Fundamentals of Nursing, The Art and Science of
Person-Centered Care, 10th Edition Test Bank |
Taylor, Lynn & Bartlett | Verified Q&A 2026/2027
1. A patient with chronic obstructive pulmonary disease (COPD) has an arterial blood gas (ABG)
showing pH 7.32, PaCO2 58 mm Hg, PaO2 70 mm Hg, HCO3- 26 mEq/L. The nurse interprets this
as which acid-base imbalance?
A. Uncompensated respiratory alkalosis
B. Partially compensated respiratory acidosis
C. Fully compensated metabolic alkalosis
D. Mixed respiratory and metabolic acidosis
Answer: B
Rationale: The pH is acidic (7.32), PaCO2 is elevated (58), and HCO3- is normal (26). This indicates
respiratory acidosis without renal compensation (partial compensation would show elevated HCO3-).
Option A is alkalosis; C has high pH and HCO3-; D would have low HCO3-.
2. When administering a blood transfusion, the nurse observes that the patient develops flank pain,
hypotension, and dark urine 30 minutes after initiation. Which type of transfusion reaction is most
likely occurring?
A. Febrile non-hemolytic reaction
B. Acute hemolytic reaction
C. Allergic reaction
D. Bacterial contamination
Answer: B
Rationale: Acute hemolytic reaction presents with flank pain, hypotension, and hemoglobinuria due to
ABO incompatibility. Febrile reactions present with fever/chills; allergic reactions with urticaria;
bacterial contamination with high fever and shock.
3. A patient has a pressure ulcer on the sacrum with full-thickness skin loss extending into
subcutaneous tissue, but not involving muscle or bone. According to the NPUAP staging system,
this is classified as:
A. Stage 1
B. Stage 2
C. Stage 3
D. Unstageable
Answer: C
Rationale: Stage 3 pressure ulcer involves full-thickness skin loss with visible subcutaneous fat; muscle
and bone are not exposed. Stage 1 is non-blanchable erythema; Stage 2 is partial-thickness; unstageable
has slough/eschar obscuring depth.
Page 1
,4. The nurse is evaluating a patient's understanding of a low-sodium diet for hypertension. Which
meal selection indicates correct learning?
A. Grilled chicken with steamed broccoli and a side of canned soup
B. Baked salmon with quinoa and fresh green beans
C. Turkey sandwich with deli meat and a pickle
D. Pasta with marinara sauce from a jar and garlic bread
Answer: B
Rationale: Fresh salmon, quinoa, and green beans are naturally low in sodium. Canned soup, deli meats,
pickles, jarred sauces, and garlic bread are high in sodium. Option A includes canned soup; C has deli
meat and pickle; D has jarred sauce and garlic bread.
5. A nurse is preparing to administer a medication via a nasogastric tube. Which action is essential
to prevent aspiration?
A. Flush the tube with 30 mL of water before and after medication
B. Administer the medication with the patient in supine position
C. Check gastric residual volume and hold if > 250 mL
D. Mix all crushed medications together in one syringe
Answer: C
Rationale: Checking residual volume helps assess gastric emptying; holding if >250 mL reduces
aspiration risk. Flushing is important but not primarily for aspiration prevention; supine position
increases risk; mixing medications can cause incompatibilities.
6. A patient with type 2 diabetes mellitus is prescribed metformin 500 mg PO BID. The nurse notes
the patient has an eGFR of 35 mL/min/1.73 m². What is the nurse's priority action?
A. Administer the medication as prescribed
B. Hold the medication and notify the prescriber
C. Reduce the dose to 250 mg daily
D. Increase fluid intake to prevent dehydration
Answer: B
Rationale: Metformin is contraindicated in patients with eGFR < 30-45 due to risk of lactic acidosis. The
nurse should hold and notify the prescriber for alternative therapy. Option A would be unsafe; C is not
within nursing scope; D does not address the contraindication.
7. A patient is receiving a continuous intravenous infusion of heparin for deep vein thrombosis.
The aPTT result is 120 seconds (therapeutic range 60-80 seconds). What should the nurse do first?
A. Stop the infusion and administer protamine sulfate
B. Decrease the infusion rate per protocol
C. Continue the infusion at the same rate
D. Increase the infusion rate per protocol
Answer: B
Rationale: An aPTT of 120 seconds indicates supratherapeutic anticoagulation with increased bleeding
risk. Per standard protocols, the nurse should decrease the infusion rate. Stopping and giving protamine
is for severe bleeding; continuing/increasing would worsen the situation.
Page 2
,8. The nurse is assessing a patient with suspected compartment syndrome after a tibial fracture.
Which finding is most indicative of this condition?
A. Pulselessness of the affected limb
B. Pain that is out of proportion to the injury and increases with passive stretch
C. Paresthesia distal to the injury
D. Pallor and coolness of the extremity
Answer: B
Rationale: Severe pain unrelieved by analgesics and exacerbated by passive stretch is the earliest and
most reliable sign of compartment syndrome. Pulselessness, paresthesia, and pallor are later signs.
Option B is the classic hallmark.
9. A nurse is providing discharge teaching to a patient after a myocardial infarction. The patient
asks why they need to take a beta-blocker. Which response by the nurse is most accurate?
A. It will help lower your blood pressure and reduce chest pain.
B. It reduces the workload on your heart and decreases the risk of another heart attack.
C. It prevents arrhythmias by slowing your heart rate.
D. It dilates your coronary arteries to improve blood flow.
Answer: B
Rationale: Beta-blockers reduce myocardial oxygen demand by decreasing heart rate and contractility,
thereby reducing mortality post-MI. While they also lower BP and heart rate, the primary
evidence-based benefit is reducing reinfarction and sudden death. Option D describes nitrates.
10. A patient with a history of cirrhosis is admitted with confusion, asterixis, and elevated serum
ammonia. Which dietary intervention is most appropriate initially?
A. High-protein, low-carbohydrate diet
B. Low-protein diet with lactulose therapy
C. Low-sodium diet with fluid restriction
D. High-calorie, low-fat diet
Answer: B
Rationale: Hepatic encephalopathy is treated by reducing ammonia production. A low-protein diet
decreases ammonia precursors, and lactulose promotes ammonia excretion. High-protein would worsen
encephalopathy; low-sodium is for ascites, not encephalopathy; high-calorie is supportive but not
primary.
11. A nurse is using the clinical judgment model to assess a patient with shortness of breath. Which
step involves clustering cues to identify a potential problem?
A. Recognizing cues
B. Analyzing cues
C. Prioritizing hypotheses
D. Generating solutions
Answer: B
Rationale: Analyzing cues involves clustering related cues to identify patterns and form hypotheses.
Recognizing cues is the initial step of gathering data, not clustering. Prioritizing hypotheses and
Page 3
, generating solutions occur later in the clinical judgment process.
12. A nursing student is preparing to administer a blood transfusion. According to the latest
evidence-based practice, which action is most critical to prevent a transfusion reaction?
A. Verifying patient identification with two identifiers before transfusion
B. Ensuring the blood product is infused within 4 hours of removal from refrigeration
C. Administering pre-medication with acetaminophen and diphenhydramine for all patients
D. Starting the transfusion slowly at 5 mL/min for the first 15 minutes
Answer: A
Rationale: The most critical step to prevent transfusion reactions is proper patient identification using
two identifiers, as errors in identification are a leading cause of reactions. While infusion time and rate
are important, they do not prevent reactions. Pre-medication is not recommended for all patients per
current guidelines.
13. A patient with chronic kidney disease is prescribed a low-protein diet. Which physiological
rationale best supports this dietary modification?
A. Reduces the workload on the kidneys by decreasing nitrogenous waste production
B. Prevents hyperkalemia by limiting dietary potassium intake
C. Decreases the risk of metabolic acidosis by reducing acid load
D. Minimizes fluid retention by lowering sodium content
Answer: A
Rationale: A low-protein diet reduces the production of nitrogenous wastes (urea) that must be excreted
by the kidneys, thereby decreasing the kidneys' workload. While it may indirectly affect potassium and
acid load, the primary rationale is to reduce nitrogenous waste. Fluid retention is managed with fluid
and sodium restriction, not protein.
14. A nurse is evaluating a patient's understanding of insulin administration. Which statement
indicates a need for further teaching regarding the storage of insulin?
A. I will store my unopened insulin vials in the refrigerator.
B. I can keep my opened insulin pen at room temperature for up to 28 days.
C. I will place my insulin vial in the freezer if not used within a month.
D. I will protect my insulin from direct sunlight and extreme temperatures.
Answer: C
Rationale: Insulin should never be frozen as freezing destroys its potency. Unopened insulin is stored in
the refrigerator, opened insulin pens can be kept at room temperature for up to 28 days, and insulin
should be protected from light and extreme temperatures. Therefore, option C indicates a dangerous
misunderstanding.
15. A patient with heart failure is receiving furosemide. Which assessment finding requires
immediate action by the nurse?
A. Urine output of 60 mL over the last 4 hours
B. Serum potassium level of 3.2 mEq/L
Page 4
Person-Centered Care, 10th Edition Test Bank |
Taylor, Lynn & Bartlett | Verified Q&A 2026/2027
1. A patient with chronic obstructive pulmonary disease (COPD) has an arterial blood gas (ABG)
showing pH 7.32, PaCO2 58 mm Hg, PaO2 70 mm Hg, HCO3- 26 mEq/L. The nurse interprets this
as which acid-base imbalance?
A. Uncompensated respiratory alkalosis
B. Partially compensated respiratory acidosis
C. Fully compensated metabolic alkalosis
D. Mixed respiratory and metabolic acidosis
Answer: B
Rationale: The pH is acidic (7.32), PaCO2 is elevated (58), and HCO3- is normal (26). This indicates
respiratory acidosis without renal compensation (partial compensation would show elevated HCO3-).
Option A is alkalosis; C has high pH and HCO3-; D would have low HCO3-.
2. When administering a blood transfusion, the nurse observes that the patient develops flank pain,
hypotension, and dark urine 30 minutes after initiation. Which type of transfusion reaction is most
likely occurring?
A. Febrile non-hemolytic reaction
B. Acute hemolytic reaction
C. Allergic reaction
D. Bacterial contamination
Answer: B
Rationale: Acute hemolytic reaction presents with flank pain, hypotension, and hemoglobinuria due to
ABO incompatibility. Febrile reactions present with fever/chills; allergic reactions with urticaria;
bacterial contamination with high fever and shock.
3. A patient has a pressure ulcer on the sacrum with full-thickness skin loss extending into
subcutaneous tissue, but not involving muscle or bone. According to the NPUAP staging system,
this is classified as:
A. Stage 1
B. Stage 2
C. Stage 3
D. Unstageable
Answer: C
Rationale: Stage 3 pressure ulcer involves full-thickness skin loss with visible subcutaneous fat; muscle
and bone are not exposed. Stage 1 is non-blanchable erythema; Stage 2 is partial-thickness; unstageable
has slough/eschar obscuring depth.
Page 1
,4. The nurse is evaluating a patient's understanding of a low-sodium diet for hypertension. Which
meal selection indicates correct learning?
A. Grilled chicken with steamed broccoli and a side of canned soup
B. Baked salmon with quinoa and fresh green beans
C. Turkey sandwich with deli meat and a pickle
D. Pasta with marinara sauce from a jar and garlic bread
Answer: B
Rationale: Fresh salmon, quinoa, and green beans are naturally low in sodium. Canned soup, deli meats,
pickles, jarred sauces, and garlic bread are high in sodium. Option A includes canned soup; C has deli
meat and pickle; D has jarred sauce and garlic bread.
5. A nurse is preparing to administer a medication via a nasogastric tube. Which action is essential
to prevent aspiration?
A. Flush the tube with 30 mL of water before and after medication
B. Administer the medication with the patient in supine position
C. Check gastric residual volume and hold if > 250 mL
D. Mix all crushed medications together in one syringe
Answer: C
Rationale: Checking residual volume helps assess gastric emptying; holding if >250 mL reduces
aspiration risk. Flushing is important but not primarily for aspiration prevention; supine position
increases risk; mixing medications can cause incompatibilities.
6. A patient with type 2 diabetes mellitus is prescribed metformin 500 mg PO BID. The nurse notes
the patient has an eGFR of 35 mL/min/1.73 m². What is the nurse's priority action?
A. Administer the medication as prescribed
B. Hold the medication and notify the prescriber
C. Reduce the dose to 250 mg daily
D. Increase fluid intake to prevent dehydration
Answer: B
Rationale: Metformin is contraindicated in patients with eGFR < 30-45 due to risk of lactic acidosis. The
nurse should hold and notify the prescriber for alternative therapy. Option A would be unsafe; C is not
within nursing scope; D does not address the contraindication.
7. A patient is receiving a continuous intravenous infusion of heparin for deep vein thrombosis.
The aPTT result is 120 seconds (therapeutic range 60-80 seconds). What should the nurse do first?
A. Stop the infusion and administer protamine sulfate
B. Decrease the infusion rate per protocol
C. Continue the infusion at the same rate
D. Increase the infusion rate per protocol
Answer: B
Rationale: An aPTT of 120 seconds indicates supratherapeutic anticoagulation with increased bleeding
risk. Per standard protocols, the nurse should decrease the infusion rate. Stopping and giving protamine
is for severe bleeding; continuing/increasing would worsen the situation.
Page 2
,8. The nurse is assessing a patient with suspected compartment syndrome after a tibial fracture.
Which finding is most indicative of this condition?
A. Pulselessness of the affected limb
B. Pain that is out of proportion to the injury and increases with passive stretch
C. Paresthesia distal to the injury
D. Pallor and coolness of the extremity
Answer: B
Rationale: Severe pain unrelieved by analgesics and exacerbated by passive stretch is the earliest and
most reliable sign of compartment syndrome. Pulselessness, paresthesia, and pallor are later signs.
Option B is the classic hallmark.
9. A nurse is providing discharge teaching to a patient after a myocardial infarction. The patient
asks why they need to take a beta-blocker. Which response by the nurse is most accurate?
A. It will help lower your blood pressure and reduce chest pain.
B. It reduces the workload on your heart and decreases the risk of another heart attack.
C. It prevents arrhythmias by slowing your heart rate.
D. It dilates your coronary arteries to improve blood flow.
Answer: B
Rationale: Beta-blockers reduce myocardial oxygen demand by decreasing heart rate and contractility,
thereby reducing mortality post-MI. While they also lower BP and heart rate, the primary
evidence-based benefit is reducing reinfarction and sudden death. Option D describes nitrates.
10. A patient with a history of cirrhosis is admitted with confusion, asterixis, and elevated serum
ammonia. Which dietary intervention is most appropriate initially?
A. High-protein, low-carbohydrate diet
B. Low-protein diet with lactulose therapy
C. Low-sodium diet with fluid restriction
D. High-calorie, low-fat diet
Answer: B
Rationale: Hepatic encephalopathy is treated by reducing ammonia production. A low-protein diet
decreases ammonia precursors, and lactulose promotes ammonia excretion. High-protein would worsen
encephalopathy; low-sodium is for ascites, not encephalopathy; high-calorie is supportive but not
primary.
11. A nurse is using the clinical judgment model to assess a patient with shortness of breath. Which
step involves clustering cues to identify a potential problem?
A. Recognizing cues
B. Analyzing cues
C. Prioritizing hypotheses
D. Generating solutions
Answer: B
Rationale: Analyzing cues involves clustering related cues to identify patterns and form hypotheses.
Recognizing cues is the initial step of gathering data, not clustering. Prioritizing hypotheses and
Page 3
, generating solutions occur later in the clinical judgment process.
12. A nursing student is preparing to administer a blood transfusion. According to the latest
evidence-based practice, which action is most critical to prevent a transfusion reaction?
A. Verifying patient identification with two identifiers before transfusion
B. Ensuring the blood product is infused within 4 hours of removal from refrigeration
C. Administering pre-medication with acetaminophen and diphenhydramine for all patients
D. Starting the transfusion slowly at 5 mL/min for the first 15 minutes
Answer: A
Rationale: The most critical step to prevent transfusion reactions is proper patient identification using
two identifiers, as errors in identification are a leading cause of reactions. While infusion time and rate
are important, they do not prevent reactions. Pre-medication is not recommended for all patients per
current guidelines.
13. A patient with chronic kidney disease is prescribed a low-protein diet. Which physiological
rationale best supports this dietary modification?
A. Reduces the workload on the kidneys by decreasing nitrogenous waste production
B. Prevents hyperkalemia by limiting dietary potassium intake
C. Decreases the risk of metabolic acidosis by reducing acid load
D. Minimizes fluid retention by lowering sodium content
Answer: A
Rationale: A low-protein diet reduces the production of nitrogenous wastes (urea) that must be excreted
by the kidneys, thereby decreasing the kidneys' workload. While it may indirectly affect potassium and
acid load, the primary rationale is to reduce nitrogenous waste. Fluid retention is managed with fluid
and sodium restriction, not protein.
14. A nurse is evaluating a patient's understanding of insulin administration. Which statement
indicates a need for further teaching regarding the storage of insulin?
A. I will store my unopened insulin vials in the refrigerator.
B. I can keep my opened insulin pen at room temperature for up to 28 days.
C. I will place my insulin vial in the freezer if not used within a month.
D. I will protect my insulin from direct sunlight and extreme temperatures.
Answer: C
Rationale: Insulin should never be frozen as freezing destroys its potency. Unopened insulin is stored in
the refrigerator, opened insulin pens can be kept at room temperature for up to 28 days, and insulin
should be protected from light and extreme temperatures. Therefore, option C indicates a dangerous
misunderstanding.
15. A patient with heart failure is receiving furosemide. Which assessment finding requires
immediate action by the nurse?
A. Urine output of 60 mL over the last 4 hours
B. Serum potassium level of 3.2 mEq/L
Page 4
