Fundamentals Of Nursing Exam Q&A’s With Rationale
2025 Latest Update A+ SCORED
2nd Ed By Judith M. Wilkinson & Leslie S. Treas. Vol 1 & 2
The nurse is working on a unit that uses nursing assessment flow sheets. Which statement best
describes this form of charting? Nursing assessment flow sheets:
1) Are comprehensive charting forms that integrate assessments and nursing actions
2) Contain only graphic information, such as I&O, vital signs, and medication administration
3) Are used to record routine aspects of care; they do not contain assessment data
4) Contain vital data collected upon admission, which can be compared with newly collected data -
✔✔✔ - Answer:
1) Are comprehensive charting forms that integrate assessments and nursing actions
Rationale:
Nursing assessment flow sheets are organized by body systems. The nurse checks the box
corresponding to the current assessment findings. Nursing actions, such as wound care, treatments,
or IV fluid administration, are also included. Graphic information, such as vital signs, I&O, and routine
care, may be found on the graphic record. The admission form contains baseline information.
At the end of the shift, the nurse realizes that she forgot to document a dressing change that she
performed for a patient. Which action should the nurse take?
1) Complete an occurrence report before leaving.
2) Do nothing; the next nurse will document it was done.
3) Write the note of the dressing change into an earlier note.
4) Make a late entry as an addition to the narrative notes. - ✔✔✔ - Answer:
4) Make a late entry as an addition to the narrative notes.
,Rationale:
If the nurse fails to make an important entry while charting, she should make a late entry as an
addition to the narrative notes. An occurrence report is not necessary in this case. If documentation
is omitted, there is no legal verification that the procedure was performed. It is illegal to add to a
chart entry that was previously documented. The nurse can only document care directly performed
or observed. Therefore, the nurse on the incoming shift would not record the wound change as
performed.
Which action should the nurse take before administering morphine 4.0 mg intravenously to a patient
complaining of incisional pain?
1) Assess the patient's incision.
2) Clarify the order with the prescriber.
3) Assess the patient's respiratory status.
4) Monitor the patient's heart rate. - ✔✔✔ - Answer:
3) Assess the patient's respiratory status.
Rationale:
Before administering an opioid analgesic, such as morphine, the nurse should assess the patient's
respiratory status because opioid analgesics can cause respiratory depression. It is not necessary to
clarify the order with the physician because morphine 4 mg IV is an appropriate dose. It is not
necessary to monitor the patient's heart rate.
Which action should the nurse take when preparing patient-controlled analgesia for a postoperative
patient?
1) Caution the patient to limit the number of times he presses the dosing button.
2) Ask another nurse to double-check the setup before patient use.
3) Instruct the patient to administer a dose only when experiencing pain.
4) Provide clear, simple instructions for dosing if the patient is cognitively impaired. - ✔✔✔ - Answer:
,2) Ask another nurse to double-check the setup before patient use.
Rationale:
As a safeguard to reduce the risk for dosing errors, the nurse should request another nurse to double-
check the setup before patient use. The nurse should reassure the patient that the pump has a lockout
feature that prevents him from overdosing even if he continues to push the dose administration
button. The nurse should also instruct the patient to administer a dose before potentially painful
activities, such as walking. Patient-controlled analgesia is contraindicated for those who are
cognitively impaired.
The nurse administers codeine sulfate 30 mg orally to a patient who underwent craniotomy 3 days
ago for a brain tumor. How soon after administration should the nurse reassess the patient's pain?
1) Immediately
2) In 10 minutes
3) In 15 minutes
4) In 60 minutes - ✔✔✔ - Answer:
4) In 60 minutes
Rationale:
Codeine administered by the oral route reaches peak concentration in 60 minutes; therefore, the
nurse should reassess the patient's pain 60 minutes after administration. The nurse should reassess
pain after 10 minutes when administering codeine by the intramuscular or subcutaneous routes.
Drugs administered by the intravenous (IV) route are effective almost immediately; however,
codeine is not recommended for IV administration.
Which nonsteroidal anti-inflammatory drug might be administered to inhibit platelet aggregation in
a patient at risk for thrombophlebitis?
1) Ibuprofen (Motrin)
2) Celecoxib (Celebrex)
3) Aspirin (Ecotrin)
, 4) Indomethacin (Indocin) - ✔✔✔ - Answer:
3) Aspirin (Ecotrin)
Rationale:
Aspirin is a unique NSAID that inhibits platelet aggregation. Low-dose aspirin therapy is commonly
administered to decrease the risk of thrombophlebitis, myocardial infarction, and stroke. Ibuprofen,
celecoxib, and indomethacin are NSAIDs, but they do not inhibit platelet aggregation.
A client who is receiving epidural analgesia complains of nausea and loss of motor function in his
legs. The nurse obtains his blood pressure and notes a drop in his blood pressure from the previous
reading. Which complication is the patient most likely experiencing?
1) Infection at the catheter insertion site
2) Side effect of the epidural analgesic
3) Epidural catheter migration
4) Spinal cord damage - ✔✔✔ - Answer:
3) Epidural catheter migration
Rationale:
The patient is exhibiting signs of epidural catheter migration, which include nausea, a decrease in
blood pressure, and loss of motor function without an identifiable cause. Signs of infection at the
catheter site include redness, swelling, and drainage. Loss of motor function is not a typical side effect
associated with epidural analgesics. These are common signs of catheter migration, not spinal cord
damage.
Which of the following clients is experiencing an abnormal change in vital signs? A client whose
(select all that apply):
1) Blood pressure (BP) was 132/80 mm Hg sitting and is 120/60 mm Hg upon standing
2) Rectal temperature is 97.9°F in the morning and 99.2°F in the evening
3) Heart rate was 76 before eating and is 60 after eating
2025 Latest Update A+ SCORED
2nd Ed By Judith M. Wilkinson & Leslie S. Treas. Vol 1 & 2
The nurse is working on a unit that uses nursing assessment flow sheets. Which statement best
describes this form of charting? Nursing assessment flow sheets:
1) Are comprehensive charting forms that integrate assessments and nursing actions
2) Contain only graphic information, such as I&O, vital signs, and medication administration
3) Are used to record routine aspects of care; they do not contain assessment data
4) Contain vital data collected upon admission, which can be compared with newly collected data -
✔✔✔ - Answer:
1) Are comprehensive charting forms that integrate assessments and nursing actions
Rationale:
Nursing assessment flow sheets are organized by body systems. The nurse checks the box
corresponding to the current assessment findings. Nursing actions, such as wound care, treatments,
or IV fluid administration, are also included. Graphic information, such as vital signs, I&O, and routine
care, may be found on the graphic record. The admission form contains baseline information.
At the end of the shift, the nurse realizes that she forgot to document a dressing change that she
performed for a patient. Which action should the nurse take?
1) Complete an occurrence report before leaving.
2) Do nothing; the next nurse will document it was done.
3) Write the note of the dressing change into an earlier note.
4) Make a late entry as an addition to the narrative notes. - ✔✔✔ - Answer:
4) Make a late entry as an addition to the narrative notes.
,Rationale:
If the nurse fails to make an important entry while charting, she should make a late entry as an
addition to the narrative notes. An occurrence report is not necessary in this case. If documentation
is omitted, there is no legal verification that the procedure was performed. It is illegal to add to a
chart entry that was previously documented. The nurse can only document care directly performed
or observed. Therefore, the nurse on the incoming shift would not record the wound change as
performed.
Which action should the nurse take before administering morphine 4.0 mg intravenously to a patient
complaining of incisional pain?
1) Assess the patient's incision.
2) Clarify the order with the prescriber.
3) Assess the patient's respiratory status.
4) Monitor the patient's heart rate. - ✔✔✔ - Answer:
3) Assess the patient's respiratory status.
Rationale:
Before administering an opioid analgesic, such as morphine, the nurse should assess the patient's
respiratory status because opioid analgesics can cause respiratory depression. It is not necessary to
clarify the order with the physician because morphine 4 mg IV is an appropriate dose. It is not
necessary to monitor the patient's heart rate.
Which action should the nurse take when preparing patient-controlled analgesia for a postoperative
patient?
1) Caution the patient to limit the number of times he presses the dosing button.
2) Ask another nurse to double-check the setup before patient use.
3) Instruct the patient to administer a dose only when experiencing pain.
4) Provide clear, simple instructions for dosing if the patient is cognitively impaired. - ✔✔✔ - Answer:
,2) Ask another nurse to double-check the setup before patient use.
Rationale:
As a safeguard to reduce the risk for dosing errors, the nurse should request another nurse to double-
check the setup before patient use. The nurse should reassure the patient that the pump has a lockout
feature that prevents him from overdosing even if he continues to push the dose administration
button. The nurse should also instruct the patient to administer a dose before potentially painful
activities, such as walking. Patient-controlled analgesia is contraindicated for those who are
cognitively impaired.
The nurse administers codeine sulfate 30 mg orally to a patient who underwent craniotomy 3 days
ago for a brain tumor. How soon after administration should the nurse reassess the patient's pain?
1) Immediately
2) In 10 minutes
3) In 15 minutes
4) In 60 minutes - ✔✔✔ - Answer:
4) In 60 minutes
Rationale:
Codeine administered by the oral route reaches peak concentration in 60 minutes; therefore, the
nurse should reassess the patient's pain 60 minutes after administration. The nurse should reassess
pain after 10 minutes when administering codeine by the intramuscular or subcutaneous routes.
Drugs administered by the intravenous (IV) route are effective almost immediately; however,
codeine is not recommended for IV administration.
Which nonsteroidal anti-inflammatory drug might be administered to inhibit platelet aggregation in
a patient at risk for thrombophlebitis?
1) Ibuprofen (Motrin)
2) Celecoxib (Celebrex)
3) Aspirin (Ecotrin)
, 4) Indomethacin (Indocin) - ✔✔✔ - Answer:
3) Aspirin (Ecotrin)
Rationale:
Aspirin is a unique NSAID that inhibits platelet aggregation. Low-dose aspirin therapy is commonly
administered to decrease the risk of thrombophlebitis, myocardial infarction, and stroke. Ibuprofen,
celecoxib, and indomethacin are NSAIDs, but they do not inhibit platelet aggregation.
A client who is receiving epidural analgesia complains of nausea and loss of motor function in his
legs. The nurse obtains his blood pressure and notes a drop in his blood pressure from the previous
reading. Which complication is the patient most likely experiencing?
1) Infection at the catheter insertion site
2) Side effect of the epidural analgesic
3) Epidural catheter migration
4) Spinal cord damage - ✔✔✔ - Answer:
3) Epidural catheter migration
Rationale:
The patient is exhibiting signs of epidural catheter migration, which include nausea, a decrease in
blood pressure, and loss of motor function without an identifiable cause. Signs of infection at the
catheter site include redness, swelling, and drainage. Loss of motor function is not a typical side effect
associated with epidural analgesics. These are common signs of catheter migration, not spinal cord
damage.
Which of the following clients is experiencing an abnormal change in vital signs? A client whose
(select all that apply):
1) Blood pressure (BP) was 132/80 mm Hg sitting and is 120/60 mm Hg upon standing
2) Rectal temperature is 97.9°F in the morning and 99.2°F in the evening
3) Heart rate was 76 before eating and is 60 after eating
