Foundations Exam 1 (NSU) Questions and
Correct Answers
Question 1
A patient has a blood pressure reading of 130/90 mmHg when visiting a clinic. What
would the nurse recommend to the patient?
a. Follow-up measurements of blood pressure
b. Immediate treatment by a physician
c. No action because the nurse consider this reading is due to anxiety
d. A change in dietary intake
Correct Answer
a. A single blood pressure reading that is mildly elevated is not signifcant, but the
measureent should be taken again over time to determine if hypertension is a
problem . The nurse would recommend a return visit to the clinic or a recheck
Question 2
To determine the significance of a blood pressure reading of 148/100, it is first
necessary or the nurse to:
a. Compare this reading to standards.
b. Check the taxonomy of nursing diagnoses or a pertinent
label.
c. Check a medical text or the signs and symptoms of high
blood pressure.
d. Consult with colleagues.
Correct Answer
a. A standard, or a norm, is a generally accepted rule, measure, pattern, or model to
which data can be compared in the same class or category. For example, when
determining the significance of a patient's blood pressure reading, appropriate
standards include normative values or the patient's age group, race, and illness
category. Deviation from an appropriate norm may be the basis or writing a
diagnosis.
Page 1 of 161
,Question 3
The nurse understands that a patient who has diffi culty sleeping may have shortened
NREM sleep. Therefore, the nurse should assess this patient for:
1. Decreased pain tolerance
2. Excessive sleepiness
3. Confusion
4. Irritability
Correct Answer
During Non-Rapid Eye Movement
(NREM) sleep the parasympathetic
nervous system dominates and the
vital signs and metabolic rate are low;
also growth hormone is consistently
secreted, which provides for anabolism.
Shortened NREM sleep decreases these
restorative processes resulting in excessive
sleepiness.
Question 4
Which nursing intervention enhances an older adult's sensory perception and thereby
helps prevent injury when walking from the bed to the bathroom?
1. Providing adequate lighting
2. Raising the pitch of the voice
3. Holding onto the patient's arm
4. Removing environmental hazards
Correct Answer
1. This provides for the safety of patients,
staff, and visitors within a hospital.
Inadequate lighting causes shadows, a
dark environment, and the potential for
misinterpreting stimuli (illusions), and is
a major cause of accidents in the hospital
setting.
Page 2 of 161
,Question 5
"Myocardial Infarction" Is this an example of a medical or nursing diagnosis?
Correct Answer
Medical
Question 6
The nurse plans to use a trochanter roll when repositioning a patient. The nurse
should
place the trochanter roll:
1. Under the small of the back
2. Behind the knees when supine
3. Alongside the ilium to midthigh
4. In the palm of the hand with the fi ngers fl exed
Correct Answer
3. A trochanter roll is a rolled wedge, pillow,
or sandbag placed by the lateral aspect of
the leg between the iliac crest a
Question 7
When teaching children about fire safety procedures, the school nurse should teach
them that if their clothes catch on fire they should:
1. Yell for help
2. Roll on the ground
3. Take their clothes off
4. Pour water on their clothes
Correct Answer
2. Rolling on the ground will smother the
flames and put the fi re out. Children
should be taught to: "Stop, drop, and roll."
Page 3 of 161
, Question 8
Which actions are important when the nurse uses a stretcher? Check all that apply.
1. ____ Lowering the bed below the level of the stretcher when transferring a patient
from the stretcher to a bed
2. ____ Guiding the stretcher around a turn leading with the end with the patient's
head
3. _____ Ensuring the patient's head is at the end with the swivel wheels
4. _____ Pulling the stretcher on the elevator with the patient's feet fi rst
5. _____ Pushing the stretcher from the end with the patient's head
Correct Answer
1. Keeping a bed lower than a stretcher when
transferring a patient from the stretcher
to a bed utilizes gravity which places less
stress and strain on both the patient and
nurses.
5. The swivel wheels must be under the
patient's feet on the leading end of the
stretcher for safe maneuverability. A
stretcher should always be pushed, not
pulled, so that the transporter stays at the
patient's head for protection.
Question 9
What is an evaluative statement?
Correct Answer
After data has been collected and interpreted to determine patient outcome
achievement the nurse documents a judgement summarizing his/her findings
Page 4 of 161
Correct Answers
Question 1
A patient has a blood pressure reading of 130/90 mmHg when visiting a clinic. What
would the nurse recommend to the patient?
a. Follow-up measurements of blood pressure
b. Immediate treatment by a physician
c. No action because the nurse consider this reading is due to anxiety
d. A change in dietary intake
Correct Answer
a. A single blood pressure reading that is mildly elevated is not signifcant, but the
measureent should be taken again over time to determine if hypertension is a
problem . The nurse would recommend a return visit to the clinic or a recheck
Question 2
To determine the significance of a blood pressure reading of 148/100, it is first
necessary or the nurse to:
a. Compare this reading to standards.
b. Check the taxonomy of nursing diagnoses or a pertinent
label.
c. Check a medical text or the signs and symptoms of high
blood pressure.
d. Consult with colleagues.
Correct Answer
a. A standard, or a norm, is a generally accepted rule, measure, pattern, or model to
which data can be compared in the same class or category. For example, when
determining the significance of a patient's blood pressure reading, appropriate
standards include normative values or the patient's age group, race, and illness
category. Deviation from an appropriate norm may be the basis or writing a
diagnosis.
Page 1 of 161
,Question 3
The nurse understands that a patient who has diffi culty sleeping may have shortened
NREM sleep. Therefore, the nurse should assess this patient for:
1. Decreased pain tolerance
2. Excessive sleepiness
3. Confusion
4. Irritability
Correct Answer
During Non-Rapid Eye Movement
(NREM) sleep the parasympathetic
nervous system dominates and the
vital signs and metabolic rate are low;
also growth hormone is consistently
secreted, which provides for anabolism.
Shortened NREM sleep decreases these
restorative processes resulting in excessive
sleepiness.
Question 4
Which nursing intervention enhances an older adult's sensory perception and thereby
helps prevent injury when walking from the bed to the bathroom?
1. Providing adequate lighting
2. Raising the pitch of the voice
3. Holding onto the patient's arm
4. Removing environmental hazards
Correct Answer
1. This provides for the safety of patients,
staff, and visitors within a hospital.
Inadequate lighting causes shadows, a
dark environment, and the potential for
misinterpreting stimuli (illusions), and is
a major cause of accidents in the hospital
setting.
Page 2 of 161
,Question 5
"Myocardial Infarction" Is this an example of a medical or nursing diagnosis?
Correct Answer
Medical
Question 6
The nurse plans to use a trochanter roll when repositioning a patient. The nurse
should
place the trochanter roll:
1. Under the small of the back
2. Behind the knees when supine
3. Alongside the ilium to midthigh
4. In the palm of the hand with the fi ngers fl exed
Correct Answer
3. A trochanter roll is a rolled wedge, pillow,
or sandbag placed by the lateral aspect of
the leg between the iliac crest a
Question 7
When teaching children about fire safety procedures, the school nurse should teach
them that if their clothes catch on fire they should:
1. Yell for help
2. Roll on the ground
3. Take their clothes off
4. Pour water on their clothes
Correct Answer
2. Rolling on the ground will smother the
flames and put the fi re out. Children
should be taught to: "Stop, drop, and roll."
Page 3 of 161
, Question 8
Which actions are important when the nurse uses a stretcher? Check all that apply.
1. ____ Lowering the bed below the level of the stretcher when transferring a patient
from the stretcher to a bed
2. ____ Guiding the stretcher around a turn leading with the end with the patient's
head
3. _____ Ensuring the patient's head is at the end with the swivel wheels
4. _____ Pulling the stretcher on the elevator with the patient's feet fi rst
5. _____ Pushing the stretcher from the end with the patient's head
Correct Answer
1. Keeping a bed lower than a stretcher when
transferring a patient from the stretcher
to a bed utilizes gravity which places less
stress and strain on both the patient and
nurses.
5. The swivel wheels must be under the
patient's feet on the leading end of the
stretcher for safe maneuverability. A
stretcher should always be pushed, not
pulled, so that the transporter stays at the
patient's head for protection.
Question 9
What is an evaluative statement?
Correct Answer
After data has been collected and interpreted to determine patient outcome
achievement the nurse documents a judgement summarizing his/her findings
Page 4 of 161
