Fundamentals of
nursing test
1. Elizabeth Kubler-Ross identified five stages of death and dying. Loss, grief, and intense sadness are symptoms of
which stage?
a. Denial and isolation
b. Depression
c. Anger
d. Bargaining
RATIONALE: According to Kübhler-Ross, the five stages of death and dying are denial and isolation, anger, bargaining,
depression, and acceptance. In denial, the client denies aspects of the illness and death. Loss, grief, and intense sadness indicate
depression. In anger, the client has hostility that may be directed to family members, God, heath care workers, and others. In
bargaining, the client asks God for more time, and in return promises to do something good.
2. To help minimize calcium loss from a hospitalized client's bones, the nurse should:
a. reposition the client every 2 hours.
b. encourage the client to walk in the hall
c. provide the client daily products at frequent intervals
d. provide supplemental feedings between meals.
RATIONALE: Calcium absorption diminishes with reduced physical activity because of decreased bone stimulation. Therefore,
encouraging the client to increase physical activity such as by walking the hall, helps minimize calcium loss. Turning or
repositioning the client every 2 hours wouldn’t increase activity sufficiently to minimize bone loss, Providing dairy products and
supplemental feedings wouldn't lessen calcium loss - even if the dairy products and feedings contained extra calcium — because
the additional calcium doesn’t increase bone stimulation or osteoblast activity.
3. Which statement regarding heart sounds is correct?
a. S1 and s2 sound equally loud over the entire cardiac area.
b. S1 and sound fainter at the apex than at the base.
c. S and 2 sound fainter at the base than at the apex.
d. S1 is loudest at the apex, and S2 is loudest at the base.
Rationale: The S1 sound — the “lub” sound — is loudest at the apex of the heart. It sounds longer, lower, and louder there than
the S2 — the “dub” sound — is loudest at the base. It sounds shorter, sharper, higher, and louder there than the S1.
4. A client has a nursing diagnosis of Ineffective airway clearance related to poor coughing. When planning this
client’s care, the nurse should include which intervention? a. Increasing fluids to 2,500 ml/day
b. Teaching the client how to deep-breathe and cough
c. Improving airway clearance
d. Suctioning the client every 2 hours
RATIONALE: Interventions should address the etiology of the client's problem — poor coughing. Teaching deep breathing and
coughing addresses this etiology. Increasing fluids may improve the client’s condition, but this intervention doesn't address poor
coughing. Improving airway clearance is too vague to be considered an appropriate intervention. Suctioning isn't indicated
unless other measures fail to clear the airway.
5. A nurse is using the computer when a client calls for pain medication. Which action by the nurse is the best?
a. Staying logged on, leaving the terminal on, and administering the medication immediately
b. telling the client that he’ll have to wait 15 minutes while she completes the entry
c. Asking a coworker to log out for her and administering the medicine right away
d. Logging out of the computer, then administering the pain medication
RATIONALE: A nurse should meet a client’s request for pain medication as quickly as possible after she logs out of the computer.
A nurse shouldn't ask a client to wait for as long as 15 minutes for requested pain medication. If the nurse leaves the terminal
without logging out, others may view confidential information or use her password. Asking a coworker to log her out isn't safe
computer practice.
6. What is the most appropriate nursing diagnosis for the client with acute pancreatitis? a.
,c. Decreased cardiac output
d. Ineffective gastrointestinal tissue perfusion
RATIONALE: Clients with acute pancreatitis often experience deficient fluid volume, which can lead to hypovolemic
shock. Vomiting, hemorrhage (in hemorrhagic pancreatitis), and plasma leaking into the peritoneal cavity may
cause the volume deficit. Hypovolemic shock will cause a decrease in cardiac output. Gastrointestinal tissue
perfusion will be ineffective if hypovolemic shock occurs, but this wouldn't be the primary nursing diagnosis.
7. One aspect of implementation related to drug therapy is:
a. developing a plan of care
b. documenting drugs given.
c. establishing outcome criteria.
d. setting realistic client goals.
RATIONALE: Athough documentation isn't a step in the nursing process, the nurse is legally required to document
activities related to drug therapy, including the time of administration, the quantity, and the client's reaction.
Developing a plan of care, establishing outcome criteria, and setting realistic client goals are parts of planning
rather than implementation.
8. A nurse notes that a client’s I.V. insertion site is red, swollen, and warm to the touch. which action should the nurse
take first?
a. Discontinue the I.V. infusion.
b. Apply a warm, moist compress to the I.V. site.
c. Assess the I.V. infusion for patency.
d. Apply an ice pack to the I.V. site.
RATIONALE: Because redness, swelling, and warmth at an I.V. site are signs of infection, the nurse should
discontinue the infusion immediately and restart at another site. After doing this, the nurse should apply warmth to
the original site. Checking infusion patency isn't warranted because assessment findings suggest infection and
inflammation, not infiltration. Heat, not cold is the appropriate treatment for inflammation.
9. A nurse is caring for a client with a history of falls. The nurse's first priority when caring for a client at risk for falls
is:
a. placing the call light for easy access.
b. keeping the bed in the lowest possible position.
c. instructing the client not to get out of the bed without assistance
d. keeping the bedpan available so that the client doesn’t have to get out of bed.
RATIONALE: Keeping the bed at the lowest possible position the first priority for clients at risk for falling. Keeping the
call light easy accessible is important but isn’t a top priority. Instructing the client not to get out of bed may not
effectively prevent falls — for example, if the client is confused. Even when the client needs assistance to get out of
bed, the nurse should place the bed in the lowest position. The client may not require a bedpan.
10. A nurse is caring for a client who is exhibiting signs and symptoms characteristic of a myocardial infarction (MI).
which statement describes priorities the nurse should establish while performing the physical assessment? a.
Assess the client's level of pain and administer prescribed analgesics.
b. Assess the client’s level of anxiety and provide emotional support.
c. Prepare the client for pulmonary artery catheterization.
d. Ensure that the client's family is kept informed of his status.
RATIONALE: The cardinal symptom of MI is persistent, crushing substernal pain or pressure. The nurse should first
assess the client's pain and prepare to administer nitroglycerin or morphine for pain control. The client must be
medically stabilized before pulmonary artery catheterization can be used as a diagnostic procedure. Anxiety and a
feeling of impending doom are characteristic of MI, but the priority is to stabilize the client medically. Although the
client and his family should be kept informed at every step of the recovery process, this action isn’t the priority when
treating a client with a suspected MI.
11. A nurse is monitoring a client for adverse reactions during barbiturate therapy. What is the major disadvantage
of barbiturate use?
a. Prolonged half-life
b. Poor absorption
c. Potential for drug dependence
d. Potential for hepatotoxicity
RATIONALE: Clients can become dependent on barbiturates, especially with prolonged use. Because of the rapid
distribution of some barbiturates, no correlation exists between duration of action and half-life. Barbiturates are
absorbed well and don't cause hepatotoxicity, but because barbiturates are metabolized in the liver, existing hepatic
, 12. A nurse is caring for a client who required chest tube insertion for a pneumothorax. To assess for
pneumothorax resolution, the nurse anticipates that the client will require: a. monitoring of arterial
oxygen saturation ,
b. arterial blood gas (ABG) studies.
c. chest auscultation.
d. a chest x-ray.
Rationale: Chest x-ray confirms diagnosis by revealing air or fluid in the pleural space. SaO2 values may initially
decrease with a pneumothorax but typically return to normal within 24 hours. ABG studies may show hypoxemia,
possibly with respiratory acidosis and hypercapnia not related to a pneumothorax. Chest auscultation will determine
overall lung status, but it's difficult to determine if the chest has reexpanded sufficiently.
13. During her morning assessment, a nurse notes that a client has severe dyspnea, his respirations are 34
breaths/minute and labored. Oxygen saturation is 79% on 3L of oxygen. The nurse remembers that the client's
chart includes his living will, When considering best practice, the nurse should:
a. withhold all potentially life-prolonging treatments in accordance with the client's living will
b. increase the oxygen flow rate to 4L, but avoid initiating other interventions
c. call the client’s family and ask what they think is best.
d. initiate potentially life-prolonging treatment unless the client refuses.
RATIONALE: A living will doesn't go into effect unless the client is unable to make his own decisions. A nurse
shouldn't withhold care for an alert client unless he specifically refuses care. The nurse should give all appropriate
care while also maintaining the client's right to refuse treatment. Increasing the oxygen flow rate might be an
appropriate response, but isn't the best action at this time. The family isn't responsible for determining care at this
time.
14. A client is to receive a glycerin suppository. Which nursing action is appropriate when administering a
suppository?
a. Removing the suppository from the refrigerator 30 minutes before insertion
b. Applying a lubricant to the suppository
c. Dissolving the suppository in 3 ml of warm water
d. Instructing the client to bear down during insertion
RATIONALE: A suppository must be lubricated before insertion. Because suppositories melt at body temperature,
they usually require refrigeration until administration. It isn’t appropriate to dissolve a suppository in warm water. It
should remain in a solid state. Instructing the client to bear down would cause the anal sphincter to contract,
making insertion difficult.
15. A physician orders regular insulin 10 units LV. along with 50 ml of dextrose 50% for a client with acute renal
failure. What problem is this client most likely experiencing? a. Hypercalcemia
b. Hypernatremia
c. Hyperglycemia
d. Hyperkalemia
Rationale: Administering regular IV concomitantly with 50 ml of dextrose 50% helps shift potassium from the
extracellular fluid into the cell, which normalizes serum potassium levels in the client with hyperkalemia. This
combination doesn't he reverse the effects of hypercalcemia, hypenatremia, or hyperglycemia.
16. A nurse identifies a client’s responses to actual or potential health problems during which step of the nursing
process?
a. Assessment
b. Diagnosis
c. Planning
d. Evaluation
RATIONALE: The nurse identifies human responses to actual or potential health problems during the diagnosis step
of the nursing process, which encompasses the nurse’s ability to formulate a nursing diagnosis. During the
assessment step, the nurse systematically collects data about the client or his family. During the planning step, she
develops strategies to resolve or decrease the client’s problem. During the evaluation step, the nurse determines the
effectiveness of the care plan.
17. In a client with a urine specific gravity of 1.040, a subnormal serum osmolality, and a serum sodium level of
128 mEq/L, the nurse should question an order for which I.V. fluid? a. dextrose 5% in half-normal saline
solution.
b. normal saline solution.
nursing test
1. Elizabeth Kubler-Ross identified five stages of death and dying. Loss, grief, and intense sadness are symptoms of
which stage?
a. Denial and isolation
b. Depression
c. Anger
d. Bargaining
RATIONALE: According to Kübhler-Ross, the five stages of death and dying are denial and isolation, anger, bargaining,
depression, and acceptance. In denial, the client denies aspects of the illness and death. Loss, grief, and intense sadness indicate
depression. In anger, the client has hostility that may be directed to family members, God, heath care workers, and others. In
bargaining, the client asks God for more time, and in return promises to do something good.
2. To help minimize calcium loss from a hospitalized client's bones, the nurse should:
a. reposition the client every 2 hours.
b. encourage the client to walk in the hall
c. provide the client daily products at frequent intervals
d. provide supplemental feedings between meals.
RATIONALE: Calcium absorption diminishes with reduced physical activity because of decreased bone stimulation. Therefore,
encouraging the client to increase physical activity such as by walking the hall, helps minimize calcium loss. Turning or
repositioning the client every 2 hours wouldn’t increase activity sufficiently to minimize bone loss, Providing dairy products and
supplemental feedings wouldn't lessen calcium loss - even if the dairy products and feedings contained extra calcium — because
the additional calcium doesn’t increase bone stimulation or osteoblast activity.
3. Which statement regarding heart sounds is correct?
a. S1 and s2 sound equally loud over the entire cardiac area.
b. S1 and sound fainter at the apex than at the base.
c. S and 2 sound fainter at the base than at the apex.
d. S1 is loudest at the apex, and S2 is loudest at the base.
Rationale: The S1 sound — the “lub” sound — is loudest at the apex of the heart. It sounds longer, lower, and louder there than
the S2 — the “dub” sound — is loudest at the base. It sounds shorter, sharper, higher, and louder there than the S1.
4. A client has a nursing diagnosis of Ineffective airway clearance related to poor coughing. When planning this
client’s care, the nurse should include which intervention? a. Increasing fluids to 2,500 ml/day
b. Teaching the client how to deep-breathe and cough
c. Improving airway clearance
d. Suctioning the client every 2 hours
RATIONALE: Interventions should address the etiology of the client's problem — poor coughing. Teaching deep breathing and
coughing addresses this etiology. Increasing fluids may improve the client’s condition, but this intervention doesn't address poor
coughing. Improving airway clearance is too vague to be considered an appropriate intervention. Suctioning isn't indicated
unless other measures fail to clear the airway.
5. A nurse is using the computer when a client calls for pain medication. Which action by the nurse is the best?
a. Staying logged on, leaving the terminal on, and administering the medication immediately
b. telling the client that he’ll have to wait 15 minutes while she completes the entry
c. Asking a coworker to log out for her and administering the medicine right away
d. Logging out of the computer, then administering the pain medication
RATIONALE: A nurse should meet a client’s request for pain medication as quickly as possible after she logs out of the computer.
A nurse shouldn't ask a client to wait for as long as 15 minutes for requested pain medication. If the nurse leaves the terminal
without logging out, others may view confidential information or use her password. Asking a coworker to log her out isn't safe
computer practice.
6. What is the most appropriate nursing diagnosis for the client with acute pancreatitis? a.
,c. Decreased cardiac output
d. Ineffective gastrointestinal tissue perfusion
RATIONALE: Clients with acute pancreatitis often experience deficient fluid volume, which can lead to hypovolemic
shock. Vomiting, hemorrhage (in hemorrhagic pancreatitis), and plasma leaking into the peritoneal cavity may
cause the volume deficit. Hypovolemic shock will cause a decrease in cardiac output. Gastrointestinal tissue
perfusion will be ineffective if hypovolemic shock occurs, but this wouldn't be the primary nursing diagnosis.
7. One aspect of implementation related to drug therapy is:
a. developing a plan of care
b. documenting drugs given.
c. establishing outcome criteria.
d. setting realistic client goals.
RATIONALE: Athough documentation isn't a step in the nursing process, the nurse is legally required to document
activities related to drug therapy, including the time of administration, the quantity, and the client's reaction.
Developing a plan of care, establishing outcome criteria, and setting realistic client goals are parts of planning
rather than implementation.
8. A nurse notes that a client’s I.V. insertion site is red, swollen, and warm to the touch. which action should the nurse
take first?
a. Discontinue the I.V. infusion.
b. Apply a warm, moist compress to the I.V. site.
c. Assess the I.V. infusion for patency.
d. Apply an ice pack to the I.V. site.
RATIONALE: Because redness, swelling, and warmth at an I.V. site are signs of infection, the nurse should
discontinue the infusion immediately and restart at another site. After doing this, the nurse should apply warmth to
the original site. Checking infusion patency isn't warranted because assessment findings suggest infection and
inflammation, not infiltration. Heat, not cold is the appropriate treatment for inflammation.
9. A nurse is caring for a client with a history of falls. The nurse's first priority when caring for a client at risk for falls
is:
a. placing the call light for easy access.
b. keeping the bed in the lowest possible position.
c. instructing the client not to get out of the bed without assistance
d. keeping the bedpan available so that the client doesn’t have to get out of bed.
RATIONALE: Keeping the bed at the lowest possible position the first priority for clients at risk for falling. Keeping the
call light easy accessible is important but isn’t a top priority. Instructing the client not to get out of bed may not
effectively prevent falls — for example, if the client is confused. Even when the client needs assistance to get out of
bed, the nurse should place the bed in the lowest position. The client may not require a bedpan.
10. A nurse is caring for a client who is exhibiting signs and symptoms characteristic of a myocardial infarction (MI).
which statement describes priorities the nurse should establish while performing the physical assessment? a.
Assess the client's level of pain and administer prescribed analgesics.
b. Assess the client’s level of anxiety and provide emotional support.
c. Prepare the client for pulmonary artery catheterization.
d. Ensure that the client's family is kept informed of his status.
RATIONALE: The cardinal symptom of MI is persistent, crushing substernal pain or pressure. The nurse should first
assess the client's pain and prepare to administer nitroglycerin or morphine for pain control. The client must be
medically stabilized before pulmonary artery catheterization can be used as a diagnostic procedure. Anxiety and a
feeling of impending doom are characteristic of MI, but the priority is to stabilize the client medically. Although the
client and his family should be kept informed at every step of the recovery process, this action isn’t the priority when
treating a client with a suspected MI.
11. A nurse is monitoring a client for adverse reactions during barbiturate therapy. What is the major disadvantage
of barbiturate use?
a. Prolonged half-life
b. Poor absorption
c. Potential for drug dependence
d. Potential for hepatotoxicity
RATIONALE: Clients can become dependent on barbiturates, especially with prolonged use. Because of the rapid
distribution of some barbiturates, no correlation exists between duration of action and half-life. Barbiturates are
absorbed well and don't cause hepatotoxicity, but because barbiturates are metabolized in the liver, existing hepatic
, 12. A nurse is caring for a client who required chest tube insertion for a pneumothorax. To assess for
pneumothorax resolution, the nurse anticipates that the client will require: a. monitoring of arterial
oxygen saturation ,
b. arterial blood gas (ABG) studies.
c. chest auscultation.
d. a chest x-ray.
Rationale: Chest x-ray confirms diagnosis by revealing air or fluid in the pleural space. SaO2 values may initially
decrease with a pneumothorax but typically return to normal within 24 hours. ABG studies may show hypoxemia,
possibly with respiratory acidosis and hypercapnia not related to a pneumothorax. Chest auscultation will determine
overall lung status, but it's difficult to determine if the chest has reexpanded sufficiently.
13. During her morning assessment, a nurse notes that a client has severe dyspnea, his respirations are 34
breaths/minute and labored. Oxygen saturation is 79% on 3L of oxygen. The nurse remembers that the client's
chart includes his living will, When considering best practice, the nurse should:
a. withhold all potentially life-prolonging treatments in accordance with the client's living will
b. increase the oxygen flow rate to 4L, but avoid initiating other interventions
c. call the client’s family and ask what they think is best.
d. initiate potentially life-prolonging treatment unless the client refuses.
RATIONALE: A living will doesn't go into effect unless the client is unable to make his own decisions. A nurse
shouldn't withhold care for an alert client unless he specifically refuses care. The nurse should give all appropriate
care while also maintaining the client's right to refuse treatment. Increasing the oxygen flow rate might be an
appropriate response, but isn't the best action at this time. The family isn't responsible for determining care at this
time.
14. A client is to receive a glycerin suppository. Which nursing action is appropriate when administering a
suppository?
a. Removing the suppository from the refrigerator 30 minutes before insertion
b. Applying a lubricant to the suppository
c. Dissolving the suppository in 3 ml of warm water
d. Instructing the client to bear down during insertion
RATIONALE: A suppository must be lubricated before insertion. Because suppositories melt at body temperature,
they usually require refrigeration until administration. It isn’t appropriate to dissolve a suppository in warm water. It
should remain in a solid state. Instructing the client to bear down would cause the anal sphincter to contract,
making insertion difficult.
15. A physician orders regular insulin 10 units LV. along with 50 ml of dextrose 50% for a client with acute renal
failure. What problem is this client most likely experiencing? a. Hypercalcemia
b. Hypernatremia
c. Hyperglycemia
d. Hyperkalemia
Rationale: Administering regular IV concomitantly with 50 ml of dextrose 50% helps shift potassium from the
extracellular fluid into the cell, which normalizes serum potassium levels in the client with hyperkalemia. This
combination doesn't he reverse the effects of hypercalcemia, hypenatremia, or hyperglycemia.
16. A nurse identifies a client’s responses to actual or potential health problems during which step of the nursing
process?
a. Assessment
b. Diagnosis
c. Planning
d. Evaluation
RATIONALE: The nurse identifies human responses to actual or potential health problems during the diagnosis step
of the nursing process, which encompasses the nurse’s ability to formulate a nursing diagnosis. During the
assessment step, the nurse systematically collects data about the client or his family. During the planning step, she
develops strategies to resolve or decrease the client’s problem. During the evaluation step, the nurse determines the
effectiveness of the care plan.
17. In a client with a urine specific gravity of 1.040, a subnormal serum osmolality, and a serum sodium level of
128 mEq/L, the nurse should question an order for which I.V. fluid? a. dextrose 5% in half-normal saline
solution.
b. normal saline solution.
