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Fundamentals Of Nursing

100 Questions  I  By Abangjoseph
FUNDAMENTALS OF NURSING
The basic principles and practices of nursing as taught in educational programs for nurses. In a course on the fundamentals of nursing, traditionally required in the first semester of the program, the student attends classes and gives care to selected patients. A fundamentals of nursing course emphasizes the importance of the fundamental needs of humans as well as competence in basic skills as prerequisites to providing comprehensive nursing care.
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1.  The nurse is helping to plan a teaching session for a client who will be discharged with a colostomy. When describing a healthy stoma, which statement should the nurse be sure to include?
A.
B.
C.
D.
2.  The nurse prepares to auscultate a client's carotid arteries for bruits. For this procedure, the nurse should:
A.
B.
C.
D.
3.  When should the nurse check a client for rebound tenderness?
A.
B.
C.
D.
4.  A client complains of abdominal pain. To elicit as much information about the pain as possible, the nurse should ask:
A.
B.
C.
D.
5.  The nurse is assessing a client's pulse. Which pulse feature should the nurse document?
A.
B.
C.
D.
6.  Which descriptions are true about crackles?
A.
B.
C.
D.
7.  The nurse is assessing a client who may be in the early stages of dehydration. Early manifestations of dehydration include:
A.
B.
C.
D.
8.  The nurse measures a client's apical pulse rate and compares it with the radial pulse rate. The differential between these two pulses is called:
A.
B.
C.
D.
9.  When palpating the bladder of an adult client, the nurse should identify which finding as normal?
A.
B.
C.
D.
10.  The nurse is assessing a client who has a rash on his chest and upper arms. Which questions should the nurse ask in order to gain further information about the client's rash?
A.
B.
C.
D.
E.
F.
11.  The nurse prepares to assess a client who has just been admitted to the health care facility. During assessment, the nurse performs which activity?
A.
B.
C.
D.
12.  Why should the nurse inspect first and then auscultate when performing an assessment of a pediatric client?
A.
B.
C.
D.
13.  During the physical examination, the nurse uses various techniques to assess structures, organs, and body systems. Which technique allows the nurse to feel for vibration and locate body structures?
A.
B.
C.
D.
14.  The nurse prepares to palpate a client's maxillary sinuses. For this procedure, where should the nurse place the hands?
A.
B.
C.
D.
15.  Hyperactive bowel sounds can result from all of the following except:
A.
B.
C.
D.
16.  The nurse prepares to measure a client's blood pressure. What is the correct procedure for measuring blood pressure?
A.
B.
C.
D.
17.  The nurse reviews the arterial blood gas (ABG) values of a client admitted with pneumonia: pH, 7.51; PaCO2, 28 mm Hg; PaO2, 70 mm Hg; and HCO3–, 24 mEq/L. What do these values indicate?
A.
B.
C.
D.
18.  When percussing a client's chest, the nurse should identify which sound as a normal finding?
A.
B.
C.
D.
19.  To avoid recording an erroneously low systolic blood pressure because of failure to recognize an auscultatory gap, the nurse should:
A.
B.
C.
D.
20.  A pediatric nurse is asked to work temporarily (float) in the intensive care unit (ICU) because there are few clients in the pediatric unit. The nurse has never worked in ICU and has no critical care experience. Which action is most appropriate for this nurse?
A.
B.
C.
D.
21.  The nurse uses a stethoscope to auscultate a client's chest. Which statement about a stethoscope with a bell and diaphragm is true?
A.
B.
C.
D.
22.  The nurse is assessing a postoperative client. Which of the following should the nurse document as subjective data?
A.
B.
C.
D.
23.  Which of the following factors are major components of a client's general background drug history?
A.
B.
C.
D.
24.  When testing a client's pupils for accommodation, the nurse should interpret which findings as normal?
A.
B.
C.
D.
25.  Tachycardia can result from:
A.
B.
C.
D.
26.  To evaluate a client's reason for seeking care, the nurse performs deep palpation. The purpose of deep palpation is to assess which of the following?
A.
B.
C.
D.
27.  The nurse is monitoring a client for adverse reactions during barbiturate therapy. What is the major disadvantage of barbiturate use?
A.
B.
C.
D.
28.  The nurse must assess skin turgor of an elderly client. When evaluating skin turgor, the nurse should remember that:
A.
B.
C.
D.
29.  Two days after undergoing a total abdominal hysterectomy, a client complains of left calf pain, and venography reveals deep vein thrombosis (DVT). When assessing this client, the nurse is most likely to detect:
A.
B.
C.
D.
30.  The nurse must assess a client's splinted extremity for neurovascular damage. What should she do?
A.
B.
C.
D.
31.  A client comes to the clinic for diagnostic allergy testing. Why is intradermal injection used for such testing?
A.
B.
C.
D.
32.  The nurse prepares to perform light palpation. How is light palpation performed?
A.
B.
C.
D.
33.  All of the following components may be part of a client's medical record. Which one is the major source of subjective data about the client's health status?
A.
B.
C.
D.
34.  A client with fever, weight loss, and watery diarrhea is being admitted to the facility. While assessing the client, a nurse inspects the client's abdomen and notices that it's slightly concave. Additional assessment should proceed in which order?
A.
B.
C.
D.
35.  During assessment, the nurse auscultates for a client's breath sounds. Auscultation produces which type of data?
A.
B.
C.
D.
36.  Vasodilation or vasoconstriction produced by an external cause will interfere with an accurate assessment of a client with peripheral vascular disease (PVD). Therefore, the nurse should:
A.
B.
C.
D.
37.  A 60-year old client reports to the nurse that he has a rash on his back and right flank. The nurse observes elevated, round, blisterlike lesions that are filled with clear fluid. When documenting the findings, what medical term should the nurse use to describe these lesions?
A.
B.
C.
D.
38.  The nurse is assessing an elderly client. When performing the assessment, the nurse should consider that one normal aging change is:
A.
B.
C.
D.
39.  Which plane divides the body longitudinally into anterior and posterior regions?
A.
B.
C.
D.
40.  The nurse is performing a preoperative assessment. Which statement by the client would alert the nurse to the presence of risk factors for postoperative complications?
A.
B.
C.
D.
41.  To evaluate a client's posterior tibial pulse, where should the nurse palpate?
A.
B.
C.
D.
42.  A child with rheumatic fever must have his heart rate measured while awake and while sleeping. Why are two readings necessary?
A.
B.
C.
D.
43.  To assess the effectiveness of cardiac compressions during adult cardiopulmonary resuscitation (CPR), the nurse should palpate which pulse site?
A.
B.
C.
D.
44.  When palpating a client's body to detect warmth, the nurse should use which part of the hand?
A.
B.
C.
D.
45.  When auscultating a client's chest, the nurse assesses a second heart sound (S2). This sound results from:
A.
B.
C.
D.
46.  A client who was involved in a motor vehicle accident is admitted to the intensive care unit. The emergency department admission record indicates that the client hit her head on the steering wheel. The client complains of a headache, and a nursing assessment reveals that she has difficulty comprehending language and diminished hearing. Based on these findings, the nurse suspects injury to which lobe of the brain?
A.
B.
C.
D.
47.  When determining appropriate nursing interventions for a client with a medical diagnosis, the nurse is using which of the following?
A.
B.
C.
D.
48.  To help assess a client's cerebral function, the nurse should ask:
A.
B.
C.
D.
49.  The nurse is auscultating a client's chest. How can the nurse differentiate a pleural friction rub from other abnormal breath sounds?
A.
B.
C.
D.
50.  When assessing the facial lacerations of a middle-aged client admitted to the facility 1 week ago, the nurse observes scabs around the lacerations. Scabs indicate which phase of wound healing?
A.
B.
C.
D.
51.  Which statement regarding heart sounds is correct?
A.
B.
C.
D.
52.  Why should an infant be quiet and seated upright when the nurse assesses his fontanels?
A.
B.
C.
D.
53.  When examining a client with abdominal pain, the nurse should assess:
A.
B.
C.
D.
54.  When routinely evaluating a geriatric client for any atypical signs or symptoms, the nurse should remember that:
A.
B.
C.
D.
55.  A client comes to the clinic for a routine checkup. To assess the client's gag reflex, the nurse should use which method?
A.
B.
C.
D.
56.  A client who recently immigrated to the United States from Korea is hospitalized with second- and third-degree burns. He speaks little English and has been lying quietly in bed. Ten hours after his admission, the nurse conducts a serial assessment and asks him whether he's in pain. He smiles and shakes his head vigorously back and forth. Which nursing action would be most appropriate at this time?
A.
B.
C.
D.
57.  The nurse is assessing a 47-year-old client who has come to the physician's office for his annual physical. One of the first physical signs of aging is:
A.
B.
C.
D.
58.  During a physical examination, the nurse asks a client to hold the breath briefly, and then uses a stethoscope to auscultate over the carotid arteries. Which finding is normal when auscultating over these arteries?
A.
B.
C.
D.
59.  The nurse is assessing tactile fremitus in a client with pneumonia. For this examination, the nurse should use the:
A.
B.
C.
D.
60.  The nurse is assessing a client's abdomen. Which finding should the nurse report as abnormal?
A.
B.
C.
D.
61.  A client reports abdominal pain. Which action would aid the nurse's investigation of this complaint?
A.
B.
C.
D.
62.  After suctioning a tracheostomy tube, the nurse assesses the client to determine the effectiveness of the suctioning. Which findings indicate that the airway is now patent?
A.
B.
C.
D.
63.  When a nurse enters the client's room, the client complains that she's spitting up blood when she coughs. The nurse takes a quick health history that includes:
A.
B.
C.
D.
64.  The nurse is teaching the parents of a child with cystic fibrosis about proper nutrition. Which instruction should the nurse include?
A.
B.
C.
D.
65.  Which of the following is the most common source of airway obstruction in an unconscious victim?
A.
B.
C.
D.
66.  The nurse is teaching a client who will be discharged soon how to change a sterile dressing on the right leg. During the teaching session, the nurse notices redness, swelling, and induration at the wound site. What do these signs suggest?
A.
B.
C.
D.
67.  A client, age 75, is admitted to the facility. Because of the client's age, the nurse should modify the assessment by:
A.
B.
C.
D.
68.  The nurse can auscultate for heart sounds more easily if the client is:
A.
B.
C.
D.
69.  The nurse measures a client's temperature at 102° F. What is the equivalent Centigrade temperature?
A.
B.
C.
D.
70.  Before a transesophageal echocardiogram, a client is given an oral topical anesthetic spray. Upon return from the procedure, the nurse observes that the client has no active gag reflex. In response, the nurse should
A.
B.
C.
D.
71.  A 76-year-old client with no debilitating conditions belongs to which geriatric population?
A.
B.
C.
D.
72.  The nurse prepares to perform an otoscopic examination on an adult. For proper visualization, the nurse should position the client's ear by pulling the:
A.
B.
C.
D.
73.  The nurse is helping a client ambulate for the first time after 3 days of bed rest. Which observation by the nurse suggests that the client tolerated the activity without distress?
A.
B.
C.
D.
74.  The nurse is evaluating a client's auditory function. To compare air conduction to bone conduction, the nurse should conduct which test?
A.
B.
C.
D.
75.  The nurse is assessing a client who has a rash on his chest and upper arms. Which questions should the nurse ask in order to gain further information about the client's rash?
A.
B.
C.
D.
E.
F.
76.  When assessing a client with cellulitis of the right leg, which of the following would the nurse expect to find?
A.
B.
C.
D.
77.  The nurse is examining a client with suspected peritonitis. How does the nurse elicit rebound tenderness?
A.
B.
C.
D.
78.  A client has just undergone bronchoscopy. Which nursing assessment is most important at this time?
A.
B.
C.
D.
79.  When auscultating a client's abdomen, the nurse detects high-pitched gurgles over the lower right quadrant. Based on this finding, the nurse suspects:
A.
B.
C.
D.
80.  The nurse correctly identifies which items as belonging to the dorsal cavity?
A.
B.
C.
D.
81.  To evaluate a client's cerebellar function, the nurse should ask:
A.
B.
C.
D.
82.  The nurse is obtaining the health history of a client whose background differs from the nurse's. To develop culturally acceptable strategies for nursing care, the nurse should assess which client factor?
A.
B.
C.
D.
83.  The nurse conducts a test for the Romberg's sign. What is the correct procedure for this test?
A.
B.
C.
D.
84.  The nurse determines that a client has 20/40 vision. Which statement about this client's vision is true?
A.
B.
C.
D.
85.  At 8 a.m., the nurse assesses a client who's scheduled for surgery at 10 a.m. During the assessment, the nurse detects dyspnea, a nonproductive cough, and back pain. What should the nurse do next?
A.
B.
C.
D.
86.  When performing an abdominal assessment, the nurse should follow which examination sequence?
A.
B.
C.
D.
87.  When assessing a geriatric client, the nurse expects to find various aging-related physiologic changes. These changes include:
A.
B.
C.
D.
88.  The nurse is assessing a client's abdomen. Which examination technique should the nurse use first?
A.
B.
C.
D.
89.  When obtaining a client's history, the nurse develops a genogram. What is the purpose of developing a genogram?
A.
B.
C.
D.
90.  A client undergoes a total abdominal hysterectomy. When assessing the client 10 hours later, the nurse identifies which finding as an early sign of shock?
A.
B.
C.
D.
91.  The nurse plans to obtain client information from a primary source. Which is a primary information source?
A.
B.
C.
D.
92.  Which pulse should the nurse palpate during rapid assessment of an unconscious adult?
A.
B.
C.
D.
93.  Which of the following sentences correctly describes the anatomic position?
A.
B.
C.
D.
94.  An 82-year-old client is admitted to the hospital with a diagnosis of pneumonia. The nurse learns that the client lives alone and hasn't been eating or drinking. When assessing him for dehydration, the nurse would expect to find:
A.
B.
C.
D.
95.  The nurse is caring for a client who has suffered a severe stroke. During routine assessment, the nurse notices Cheyne-Stokes respirations. Cheyne-Stokes respirations are:
A.
B.
C.
D.
96.  A client has lymphedema in both arms and the nurse must measure blood pressure using a thigh cuff. In reference to the client's baseline arm blood pressure, the nurse should expect the thigh to have a:
A.
B.
C.
D.
97.  Why shouldn't the nurse palpate both carotid arteries at one time?
A.
B.
C.
D.
98.  When inspecting a client's skin, the nurse finds a vesicle on the client's arm. Which description applies to a vesicle?
A.
B.
C.
D.
99.  A mother comes to the clinic with her 5-year-old son who's complaining of a fever and sore throat. The nurse documents the client's tonsils as 3+. This means they're:
A.
B.
C.
D.
100.  The ear canal of an infant or young child:
A.
B.
C.
D.
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