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 - -ANSWER-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.-ANSWER-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 - -ANSWER-C. Give the patient a glass of warm milk
before bedtime
Warm milk will relax the patient because it contains tryptophan, a natural sedative.-ANSWER-A
skin lesion which is fluid-filled, less than 1 cm in size is called:
A. Papule
B. Vesicle
C. Bulla
D. Macule - -ANSWER-B. Vesicle
,Vesicle is a circumscribed circulation containing serous fluid or blood and less than 1 cm (ex.
Blister, chicken pox).-ANSWER-A sudden redness of the skin is known as:
A. Flush
B. Cyanosis
C. Jaundice
D. Pallor - -ANSWER-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.-ANSWER-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 - -ANSWER-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.-ANSWER-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 - -ANSWER-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.-ANSWER-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 - -ANSWER-B. 6 months
Chronic pain is usually defined as pain lasting longer than 6 months.-ANSWER-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 - -ANSWER-C. Decreased peristalsis and positional discomfort
Increased adrenalin production in the immobile patient results in decrease peristalsis and colon
motility and more tightly constricted sphincters.-ANSWER-During a change-of-shift report, it
would be important for the nurse relinquishing responsibility for care of the patient to
communicate. Which of the following facts to the nurse assuming responsibility for care of the
patient?
A. That the patient verbalized, "My headache is gone."
B. That the patient's barium enema performed 3 days ago was negative
C. Patient's NGT was removed 2 hours ago
D. Patient's family came for a visit this morning. - -ANSWER-C. Patient's NGT was removed 2
hours ago
The change-of-shift report should indicate significant recent changes in the patient's condition
that the nurse assuming responsibility for care of the patient will need to monitor. The other
options are not critical enough to include in the report-ANSWER-During a physical assessment,
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 - -ANSWER-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.-ANSWER-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 - -ANSWER-C. Give the patient a glass of warm milk
before bedtime
Warm milk will relax the patient because it contains tryptophan, a natural sedative.-ANSWER-A
skin lesion which is fluid-filled, less than 1 cm in size is called:
A. Papule
B. Vesicle
C. Bulla
D. Macule - -ANSWER-B. Vesicle
,Vesicle is a circumscribed circulation containing serous fluid or blood and less than 1 cm (ex.
Blister, chicken pox).-ANSWER-A sudden redness of the skin is known as:
A. Flush
B. Cyanosis
C. Jaundice
D. Pallor - -ANSWER-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.-ANSWER-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 - -ANSWER-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.-ANSWER-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 - -ANSWER-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.-ANSWER-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 - -ANSWER-B. 6 months
Chronic pain is usually defined as pain lasting longer than 6 months.-ANSWER-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 - -ANSWER-C. Decreased peristalsis and positional discomfort
Increased adrenalin production in the immobile patient results in decrease peristalsis and colon
motility and more tightly constricted sphincters.-ANSWER-During a change-of-shift report, it
would be important for the nurse relinquishing responsibility for care of the patient to
communicate. Which of the following facts to the nurse assuming responsibility for care of the
patient?
A. That the patient verbalized, "My headache is gone."
B. That the patient's barium enema performed 3 days ago was negative
C. Patient's NGT was removed 2 hours ago
D. Patient's family came for a visit this morning. - -ANSWER-C. Patient's NGT was removed 2
hours ago
The change-of-shift report should indicate significant recent changes in the patient's condition
that the nurse assuming responsibility for care of the patient will need to monitor. The other
options are not critical enough to include in the report-ANSWER-During a physical assessment,
