Nursing 101 Fundamentals of Nursing
Practice Exam 1, Part 1
A client is receiving 115 ml/hr of continuous IVF. The nurse notices that the
venipuncture site is red and swollen. Which of the following interventions would
the nurse perform first?
A. Stop the infusion
B. Call the attending physician
C. Slow that infusion to 20 ml/hr
D. Place a cold towel on the site - ANS - A. Stop the infusion
The sign and symptoms indicate extravasation so the IVF should be stopped
immediately and put warm not cold towel on the affected site.
\A patient states that he has difficulty sleeping in the hospital because of noise.
Which of the following would be an appropriate nursing action?
A. Administer a sedative at bedtime, as ordered by the physician
B. Ambulate the patient for 5 minutes before he retires
C. Give the patient a glass of warm milk before bedtime
D. Close the patient's door from 9pm to 7am - ANS - C. Give the patient a glass of
warm milk before bedtime
Warm milk will relax the patient because it contains tryptophan, a natural
sedative.
\A skin lesion which is fluid-filled, less than 1 cm in size is called:
A. Papule
B. Vesicle
C. Bulla
D. Macule - ANS - B. Vesicle
Vesicle is a circumscribed circulation containing serous fluid or blood and less
than 1 cm (ex. Blister, chicken pox).
\A sudden redness of the skin is known as:
A. Flush
B. Cyanosis
C. Jaundice
D. Pallor - ANS - A. Flush
, Flush is a sudden redness of the skin. Cyanosis is a slightly bluish, grayish skin
discoloration caused by abnormal amounts or reduced hemoglobin in the blood.
Jaundice is a yellow discoloration of the skin, mucous membranes and sclera
caused by excessive amounts of bilirubin in the blood. Pallor is an unnatural
paleness or absence of color in the skin indicating insufficient oxygen and
excessive carbon dioxide in the blood.
\According to Maslow's hierarchy of needs, which of the following is a basic
physiologic need after oxygen?
A. Safety
B. Activity
C. Love
D. Self esteem - ANS - B. Activity
According to Maslow, activity is one of the man's most basic physiologic needs,
along with oxygen, shelter, food, water, thirst, sleep and temperature
maintenance.
\Becky is on NPO since midnight as preparation for blood test. Adreno-cortical
response is activated. Which of the following is an expected response?
A. Low blood pressure
B. Warm, dry skin
C. Decreased serum sodium levels
D. Decreased urine output - ANS - D. Decreased urine output
Adreno-cortical response involves release of aldosterone that leads to retention
of sodium and water. This results to decreased urine output.
\Claire is admitted with a diagnosis of chronic shoulder pain. By definition, the
nurse understands that the patient has had pain for more than:
A. 3 months
B. 6 months
C. 9 months
D. 1 year - ANS - B. 6 months
Chronic pain is usually defined as pain lasting longer than 6 months.
\Constipation is a common problem for immobilized patients because of:
A. Decreased tightening of the anal sphincter
B. An increased defecation reflex
C. Decreased peristalsis and positional discomfort
D. Increased colon motility - ANS - C. Decreased peristalsis and positional
discomfort
Practice Exam 1, Part 1
A client is receiving 115 ml/hr of continuous IVF. The nurse notices that the
venipuncture site is red and swollen. Which of the following interventions would
the nurse perform first?
A. Stop the infusion
B. Call the attending physician
C. Slow that infusion to 20 ml/hr
D. Place a cold towel on the site - ANS - A. Stop the infusion
The sign and symptoms indicate extravasation so the IVF should be stopped
immediately and put warm not cold towel on the affected site.
\A patient states that he has difficulty sleeping in the hospital because of noise.
Which of the following would be an appropriate nursing action?
A. Administer a sedative at bedtime, as ordered by the physician
B. Ambulate the patient for 5 minutes before he retires
C. Give the patient a glass of warm milk before bedtime
D. Close the patient's door from 9pm to 7am - ANS - C. Give the patient a glass of
warm milk before bedtime
Warm milk will relax the patient because it contains tryptophan, a natural
sedative.
\A skin lesion which is fluid-filled, less than 1 cm in size is called:
A. Papule
B. Vesicle
C. Bulla
D. Macule - ANS - B. Vesicle
Vesicle is a circumscribed circulation containing serous fluid or blood and less
than 1 cm (ex. Blister, chicken pox).
\A sudden redness of the skin is known as:
A. Flush
B. Cyanosis
C. Jaundice
D. Pallor - ANS - A. Flush
, Flush is a sudden redness of the skin. Cyanosis is a slightly bluish, grayish skin
discoloration caused by abnormal amounts or reduced hemoglobin in the blood.
Jaundice is a yellow discoloration of the skin, mucous membranes and sclera
caused by excessive amounts of bilirubin in the blood. Pallor is an unnatural
paleness or absence of color in the skin indicating insufficient oxygen and
excessive carbon dioxide in the blood.
\According to Maslow's hierarchy of needs, which of the following is a basic
physiologic need after oxygen?
A. Safety
B. Activity
C. Love
D. Self esteem - ANS - B. Activity
According to Maslow, activity is one of the man's most basic physiologic needs,
along with oxygen, shelter, food, water, thirst, sleep and temperature
maintenance.
\Becky is on NPO since midnight as preparation for blood test. Adreno-cortical
response is activated. Which of the following is an expected response?
A. Low blood pressure
B. Warm, dry skin
C. Decreased serum sodium levels
D. Decreased urine output - ANS - D. Decreased urine output
Adreno-cortical response involves release of aldosterone that leads to retention
of sodium and water. This results to decreased urine output.
\Claire is admitted with a diagnosis of chronic shoulder pain. By definition, the
nurse understands that the patient has had pain for more than:
A. 3 months
B. 6 months
C. 9 months
D. 1 year - ANS - B. 6 months
Chronic pain is usually defined as pain lasting longer than 6 months.
\Constipation is a common problem for immobilized patients because of:
A. Decreased tightening of the anal sphincter
B. An increased defecation reflex
C. Decreased peristalsis and positional discomfort
D. Increased colon motility - ANS - C. Decreased peristalsis and positional
discomfort
