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Nursing 101 Fundamentals of Nursing Practice Exam
1, (Latest Update) Real Questions and
Verified Answers | 100% Correct | Already Graded A+.
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 - (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
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E. Client will be medicated every 4 hours by the nurse - (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 - (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
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B. Percussion
C. Palpitation
D. Inspection - (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 - (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.
Nursing 101 Fundamentals of Nursing Practice Exam
1, (Latest Update) Real Questions and
Verified Answers | 100% Correct | Already Graded A+.
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 - (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
,2|Page
E. Client will be medicated every 4 hours by the nurse - (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 - (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
, 3|Page
B. Percussion
C. Palpitation
D. Inspection - (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 - (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.
