Another set of 25-item examination about Fundamentals of Nursing. Take this interactive exam that covers topics from drug computation, documentation and Nursing Research.
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Fundamentals of Nursing Exam 2
Fundamentals of Nursing Exam 1
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The physician orders DS 500 cc with KCl 10 mEq/liter at 30 cc/hr. The nurse in-charge is going to hang a 500 cc bag. KCl is supplied 20 mEq/10 cc. How many cc’s of KCl will be added to the IV solution?
Question 1 Explanation:
2.5 cc is to be added, because only a 500 cc bag of solution is being medicated instead of a 1 liter.
A child of 10 years old is to receive 400 cc of IV fluid in an 8 hour shift. The IV drip factor is 60. The IV rate that will deliver this amount is:
50 cc/ hour
55 cc/ hour
24 cc/ hour
66 cc/ hour
Question 2 Explanation:
A rate of 50 cc/hr. The child is to receive 400 cc over a period of 8 hours = 50 cc/hr.
The nurse is aware that the most important nursing action when a client returns from surgery is:
Assess the IV for type of fluid and rate of flow.
Assess the client for presence of pain.
Assess the Foley catheter for patency and urine output
Assess the dressing for drainage.
Question 3 Explanation:
Assessing the client for pain is a very important measure. Postoperative pain is an indication of complication. The nurse should also assess the client for pain to provide for the client’s comfort.
Which of the following vital sign assessments that may indicate cardiogenic shock after myocardial infarction?
BP – 80/60, Pulse – 110 irregular
BP – 90/50, Pulse – 50 regular
BP – 130/80, Pulse – 100 regular
BP – 180/100, Pulse – 90 irregular
Question 4 Explanation:
The classic signs of cardiogenic shock are low blood pressure, rapid and weak irregular pulse, cold, clammy skin, decreased urinary output, and cerebral hypoxia.
Which is the most appropriate nursing action in obtaining a blood pressure measurement?
Take the proper equipment, place the client in a comfortable position, and record the appropriate information in the client’s chart.
Measure the client’s arm, if you are not sure of the size of cuff to use.
Have the client recline or sit comfortably in a chair with the forearm at the level of the heart.
Document the measurement, which extremity was used, and the position that the client was in during the measurement.
Question 5 Explanation:
It is a general or comprehensive statement about the correct procedure, and it includes the basic ideas which are found in the other options
Asking the questions to determine if the person understands the health teaching provided by the nurse would be included during which step of the nursing process?
Planning and goals
Question 6 Explanation:
Evaluation includes observing the person, asking questions, and comparing the patient’s behavioral responses with the expected outcomes.
Which of the following item is considered the single most important factor in assisting the health professional in arriving at a diagnosis or determining the person’s needs?
Diagnostic test results
History of present illness
Question 7 Explanation:
The history of present illness is the single most important factor in assisting the health professional in arriving at a diagnosis or determining the person’s needs.
In preventing the development of an external rotation deformity of the hip in a client who must remain in bed for any period of time, the most appropriate nursing action would be to use:
Trochanter roll extending from the crest of the ileum to the midthigh.
Pillows under the lower legs.
Question 8 Explanation:
A trochanter roll, properly placed, provides resistance to the external rotation of the hip.
Which stage of pressure ulcer development does the ulcer extend into the subcutaneous tissue?
Question 9 Explanation:
Clinically, a deep crater or without undermining of adjacent tissue is noted.
When the method of wound healing is one in which wound edges are not surgically approximated and integumentary continuity is restored by granulations, the wound healing is termed
Second intention healing
Primary intention healing
Third intention healing
First intention healing
Question 10 Explanation:
When wounds dehisce, they will allowed to heal by secondary intention
An 80-year-old male client is admitted to the hospital with a diagnosis of pneumonia. Nurse Oliver learns that the client lives alone and hasn’t been eating or drinking. When assessing him for dehydration, nurse Oliver would expect to find:
Distended neck veins
Question 11 Explanation:
With an extracellular fluid or plasma volume deficit, compensatory mechanisms stimulate the heart, causing an increase in heart rate.
The physician prescribes meperidine (Demerol), 75 mg I.M. every 4 hours as needed, to control a client’s postoperative pain. The package insert is “Meperidine, 100 mg/ml.” How many milliliters of meperidine should the client receive?
Question 12 Explanation:
To determine the number of milliliters the client should receive, the nurse uses the fraction method in the following equation. 75 mg/X ml = 100 mg/1 ml To solve for X, cross-multiply: 75 mg x 1 ml = X ml x 100 mg 75 = 100X 75/100 = X 0.75 ml (or ¾ ml) = X
A male client with diabetes mellitus is receiving insulin. Which statement correctly describes an insulin unit?
It’s a common measurement in the metric system.
It’s the basis for solids in the avoirdupois system.
It’s the smallest measurement in the apothecary system.
It’s a measure of effect, not a standard measure of weight or quantity.
Question 13 Explanation:
An insulin unit is a measure of effect, not a standard measure of weight or quantity. Different drugs measured in units may have no relationship to one another in quality or quantity.
Nurse Oliver measures a client’s temperature at 102° F. What is the equivalent Centigrade temperature?
Question 14 Explanation:
To convert Fahrenheit degreed to Centigrade, use this formula °C = (°F – 32) ÷ 1.8 °C = (102 – 32) ÷ 1.8 °C = 70 ÷ 1.8 °C = 38.9
The nurse is assessing a 48-year-old client who has come to the physician’s office for his annual physical exam. One of the first physical signs of aging is:
Accepting limitations while developing assets.
Increasing loss of muscle tone.
Failing eyesight, especially close vision.
Having more frequent aches and pains.
Question 15 Explanation:
Failing eyesight, especially close vision, is one of the first signs of aging in middle life (ages 46 to 64). More frequent aches and pains begin in the early late years (ages 65 to 79). Increase in loss of muscle tone occurs in later years (age 80 and older).
The physician inserts a chest tube into a female client to treat a pneumothorax. The tube is connected to water-seal drainage. The nurse in-charge can prevent chest tube air leaks by:
Checking and taping all connections.
Checking patency of the chest tube.
Keeping the head of the bed slightly elevated.
Keeping the chest drainage system below the level of the chest.
Question 16 Explanation:
Air leaks commonly occur if the system isn’t secure. Checking all connections and taping them will prevent air leaks. The chest drainage system is kept lower to promote drainage – not to prevent leaks.
Nurse Trish must verify the client’s identity before administering medication. She is aware that the safest way to verify identity is to:
Check the client’s identification band.
Ask the client to state his name.
State the client’s name out loud and wait a client to repeat it.
Check the room number and the client’s name on the bed.
Question 17 Explanation:
Checking the client’s identification band is the safest way to verify a client’s identity because the band is assigned on admission and isn’t be removed at any time. (If it is removed, it must be replaced). Asking the client’s name or having the client repeated his name would be appropriate only for a client who’s alert, oriented, and able to understand what is being said, but isn’t the safe standard of practice. Names on bed aren’t always reliable
The physician orders dextrose 5 % in water, 1,000 ml to be infused over 8 hours. The I.V. tubing delivers 15 drops/ml. Nurse John should run the I.V. infusion at a rate of:
Question 18 Explanation:
Giving 1,000 ml over 8 hours is the same as giving 125 ml over 1 hour (60 minutes). Find the number of milliliters per minute as follows: 125/60 minutes = X/1 minute 60X = 125 = 2.1 ml/minute To find the number of drops per minute: 2.1 ml/X gtt = 1 ml/ 15 gtt X = 32 gtt/minute, or 32 drops/minute
If a central venous catheter becomes disconnected accidentally, what should the nurse in-charge do immediately?
Clamp the catheter
Call another nurse
Call the physician
Apply a dry sterile dressing to the site.
Question 19 Explanation:
If a central venous catheter becomes disconnected, the nurse should immediately apply a catheter clamp, if available. If a clamp isn’t available, the nurse can place a sterile syringe or catheter plug in the catheter hub. After cleaning the hub with alcohol or povidone-iodine solution, the nurse must replace the I.V. extension and restart the infusion.
A female client was recently admitted. She has fever, weight loss, and watery diarrhea is being admitted to the facility. While assessing the client, Nurse Hazel inspects the client’s abdomen and notice that it is slightly concave. Additional assessment should proceed in which order:
Palpation, auscultation, and percussion.
Percussion, palpation, and auscultation.
Palpation, percussion, and auscultation.
Auscultation, percussion, and palpation.
Question 20 Explanation:
The correct order of assessment for examining the abdomen is inspection, auscultation, percussion, and palpation. The reason for this approach is that the less intrusive techniques should be performed before the more intrusive techniques. Percussion and palpation can alter natural findings during auscultation.
Nurse Betty is assessing tactile fremitus in a client with pneumonia. For this examination, nurse Betty should use the:
Dorsal surface of the hand
Ulnar surface of the hand
Question 21 Explanation:
The nurse uses the ulnar surface, or ball, of the hand to asses tactile fremitus, thrills, and vocal vibrations through the chest wall. The fingertips and finger pads best distinguish texture and shape. The dorsal surface best feels warmth.
Which type of evaluation occurs continuously throughout the teaching and learning process?
Question 22 Explanation:
Formative (or concurrent) evaluation occurs continuously throughout the teaching and learning process. One benefit is that the nurse can adjust teaching strategies as necessary to enhance learning. Summative, or retrospective, evaluation occurs at the conclusion of the teaching and learning session. Informative is not a type of evaluation.
A 45 year old client, has no family history of breast cancer or other risk factors for this disease. Nurse John should instruct her to have mammogram how often?
Twice per year
Once per year
Every 2 years
Once, to establish baseline
Question 23 Explanation:
Yearly mammograms should begin at age 40 and continue for as long as the woman is in good health. If health risks, such as family history, genetic tendency, or past breast cancer, exist, more frequent examinations may be necessary.
A male client has the following arterial blood gas values: pH 7.30; Pao2 89 mmHg; Paco2 50 mmHg; and HCO3 26mEq/L. Based on these values, Nurse Patricia should expect which condition?
Question 24 Explanation:
The client has a below-normal (acidic) blood pH value and an above-normal partial pressure of arterial carbon dioxide (Paco2) value, indicating respiratory acidosis. In respiratory alkalosis, the pH value is above normal and in the Paco2 value is below normal. In metabolic acidosis, the pH and bicarbonate (Hco3) values are below normal. In metabolic alkalosis, the pH and Hco3 values are above normal.
Nurse Len refers a female client with terminal cancer to a local hospice. What is the goal of this referral?
To help the client find appropriate treatment options.
To provide support for the client and family in coping with terminal illness.
To ensure that the client gets counseling regarding health care costs.
To teach the client and family about cancer and its treatment.
Question 25 Explanation:
Hospices provide supportive care for terminally ill clients and their families. Hospice care doesn’t focus on counseling regarding health care costs. Most client referred to hospices have been treated for their disease without success and will receive only palliative care in the hospice.
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