staff nurses determine first that it is acceptable under
which of the following?
a. The agency’s policy and procedure book
b. The nurse’s liability insurance
c. Good Samaritan Law
d. The Nurses Practice Act (RA 9173)
36. A client diagnose with Alzheimer’s disease is currently competent to make healthcare decisions
regarding future needs. The Nurse counsels the client to contact a lawyer about which of the
following?
a. Advance directive c. Self-determination
b. Temporary power of attorney d. Informed consent
37. The nurse is aware that no physician is visited for hospitalized clients for three consecutive days.
The nurse report this event to the nursing supervisor after determining that it is a priority to
execute which nursing role?
a. Direct care provider role c. Client educator role
b. Case manager role d. Client advocate role
38. The nurse assigned ancillary personnel to take visit signs (VS) of all the clients on the unit after
nothing one set of VS that is questionable, the nurse retake the VS after considering which of the
following principles?
a. Supervision c. The highest level of
b. Obligation empowerment
d. Accountability
39. A nurse who is enrolled in a continuing education leadership course considers that which of the
following would be an example of over delegation in the workplace?
a. A registered nurse with three months of experience recently finished orientation of a
hospital unit. The nurse manager assigns the new nurse to be charge nurse for the
evening shift because the regular nurse has called in sick.

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 b. The evening staff expects the charge nurse to give report on all clients to the night
shift so they can leave the unit on time.
c. A staff nurse is reluctant to ask a nursing assistant to take vital; signs on her clients,
so the nurse takes all vital signs without assistance.
d. An experience staff nurse is assigned to orient a new graduate to the unit after the
nurse after the new nurse complete general orientation to the hospital
40. A new staff nurse is assigned responsibility for the care of an assigned client from admission to
discharge. When the staff nurse is on duty, others provide care base on in instructions left by the
staff nurse. The nurse understands that which care delivery system is being utilized on this unit?
a. Primary nursing
b. Team nursing
c. Case management
d. Functional nursing
HEALTH PROMOTION
41. The nurse is caring for a male client who has recently had his left leg amputated. To assess body
image, the nurse should gather subjective data such as;
a. Client’s feeling regarding the surgery
b. Strength of femoral pulse bilaterally
c. Client’s description of his personality
d. Status of wound healing
42. A nurse is admitting a client who became ill while visiting in this country. The nurse is unfamiliar
with the cultural practices and health beliefs of the client’s home country. Which of the following
question would be appropriate to ask in the admission assessment? Select all that apply.
a. Are there remedies you have use for this illness before coming to the hospital?
b. Who do you usually see for help or care when you are ill?
c. What do you believe is causing your current illness?
d. Why do you dress in that type of clothing?
e. Can you tell me about your usual diet?
43. A client reports a decrease in sexual desire. The nurse should examine the client’s medication list
for which of the following medication? Select all the apply.
a. Azythromycin (zithromax) d. Warfarin (coumadin)
b. Propranolol (inderal) e. Sertraline (Zoloft)
c. Ascorbic acid (vitaminc)
44. The nurse is interviewing an adolescent client. The nurse can best facilitate communication with
the adolescent client by making which statement?
a. “if you read the pamphlet you’ll know all you need to know”
b. “we can talk about this with your mother”
c. “other teenage girls also feel depressed”
d. “tell me about the last time you had sexual intercourse”
45. Several parents have asked the pediatric nurse to assess whether their toddlers are ready for
toilet training. The nurse concludes that which of the following toddlers demonstrate readiness for
the toilet training?
a. One who can dress and undress self and walk well
b. One who pulls to standing position and says “pee“ when urinating
c. One who crawls and cries loudly after urination.
d. One who crawls well and cries loudly after urination
46. A 4- year old Mexican American child has recently been diagnosed with leukemia. When
considering the client’s culture, the nurse would employ which of the following as the most
appropriate intervention?
a. Limit all visitors, including extended family.
b. Encourage visits from extended as well as immediate family.
c. Ban all visits from alter native healers
d. Make diet selection for the child and family.
47. Before acting upon the perceived non verbal behavior of a client from Italy, the nurse should do
which of the following?
a. Validate his or her perception
b. Use a translator
c. Get another nurse to assess the client
d. Form a nursing diagnosis
48. An elderly client expresses difficulty sleeping because her spirit is disturbed due to sin in her life.
The nurse should select which of the following as the priority intervention?
a. Call the chaplain and schedule a visit
b. Ascertain what religious practice is appropriate to the client
c. Pray immediately with the client
d. Administer sleep medications as ordered
49. A client who is in the final stage of cancer is depressed and distant. The client as the nurse, “why
is God punishing me? “ Which of the following would be the most appropriate action for the nurse
to take?
a. Be available to the client
b. Share personal religious belief with the client
c. Tell the client to pray for answer
d. Call the physician for anti-anxiety medication orders
50. A nurse finds multiple bruises in various stage of healing and signs of old injuries on an infant
during an assessment. The nurse suspect the child may be the victim of abuse. Which of the
following would be most important for the nurse to do?
a. Investigate the mother’s feeling towards the infant
b. Refer the child to a center for abused children
c. Document objective findings and report suspected abused as outline in agency policy
d. Make a note on the chart so the child will be assessed carefully on future visits

iMIND iNSIGHTS COMMITMENT. EXCELLENCE. QUALIITY 1st Edition