Fundamentals Exam 3
A patient confused and has become violent after recovering from a seizure episode. How would
the nurse reorient this patient and provide further care? - ANS-1) answer the patient's questions
2) explain what happened
\A patient is diagnosed with impaired physical mobility related to left-sided weakness. The
registered nurse is teaching the patient's family member about the interventions that would be
effective for the patient. Which statement made by the family member indicates effective
learning? - ANS-Instruct the patient to use a walker
\A patient rates his pain as a 6 on a scale of 0 to 10. The patient's wife says that he cannot be in
that much pain because he has been sleeping for 30 minutes. Which resource is most accurate
for assessing the pain? - ANS-The patient's report of pain is the best method for assessing the
pain.
\A patient reports difficulty seeing objects at a distance after a cerebrovascular accident. Which
result would the nurse anticipate? - ANS-Risk of falls
\A patient sustained a severe injury in a motor vehicle accident. The patient is unable to perform
any movement. Which metabolic change would be found in the patient because of immobility? -
ANS-1) calcium imbalance 2) gastrointestinal disturbances 3) alteration in the metabolism of
protein
\A patient who was admitted to the hospital receives a red wristband for identification purposes.
Which explanation is the significance of the wristband? - ANS-patient allergies
\A patient with chronic low back pain who took an opioid around-the-clock for the past year
decided to abruptly stop the medication for fear of addiction. The patient is now experiencing
shaking, chills, abdominal cramps, and joint pain. The nurse recognized these symptoms as
manifestations of which condition? - ANS-Physical dependence
\A patient with postural hypotension is hospitalized. Which safety measure would the nurse
implement during ambulation? - ANS-use of gait belt
\A registered nurse is teaching a nursing student about acetaminophen for pain management.
Which statement by the nursing student indicates the need for further teaching? - ANS-1)
Naloxone is an acetaminophen antagonist 2) The maximum 24-hour dose of acetaminophen is
325 mg
\A registered nurse is teaching an older adult about safety measures related to the physiological
changes associated with aging. Which statement by the patient indicates the need for further
teaching? - ANS-1) take diuretics in the late evening 2) perform vision & hearing examinations
every 2 years.
\A young patient reports short intense pain that lasts a few minutes after administration of
analgesia. Which distraction activity would the nurse suggest to the patient? - ANS-1) you
should play games 2) you can offer prayers 3) you can sing songs of your choice
\An individual has accidentally been poisoned and loses consciousness. Which statement by
the caregiver indicates an understanding of emergency care in this situation? - ANS-It is never
safe to induce vomiting in an unconscious victim
, \For a patient who has wrist and ankle restraints, which position will place the patient at risk of
aspiration? - ANS-Supine
\Health care professionals have an increased risk of musculoskeletal injuries, because their
occupation involves lifting and transferring patients. How can the nurse reduce the risk of
musculoskeletal injuries when lifting any person or object? - ANS-Keep trunk erect and bend the
knees
\How would the nurse support a culture of safety? - ANS-1) Completing incident reports when
appropriate 2) Completing incident reports for a near miss 3) Communicating product concerns
to an immediate supervisor
\In which situation would drug administration be considered palliative? - ANS-Pain management
for a patient with terminal cancer
\The laboratory reports of an immobilized patient indicate the presence of thrombus. Which
changes in the body are responsible for this condition in the patient? - ANS-Cardiovascular
changes
\The nurse administers 250 mg of acetaminophen along with 5 mg of hydrocodone to a patient
in pain. Which reason explains why acetaminophen is part of this protocol? - ANS-To decrease
the dose of opioid required for pain control
\The nurse is assessing a patient for the movement of the hip ball-and-socket joint. Which
range-of-motion (ROM) exercise would the nurse ask the patient to perform to assess
adduction? - ANS-Move the leg back toward the medial position
\The nurse is assessing a patient who complains of pain in the abdomen. Which method is most
appropriate to assess the intensity of pain? - ANS-Asking the patient to describe the pain using
a pain scale
\The nurse is assessing the pain for an adult patient who has cognitive impairment. Which
nursing action is most appropriate? - ANS-Observing the facial expressions and body
movements for any pain behavior
\The nurse is caring for a patient receiving hydromorphone via patient-controlled analgesia
(PCA) infusion. After 1 hour, the nurse finds that the patient is difficult to arouse and breathing
rate is 8 breaths/min. Which action would the nurse take first? - ANS-Stopping the PCA infusion
pump
\The nurse is caring for a patient who is on bed rest for a month. The nurse understands that an
immobile patient may have poor body alignment, which may lead to complications. How would
the nurse assess body alignment in this patient? - ANS-1) Place the patient in a lateral position
2) Support the head with a pillow 3) support the body with an adequate mattress
\The nurse is caring for a patient who is scheduled for an x-ray for an injured right leg. Which
intervention may help reduce the patient's pain? - ANS-Applying ice near the site of the pain
\The nurse is counseling a patient who was prescribed morphine for pain. Which statement by
the patient indicates the need for further teaching? - ANS-I should avoid eating foods that are
rich in fiber
\The nurse is evaluating the statements made by the nursing student about pain. Which
statement by the nursing student is true? - ANS-Intensity of the pain does not accurately
indicate the tissue damage
\The nurse is explaining and demonstrating the correct use of fire extinguishers at home to a
group of adolescents. Which order of steps listed by an adolescent indicates effective learning?
A patient confused and has become violent after recovering from a seizure episode. How would
the nurse reorient this patient and provide further care? - ANS-1) answer the patient's questions
2) explain what happened
\A patient is diagnosed with impaired physical mobility related to left-sided weakness. The
registered nurse is teaching the patient's family member about the interventions that would be
effective for the patient. Which statement made by the family member indicates effective
learning? - ANS-Instruct the patient to use a walker
\A patient rates his pain as a 6 on a scale of 0 to 10. The patient's wife says that he cannot be in
that much pain because he has been sleeping for 30 minutes. Which resource is most accurate
for assessing the pain? - ANS-The patient's report of pain is the best method for assessing the
pain.
\A patient reports difficulty seeing objects at a distance after a cerebrovascular accident. Which
result would the nurse anticipate? - ANS-Risk of falls
\A patient sustained a severe injury in a motor vehicle accident. The patient is unable to perform
any movement. Which metabolic change would be found in the patient because of immobility? -
ANS-1) calcium imbalance 2) gastrointestinal disturbances 3) alteration in the metabolism of
protein
\A patient who was admitted to the hospital receives a red wristband for identification purposes.
Which explanation is the significance of the wristband? - ANS-patient allergies
\A patient with chronic low back pain who took an opioid around-the-clock for the past year
decided to abruptly stop the medication for fear of addiction. The patient is now experiencing
shaking, chills, abdominal cramps, and joint pain. The nurse recognized these symptoms as
manifestations of which condition? - ANS-Physical dependence
\A patient with postural hypotension is hospitalized. Which safety measure would the nurse
implement during ambulation? - ANS-use of gait belt
\A registered nurse is teaching a nursing student about acetaminophen for pain management.
Which statement by the nursing student indicates the need for further teaching? - ANS-1)
Naloxone is an acetaminophen antagonist 2) The maximum 24-hour dose of acetaminophen is
325 mg
\A registered nurse is teaching an older adult about safety measures related to the physiological
changes associated with aging. Which statement by the patient indicates the need for further
teaching? - ANS-1) take diuretics in the late evening 2) perform vision & hearing examinations
every 2 years.
\A young patient reports short intense pain that lasts a few minutes after administration of
analgesia. Which distraction activity would the nurse suggest to the patient? - ANS-1) you
should play games 2) you can offer prayers 3) you can sing songs of your choice
\An individual has accidentally been poisoned and loses consciousness. Which statement by
the caregiver indicates an understanding of emergency care in this situation? - ANS-It is never
safe to induce vomiting in an unconscious victim
, \For a patient who has wrist and ankle restraints, which position will place the patient at risk of
aspiration? - ANS-Supine
\Health care professionals have an increased risk of musculoskeletal injuries, because their
occupation involves lifting and transferring patients. How can the nurse reduce the risk of
musculoskeletal injuries when lifting any person or object? - ANS-Keep trunk erect and bend the
knees
\How would the nurse support a culture of safety? - ANS-1) Completing incident reports when
appropriate 2) Completing incident reports for a near miss 3) Communicating product concerns
to an immediate supervisor
\In which situation would drug administration be considered palliative? - ANS-Pain management
for a patient with terminal cancer
\The laboratory reports of an immobilized patient indicate the presence of thrombus. Which
changes in the body are responsible for this condition in the patient? - ANS-Cardiovascular
changes
\The nurse administers 250 mg of acetaminophen along with 5 mg of hydrocodone to a patient
in pain. Which reason explains why acetaminophen is part of this protocol? - ANS-To decrease
the dose of opioid required for pain control
\The nurse is assessing a patient for the movement of the hip ball-and-socket joint. Which
range-of-motion (ROM) exercise would the nurse ask the patient to perform to assess
adduction? - ANS-Move the leg back toward the medial position
\The nurse is assessing a patient who complains of pain in the abdomen. Which method is most
appropriate to assess the intensity of pain? - ANS-Asking the patient to describe the pain using
a pain scale
\The nurse is assessing the pain for an adult patient who has cognitive impairment. Which
nursing action is most appropriate? - ANS-Observing the facial expressions and body
movements for any pain behavior
\The nurse is caring for a patient receiving hydromorphone via patient-controlled analgesia
(PCA) infusion. After 1 hour, the nurse finds that the patient is difficult to arouse and breathing
rate is 8 breaths/min. Which action would the nurse take first? - ANS-Stopping the PCA infusion
pump
\The nurse is caring for a patient who is on bed rest for a month. The nurse understands that an
immobile patient may have poor body alignment, which may lead to complications. How would
the nurse assess body alignment in this patient? - ANS-1) Place the patient in a lateral position
2) Support the head with a pillow 3) support the body with an adequate mattress
\The nurse is caring for a patient who is scheduled for an x-ray for an injured right leg. Which
intervention may help reduce the patient's pain? - ANS-Applying ice near the site of the pain
\The nurse is counseling a patient who was prescribed morphine for pain. Which statement by
the patient indicates the need for further teaching? - ANS-I should avoid eating foods that are
rich in fiber
\The nurse is evaluating the statements made by the nursing student about pain. Which
statement by the nursing student is true? - ANS-Intensity of the pain does not accurately
indicate the tissue damage
\The nurse is explaining and demonstrating the correct use of fire extinguishers at home to a
group of adolescents. Which order of steps listed by an adolescent indicates effective learning?
