Nursing 101 Final Exam Practice Questions ACTUAL UPDATED QUESTIONS AND
CORRECT ANSWERS
A postoperative client is moving from the bed to a chair Have the client lay on the back with the head elevated
when blood drips from the dressing. The nurse assesses
the incision and notes evisceration. What does the nurse R: A wound evisceration occurs when the wound completely separates, and the
do first? internal organs protrude. If disruption of a wound occurs, the client is placed in
the low Fowler's position and instructed to lie quietly. These actions minimize the
Call the health care provider protrusion of body tissues. The protruding coils of the intestine are covered with
sterile dressings moistened with sterile saline solution, and the surgeon is notified
Cover the protruding organ with sterile dressings at once.
moistened with sterile saline
Have the client lay on the back with the head elevated
Instruct the client to remain quiet
A client who is deaf without bilateral hearing aids has Provide written information.
them removed in preparation for a surgical procedure.
Which action(s) will the nurse take to communicate with Provide written information.
this client? Select all that apply.
Speak slowly so the client can lip read.
Provide written information.
Speak slowly so the client can lip read. Plan for a sign language interpreter.
Plan for a sign language interpreter. R: Special considerations for clients with physical disabilities include the need for
Use hand gestures to communicate. appropriate assistive devices, modifications in preoperative education, and
additional assistance with communication. If the client is deaf when bilateral
Talk loudly into one of the client's ears. hearing aids are removed, an alternative form of communication needs to be
planned such as providing written information, using gestures, speaking slowly so
the client can lip read, and planning for an interpreter to provide sign language.
Talking loudly into one ear will not be effective because the client is deaf when
the hearing aids are removed.
,A perioperative nurse is participating in an Sterile surfaces or articles may touch other sterile surfaces.
interdisciplinary audit of infection control practices in the
surgical department. Which action is a basic guideline for Only the top surface of a draped table is considered sterile.
maintaining surgical asepsis? Select all that apply.
R: Basic guidelines for maintaining sterile technique include that sterile surfaces or
Sterile surfaces or articles may touch other sterile articles may touch other sterile surfaces only and only the top surface of a draped
surfaces. table is considered sterile. The other options each constitute a break in sterile
technique.
The outer lip of a sterile solution is considered sterile.
Only the top surface of a draped table is considered
sterile.
Sterile supplies can be used on another client if the
packages are intact.
The scrub nurse may pour a sterile solution from a
nonsterile bottle.
,A client was admitted to the hospital unit after 2 days of dehydration
vomiting and diarrhea. The client's spouse became
alarmed when the client demonstrated confusion and R: Dehydration results when the volume of body fluid is significantly reduced in
elevated temperature, and reported "dry mouth." The both extracellular and intracellular compartments. In dehydration, all fluid
nurse suspects the client is experiencing which compartments have decreased volumes; in hypovolemia, only blood volume is
condition? low. The most common fluid imbalance in older adults is dehydration.
Hypervolemia is caused by fluid intake that exceeds fluid loss, such as from
hyperkalemia excessive oral intake or rapid IV infusion of fluid. Early signs of hypervolemia are
weight gain, elevated BP, and increased breathing effort. Hypercalcemia occurs
hypercalcemia when the serum calcium level is higher than normal. Some of its signs include
tingling in the extremities and the area around the mouth (circumoral paresthesia)
dehydration and muscle and abdominal cramps. Hyperkalemia is an excess of potassium in the
blood. Symptoms include diarrhea, nausea, muscle weakness, paresthesias, and
hypervolemia cardiac dysrhythmias.
The nurse is taking the client into the operating room The client may be at risk for malignant hyperthermia.
(OR) when the client informs the nurse that the client's
grandparent spiked a very high temperature in the OR R: Malignant hyperthermia is an inherited muscle disorder chemically induced by
and nearly died 15 years ago. What relevance does this anesthetic agents. Identifying clients at risk is imperative because the mortality
information have regarding the client? rate is 50%. The client's anxiety is not relevant, the grandparent's surgery is very
relevant, and all clients are at risk for surgical infections.
The client may be experiencing presurgical anxiety.
The grandparent's surgery has minimal relevance to the
client's surgery.
The client may be at risk for a sudden onset of
postsurgical infection.
The client may be at risk for malignant hyperthermia.
While making an initial shift assessment the nurse notes Infiltration
that the client's peripheral IV site appears edematous
around the insertion site. How should the existence of R: Infiltration is the administration of nonvesicant solution or medication into the
this complication be documented by the nurse? surrounding tissue. This can occur when the IV cannula dislodges or perforates
the wall of the vein. Infiltration is characterized by edema around the insertion
Infiltration site, leakage of IV fluid from the insertion site, discomfort and coolness in the area
of infiltration, and a significant decrease in the flow rate. Air emboli, phlebitis, and
Phlebitis fluid overload are not indications of infiltration.
Fluid overload
Air emboli
, An 80-year-old client is being admitted for dehydration Before ambulation the client should rise slowly and take mini breaks between
and syncope. The client is found to be hypotensive, and lying, sitting, and standing.
intravenous fluids are ordered. What are some teaching
strategies that the nurse should review with this client? R: A client experiencing hypotension should rise slowly. The client should
consider having five or six small meals a day to minimize hypotension that can
Before ambulation the client should rise slowly and take occur after a large meal. Extremes in temperature, especially hot showers, should
mini breaks between lying, sitting, and standing. be avoided. Hot temperatures can cause an increase in blood flow and cause
dizziness. Every client does not need a rolling walker. Changes in position,
The client must use a rolling walker and call for assistance especially in bed, should be done independently and often to prevent pressure
with any change in position. ulcers.
The temperature in the room should stay very hot, and
bathing in hot water is appropriate.
Increase consumption of meals to three times a day, with
the largest meal being at breakfast.
A 54-year-old male client is admitted to the hospital with Blood urea nitrogen (BUN) of 23 mg/dL
a case of severe dehydration. The nurse reviews the
client's laboratory results. Which of the following results Serum osmolality of 310 mOsm/kg
are consistent with the diagnosis? Select all that apply.
Serum sodium of 148 mEq/L
Serum osmolality of 310 mOsm/kg
Urine specific gravity of 1.03
Hematocrit level of 48%
R: Severe dehydration is associated with an increased BUN (N = 10 to 20 mg/dL),
Blood urea nitrogen (BUN) of 23 mg/dL serum osmolality (N = 275 to 300 mOsm/kg), serum sodium (N = 135 to 145 mEq/L)
and urine specific gravity (N = 1.01 to 1.025). Glucose and hematocrit levels would
Serum glucose of 90 mg/dL also be elevated but are within normal range for this question.
Serum sodium of 148 mEq/L
Urine specific gravity of 1.03
During a mumps outbreak at a school, a teacher is Acquired immunity.
exposed. Because of a previous immunization for mumps,
what type of immunity does the teacher possess? R: Acquired immunity usually develops as a result of prior exposure to an antigen,
often through immunization. When the body is attacked by bacteria, viruses, or
Humoral immunity. other pathogens, it has three means of defense. The first line of defense, the
phagocytic immune response, involves the white blood cells (WBCs) that have the
Phagocytic immunity. ability to ingest foreign particles. A second protective response is the humoral
immune response, which begins when the B lymphocytes transform themselves
Natural immunity. into plasma cells that manufacture antibodies. The natural immune response
system is rapid, nonspecific immunity present at birth.
Acquired immunity.
CORRECT ANSWERS
A postoperative client is moving from the bed to a chair Have the client lay on the back with the head elevated
when blood drips from the dressing. The nurse assesses
the incision and notes evisceration. What does the nurse R: A wound evisceration occurs when the wound completely separates, and the
do first? internal organs protrude. If disruption of a wound occurs, the client is placed in
the low Fowler's position and instructed to lie quietly. These actions minimize the
Call the health care provider protrusion of body tissues. The protruding coils of the intestine are covered with
sterile dressings moistened with sterile saline solution, and the surgeon is notified
Cover the protruding organ with sterile dressings at once.
moistened with sterile saline
Have the client lay on the back with the head elevated
Instruct the client to remain quiet
A client who is deaf without bilateral hearing aids has Provide written information.
them removed in preparation for a surgical procedure.
Which action(s) will the nurse take to communicate with Provide written information.
this client? Select all that apply.
Speak slowly so the client can lip read.
Provide written information.
Speak slowly so the client can lip read. Plan for a sign language interpreter.
Plan for a sign language interpreter. R: Special considerations for clients with physical disabilities include the need for
Use hand gestures to communicate. appropriate assistive devices, modifications in preoperative education, and
additional assistance with communication. If the client is deaf when bilateral
Talk loudly into one of the client's ears. hearing aids are removed, an alternative form of communication needs to be
planned such as providing written information, using gestures, speaking slowly so
the client can lip read, and planning for an interpreter to provide sign language.
Talking loudly into one ear will not be effective because the client is deaf when
the hearing aids are removed.
,A perioperative nurse is participating in an Sterile surfaces or articles may touch other sterile surfaces.
interdisciplinary audit of infection control practices in the
surgical department. Which action is a basic guideline for Only the top surface of a draped table is considered sterile.
maintaining surgical asepsis? Select all that apply.
R: Basic guidelines for maintaining sterile technique include that sterile surfaces or
Sterile surfaces or articles may touch other sterile articles may touch other sterile surfaces only and only the top surface of a draped
surfaces. table is considered sterile. The other options each constitute a break in sterile
technique.
The outer lip of a sterile solution is considered sterile.
Only the top surface of a draped table is considered
sterile.
Sterile supplies can be used on another client if the
packages are intact.
The scrub nurse may pour a sterile solution from a
nonsterile bottle.
,A client was admitted to the hospital unit after 2 days of dehydration
vomiting and diarrhea. The client's spouse became
alarmed when the client demonstrated confusion and R: Dehydration results when the volume of body fluid is significantly reduced in
elevated temperature, and reported "dry mouth." The both extracellular and intracellular compartments. In dehydration, all fluid
nurse suspects the client is experiencing which compartments have decreased volumes; in hypovolemia, only blood volume is
condition? low. The most common fluid imbalance in older adults is dehydration.
Hypervolemia is caused by fluid intake that exceeds fluid loss, such as from
hyperkalemia excessive oral intake or rapid IV infusion of fluid. Early signs of hypervolemia are
weight gain, elevated BP, and increased breathing effort. Hypercalcemia occurs
hypercalcemia when the serum calcium level is higher than normal. Some of its signs include
tingling in the extremities and the area around the mouth (circumoral paresthesia)
dehydration and muscle and abdominal cramps. Hyperkalemia is an excess of potassium in the
blood. Symptoms include diarrhea, nausea, muscle weakness, paresthesias, and
hypervolemia cardiac dysrhythmias.
The nurse is taking the client into the operating room The client may be at risk for malignant hyperthermia.
(OR) when the client informs the nurse that the client's
grandparent spiked a very high temperature in the OR R: Malignant hyperthermia is an inherited muscle disorder chemically induced by
and nearly died 15 years ago. What relevance does this anesthetic agents. Identifying clients at risk is imperative because the mortality
information have regarding the client? rate is 50%. The client's anxiety is not relevant, the grandparent's surgery is very
relevant, and all clients are at risk for surgical infections.
The client may be experiencing presurgical anxiety.
The grandparent's surgery has minimal relevance to the
client's surgery.
The client may be at risk for a sudden onset of
postsurgical infection.
The client may be at risk for malignant hyperthermia.
While making an initial shift assessment the nurse notes Infiltration
that the client's peripheral IV site appears edematous
around the insertion site. How should the existence of R: Infiltration is the administration of nonvesicant solution or medication into the
this complication be documented by the nurse? surrounding tissue. This can occur when the IV cannula dislodges or perforates
the wall of the vein. Infiltration is characterized by edema around the insertion
Infiltration site, leakage of IV fluid from the insertion site, discomfort and coolness in the area
of infiltration, and a significant decrease in the flow rate. Air emboli, phlebitis, and
Phlebitis fluid overload are not indications of infiltration.
Fluid overload
Air emboli
, An 80-year-old client is being admitted for dehydration Before ambulation the client should rise slowly and take mini breaks between
and syncope. The client is found to be hypotensive, and lying, sitting, and standing.
intravenous fluids are ordered. What are some teaching
strategies that the nurse should review with this client? R: A client experiencing hypotension should rise slowly. The client should
consider having five or six small meals a day to minimize hypotension that can
Before ambulation the client should rise slowly and take occur after a large meal. Extremes in temperature, especially hot showers, should
mini breaks between lying, sitting, and standing. be avoided. Hot temperatures can cause an increase in blood flow and cause
dizziness. Every client does not need a rolling walker. Changes in position,
The client must use a rolling walker and call for assistance especially in bed, should be done independently and often to prevent pressure
with any change in position. ulcers.
The temperature in the room should stay very hot, and
bathing in hot water is appropriate.
Increase consumption of meals to three times a day, with
the largest meal being at breakfast.
A 54-year-old male client is admitted to the hospital with Blood urea nitrogen (BUN) of 23 mg/dL
a case of severe dehydration. The nurse reviews the
client's laboratory results. Which of the following results Serum osmolality of 310 mOsm/kg
are consistent with the diagnosis? Select all that apply.
Serum sodium of 148 mEq/L
Serum osmolality of 310 mOsm/kg
Urine specific gravity of 1.03
Hematocrit level of 48%
R: Severe dehydration is associated with an increased BUN (N = 10 to 20 mg/dL),
Blood urea nitrogen (BUN) of 23 mg/dL serum osmolality (N = 275 to 300 mOsm/kg), serum sodium (N = 135 to 145 mEq/L)
and urine specific gravity (N = 1.01 to 1.025). Glucose and hematocrit levels would
Serum glucose of 90 mg/dL also be elevated but are within normal range for this question.
Serum sodium of 148 mEq/L
Urine specific gravity of 1.03
During a mumps outbreak at a school, a teacher is Acquired immunity.
exposed. Because of a previous immunization for mumps,
what type of immunity does the teacher possess? R: Acquired immunity usually develops as a result of prior exposure to an antigen,
often through immunization. When the body is attacked by bacteria, viruses, or
Humoral immunity. other pathogens, it has three means of defense. The first line of defense, the
phagocytic immune response, involves the white blood cells (WBCs) that have the
Phagocytic immunity. ability to ingest foreign particles. A second protective response is the humoral
immune response, which begins when the B lymphocytes transform themselves
Natural immunity. into plasma cells that manufacture antibodies. The natural immune response
system is rapid, nonspecific immunity present at birth.
Acquired immunity.
