Nursing 101 Fundamentals of Nursing
Practice Exam 1, Part 1 UPDATED Exam
Questions and CORRECT Answers
The nurse makes the following entry on the client's care plan: "Goal not met. Client refuses to
ambulate, stating, 'I am too afraid I will fall'." The nurse should take which of the following
actions?
A. Notify the physician
B. Reassign the client to another nurse
C. Reexamine the nursing orders
D. Write a new nursing diagnosis - CORRECT ANSWER - C. Reexamine the nursing
orders
The plan needs to be reassessed whenever the goals are not met. Nursing interventions should be
examined to ensure the best interventions were selected to assist the client achieve the goal. The
goal may be appropriate, but the client may need more time to achieve the desired outcome.
Which of the following outcome goals has the nurse designed correctly for the postoperative
client's plan of care? Select all that apply.
A. Client will state pain is less than or equal to a 3 on a 0-10 pain scale
B. Client will have no pain
C. Client will state pain is less than or equal to a 3 on a 0-10 pain scale within 24 hours
D. Client will state pain is less than or equal to a 5 on a 0-10 pain scale by time of discharge
E. Client will be medicated every 4 hours by the nurse - CORRECT ANSWER - (C) and
(D)
An outcome goal should be SMART: specific, measurable, appropriate, realistic and timely.
Twenty minutes after administering pain medication to the client, the nurse returns to ask if the
client's level of pain has decreased. The nurse documents the client's response as part of which
phase of the nursing process?
,A. Diagnosis
B. Planning
C. Implementation
D. Evaluation - CORRECT ANSWER - D. Evaluation
Evaluating is the process of comparing client responses to the outcome goals to determine
whether, or to what degree, goals have been met. Diagnosing identifies health problems, risks,
and strengths. Planning is the formulation of client goals and nursing strategies (interventions)
required to prevent, reduce, or eliminate the client's health problems. Implementing is carrying
out or delegating the nursing interventions.
The nurse would use which method of examination to assess for the presence of a bruit in the
abdomen?
A. Auscultation
B. Percussion
C. Palpitation
D. Inspection - CORRECT ANSWER - A. Auscultation
Auscultation uses the sense of hearing to identify sounds that are normal and abnormal during
the assessment. A bruit is an abnormal sound of the venous/arterial system that is only detectable
by listening with a stethoscope. A bruit cannot be detected by percussion or inspection. The
turbulent blood flow that is heard as a bruit would be palpated as a thrill.
In order to examine the ocular mobility of a client who recently experienced a stroke, the nurse
should examine which of the following cranial nerves? Select all that apply.
A. Cranial Nerves I and VII
B. Cranial Nerves II and V
C. Cranial Nerves III and IV
, D. Cranial Nerve VI
E. Cranial Nerve IX - CORRECT ANSWER - C. Cranial Nerves III and IV
D. Cranial Nerve VI
Evaluation of ocular motility provides information about the extra ocular muscles; the orbit;
cranial nerves III, IV, and VI; their brain stem connections; and the cerebral cortex. Cranial
nerves I, VII, and IX, respectively, assess smell, facial movement, swallowing, and the tongue.
A client who is alert and responsive was admitted directly from the physician's office with a
diagnosis of "rule out acute myocardial infarction." Of the following alterations found on the
initial assessment, which is of greatest concern to the nurse?
A. Blood pressure supine is 138/76
B. Respirations are 28 and labored
C. Temperature is 99.8 F
D. There are infrequent missed apical beats - CORRECT ANSWER - B. Respirations are
28 and labored
Using the principles of the ABCs (airway, breathing, and circulation), an alteration in respiration
is always a primary concern. A disturbance in normal ventilation (rate 16-20) is occurring
secondary to the medical diagnosis of myocardial infarction. The blood pressure remains in
acceptable range, and the slight temperature elevation is likely related to the overall
inflammatory response of the body. Infrequent abnormalities of cardiac rhythm are common and
should be of concern when appearing frequently or with longer duration.
The nurse preparing to assess for jugular venous distention (JVD) places the client into which
position?
A. Supine with head of the bed elevated 30 degrees
B. Supine with neck placed downward on chest
C. High-fowler's with head elevated upward
Practice Exam 1, Part 1 UPDATED Exam
Questions and CORRECT Answers
The nurse makes the following entry on the client's care plan: "Goal not met. Client refuses to
ambulate, stating, 'I am too afraid I will fall'." The nurse should take which of the following
actions?
A. Notify the physician
B. Reassign the client to another nurse
C. Reexamine the nursing orders
D. Write a new nursing diagnosis - CORRECT ANSWER - C. Reexamine the nursing
orders
The plan needs to be reassessed whenever the goals are not met. Nursing interventions should be
examined to ensure the best interventions were selected to assist the client achieve the goal. The
goal may be appropriate, but the client may need more time to achieve the desired outcome.
Which of the following outcome goals has the nurse designed correctly for the postoperative
client's plan of care? Select all that apply.
A. Client will state pain is less than or equal to a 3 on a 0-10 pain scale
B. Client will have no pain
C. Client will state pain is less than or equal to a 3 on a 0-10 pain scale within 24 hours
D. Client will state pain is less than or equal to a 5 on a 0-10 pain scale by time of discharge
E. Client will be medicated every 4 hours by the nurse - CORRECT ANSWER - (C) and
(D)
An outcome goal should be SMART: specific, measurable, appropriate, realistic and timely.
Twenty minutes after administering pain medication to the client, the nurse returns to ask if the
client's level of pain has decreased. The nurse documents the client's response as part of which
phase of the nursing process?
,A. Diagnosis
B. Planning
C. Implementation
D. Evaluation - CORRECT ANSWER - D. Evaluation
Evaluating is the process of comparing client responses to the outcome goals to determine
whether, or to what degree, goals have been met. Diagnosing identifies health problems, risks,
and strengths. Planning is the formulation of client goals and nursing strategies (interventions)
required to prevent, reduce, or eliminate the client's health problems. Implementing is carrying
out or delegating the nursing interventions.
The nurse would use which method of examination to assess for the presence of a bruit in the
abdomen?
A. Auscultation
B. Percussion
C. Palpitation
D. Inspection - CORRECT ANSWER - A. Auscultation
Auscultation uses the sense of hearing to identify sounds that are normal and abnormal during
the assessment. A bruit is an abnormal sound of the venous/arterial system that is only detectable
by listening with a stethoscope. A bruit cannot be detected by percussion or inspection. The
turbulent blood flow that is heard as a bruit would be palpated as a thrill.
In order to examine the ocular mobility of a client who recently experienced a stroke, the nurse
should examine which of the following cranial nerves? Select all that apply.
A. Cranial Nerves I and VII
B. Cranial Nerves II and V
C. Cranial Nerves III and IV
, D. Cranial Nerve VI
E. Cranial Nerve IX - CORRECT ANSWER - C. Cranial Nerves III and IV
D. Cranial Nerve VI
Evaluation of ocular motility provides information about the extra ocular muscles; the orbit;
cranial nerves III, IV, and VI; their brain stem connections; and the cerebral cortex. Cranial
nerves I, VII, and IX, respectively, assess smell, facial movement, swallowing, and the tongue.
A client who is alert and responsive was admitted directly from the physician's office with a
diagnosis of "rule out acute myocardial infarction." Of the following alterations found on the
initial assessment, which is of greatest concern to the nurse?
A. Blood pressure supine is 138/76
B. Respirations are 28 and labored
C. Temperature is 99.8 F
D. There are infrequent missed apical beats - CORRECT ANSWER - B. Respirations are
28 and labored
Using the principles of the ABCs (airway, breathing, and circulation), an alteration in respiration
is always a primary concern. A disturbance in normal ventilation (rate 16-20) is occurring
secondary to the medical diagnosis of myocardial infarction. The blood pressure remains in
acceptable range, and the slight temperature elevation is likely related to the overall
inflammatory response of the body. Infrequent abnormalities of cardiac rhythm are common and
should be of concern when appearing frequently or with longer duration.
The nurse preparing to assess for jugular venous distention (JVD) places the client into which
position?
A. Supine with head of the bed elevated 30 degrees
B. Supine with neck placed downward on chest
C. High-fowler's with head elevated upward
