Fundamentals of Nursing Care
Advantage for Fundamentals of Nursing Care:
Concepts, 4th Edition Chapters 1-38 | Questions And
Answers With Rationals|2025 Ed
_____________________________________________________________________________________
A home health-care (HHC) nurse visits a patient to assess an abdominal surgery site. The patient is 85
years old, lives alone, and takes multiple medications for chronic illnesses. The nurse notes that the
patient's wound shows signs of delayed healing. Which factor would the nurse recognize as being
least likely to be a contributing factor for the delayed healing?
✓ The patient has an agency deliver two cold meals and one hot meal daily.
A nurse is providing care for a patient readmitted to the hospital after a modified mastectomy. The
nurse notes that the primary surgical wound is inflamed, painful, and edematous. Under the patient's
arm, the nurse notices a small open area draining a moderate amount of green drainage. Which
condition would the nurse identify?
✓ Sinus tract between infected and healthy tissue
A nurse is taking care of a patient who has a surgical drain inserted during abdominal surgery, which is
producing continuous drainage. What type of healing would the nurse anticipate will take place for
this patient?
✓ Delayed primary closure
A nurse is monitoring a postoperative patient's surgical site, which appears slightly reddened and
tender. No drainage is noted but patient has a low-grade fever of 100°F (37.78°C). What would the
nurse suspect based on this clinical presentation?
✓ Increased cellular permeability and histamine release
A nurse has received a preliminary report from the laboratory on a wound culture and sensitivity.
Findings indicate that the organism is resistant to the prescribed antibiotic ordered for treatment.
What action should the nurse take next?
✓ Contact the health-care provider (HCP).
A nurse is taking care of a patient who has a Hemovac drain. What is the priority nursing responsibility
related to drain care for this device?
✓ Verify that the drain is compressed.
A nurse is preparing to start an intravenous site (IV) on a patient with poor skin turgor. Which type of
dressing should the nurse anticipate using to cover the IV site?
✓ Silicone
,A nurse is monitoring a postoperative surgical patient who is 24 hours post procedure. Upon
inspection of the dressing, she notes that there is a marked circle of drainage with nursing initials
dated 12 hours ago. No further drainage is noted. What is the next action that the nurse should take?
✓ Check orders to see when dressing change is indicated.
The nursing student is performing wound care in the simulation lab. Which action if noted by the
nursing instructor indicates that additional teaching is needed?
✓ Go back over an area already cleaned.
A nurse is caring for a patient who is 5 days postoperative. The health-care provider (HCP) orders that
every other staple be removed from the incision. The nurse notices that the staples appear to be far
apart, and after the first staple is removed, the incision begins to gap open. Which priority action
should the nurse take?
✓ Call the HCP and report wound dehiscence.
A nurse is caring for a patient who has a wound vac. What priority action should the nurse implement
when preparing to change the dressing?
✓ Premedicate the patient for pain.
A 28-year-old contacts the family clinic stating that she had a muscle injury while exercising a few
days ago. The muscle is sore and causing discomfort. What is the best nursing response?
✓ Rest the extremity.
A nurse is providing care for a patient who has skin traction. Which finding requires immediate
intervention?
✓ Weights are touching the floor.
A nurse is caring for a patient with a right lower leg cast who complains of itching. What is the best
nursing action to assist the patient with relief of this complaint?
✓ Use a hair dryer on the casted extremity.
A nurse is caring for patients on an orthopedic unit. Which patient would be the nurse's immediate
concern after receiving report?
✓ A patient with redness and purulent drainage at an external pin site
A nurse is taking care of a patient with a casted right arm who comes to the clinic with rough areas
noted on edges of the cast. What is the best nursing action?
✓ Perform petaling.
A nurse is providing pin care to a patient in skeletal traction. Which nursing action is not appropriate?
✓ apply alcohol to pins
, A nurse is performing a neurovascular check on a patient with a left below-the-knee cast. Which
finding warrants immediate intervention?
✓ Toenail bed is tinged blue.
A nurse is providing care for a patient after an above-the-knee amputation 1 day ago. Which nursing
care is most important during the initial postoperative period?
✓ Wrapping the stump with an elastic bandage
A nurse is preparing to discharge a patient who had a left hip arthroplasty. Which information should
be included in the discharge instructions?
✓ Use an assistive device to retrieve items that may have fallen on the floor.
A nurse is caring for a patient recently admitted to the unit after a right knee replacement. Which
assessment finding is most concerning to the nurse?
✓ Pedal pulses on the operative foot are weak compared to the nonoperative side.
A nurse is performing a neurovascular assessment on a patient awaiting surgery for a right hip
replacement. Which finding would be of most concern to the nurse?
✓ Cool skin on the affected leg from the knee downward
A nurse is monitoring a patient who is using crutches to maintain partial weight-bearing of the
affected extremity. Which finding indicates that additional teaching is needed?
✓ Places full weight directly on affected leg for a few seconds
A nurse is providing care for a patient who becomes short of breath when ambulating to the
bathroom. Which documentation should the nurse enter on the patient's medical record?
✓ Dyspnea noted after walking 15 feet
A nurse is caring for a patient with compromised respiratory function. The patient has a productive
cough, and sputum appears frothy and pink-tinged. Which conclusion by the nurse causes the most
concern?
✓ Patient has life-threatening pulmonary edema.
A nurse is caring for a patient with a chest tube. Upon assessment, the nurse notes the presence of
crepitus at the chest tube site, extending across the chest about 3 inches. Which action by the nurse is
immediate?
✓ Report the condition to the health-care provider (HCP).
A patient at the outpatient clinic complains of a sore throat. The patient denies cough but states it
hurts when swallowing. Which test would the nurse anticipate the health-care provider (HCP) will
order?
✓ strep culture
Advantage for Fundamentals of Nursing Care:
Concepts, 4th Edition Chapters 1-38 | Questions And
Answers With Rationals|2025 Ed
_____________________________________________________________________________________
A home health-care (HHC) nurse visits a patient to assess an abdominal surgery site. The patient is 85
years old, lives alone, and takes multiple medications for chronic illnesses. The nurse notes that the
patient's wound shows signs of delayed healing. Which factor would the nurse recognize as being
least likely to be a contributing factor for the delayed healing?
✓ The patient has an agency deliver two cold meals and one hot meal daily.
A nurse is providing care for a patient readmitted to the hospital after a modified mastectomy. The
nurse notes that the primary surgical wound is inflamed, painful, and edematous. Under the patient's
arm, the nurse notices a small open area draining a moderate amount of green drainage. Which
condition would the nurse identify?
✓ Sinus tract between infected and healthy tissue
A nurse is taking care of a patient who has a surgical drain inserted during abdominal surgery, which is
producing continuous drainage. What type of healing would the nurse anticipate will take place for
this patient?
✓ Delayed primary closure
A nurse is monitoring a postoperative patient's surgical site, which appears slightly reddened and
tender. No drainage is noted but patient has a low-grade fever of 100°F (37.78°C). What would the
nurse suspect based on this clinical presentation?
✓ Increased cellular permeability and histamine release
A nurse has received a preliminary report from the laboratory on a wound culture and sensitivity.
Findings indicate that the organism is resistant to the prescribed antibiotic ordered for treatment.
What action should the nurse take next?
✓ Contact the health-care provider (HCP).
A nurse is taking care of a patient who has a Hemovac drain. What is the priority nursing responsibility
related to drain care for this device?
✓ Verify that the drain is compressed.
A nurse is preparing to start an intravenous site (IV) on a patient with poor skin turgor. Which type of
dressing should the nurse anticipate using to cover the IV site?
✓ Silicone
,A nurse is monitoring a postoperative surgical patient who is 24 hours post procedure. Upon
inspection of the dressing, she notes that there is a marked circle of drainage with nursing initials
dated 12 hours ago. No further drainage is noted. What is the next action that the nurse should take?
✓ Check orders to see when dressing change is indicated.
The nursing student is performing wound care in the simulation lab. Which action if noted by the
nursing instructor indicates that additional teaching is needed?
✓ Go back over an area already cleaned.
A nurse is caring for a patient who is 5 days postoperative. The health-care provider (HCP) orders that
every other staple be removed from the incision. The nurse notices that the staples appear to be far
apart, and after the first staple is removed, the incision begins to gap open. Which priority action
should the nurse take?
✓ Call the HCP and report wound dehiscence.
A nurse is caring for a patient who has a wound vac. What priority action should the nurse implement
when preparing to change the dressing?
✓ Premedicate the patient for pain.
A 28-year-old contacts the family clinic stating that she had a muscle injury while exercising a few
days ago. The muscle is sore and causing discomfort. What is the best nursing response?
✓ Rest the extremity.
A nurse is providing care for a patient who has skin traction. Which finding requires immediate
intervention?
✓ Weights are touching the floor.
A nurse is caring for a patient with a right lower leg cast who complains of itching. What is the best
nursing action to assist the patient with relief of this complaint?
✓ Use a hair dryer on the casted extremity.
A nurse is caring for patients on an orthopedic unit. Which patient would be the nurse's immediate
concern after receiving report?
✓ A patient with redness and purulent drainage at an external pin site
A nurse is taking care of a patient with a casted right arm who comes to the clinic with rough areas
noted on edges of the cast. What is the best nursing action?
✓ Perform petaling.
A nurse is providing pin care to a patient in skeletal traction. Which nursing action is not appropriate?
✓ apply alcohol to pins
, A nurse is performing a neurovascular check on a patient with a left below-the-knee cast. Which
finding warrants immediate intervention?
✓ Toenail bed is tinged blue.
A nurse is providing care for a patient after an above-the-knee amputation 1 day ago. Which nursing
care is most important during the initial postoperative period?
✓ Wrapping the stump with an elastic bandage
A nurse is preparing to discharge a patient who had a left hip arthroplasty. Which information should
be included in the discharge instructions?
✓ Use an assistive device to retrieve items that may have fallen on the floor.
A nurse is caring for a patient recently admitted to the unit after a right knee replacement. Which
assessment finding is most concerning to the nurse?
✓ Pedal pulses on the operative foot are weak compared to the nonoperative side.
A nurse is performing a neurovascular assessment on a patient awaiting surgery for a right hip
replacement. Which finding would be of most concern to the nurse?
✓ Cool skin on the affected leg from the knee downward
A nurse is monitoring a patient who is using crutches to maintain partial weight-bearing of the
affected extremity. Which finding indicates that additional teaching is needed?
✓ Places full weight directly on affected leg for a few seconds
A nurse is providing care for a patient who becomes short of breath when ambulating to the
bathroom. Which documentation should the nurse enter on the patient's medical record?
✓ Dyspnea noted after walking 15 feet
A nurse is caring for a patient with compromised respiratory function. The patient has a productive
cough, and sputum appears frothy and pink-tinged. Which conclusion by the nurse causes the most
concern?
✓ Patient has life-threatening pulmonary edema.
A nurse is caring for a patient with a chest tube. Upon assessment, the nurse notes the presence of
crepitus at the chest tube site, extending across the chest about 3 inches. Which action by the nurse is
immediate?
✓ Report the condition to the health-care provider (HCP).
A patient at the outpatient clinic complains of a sore throat. The patient denies cough but states it
hurts when swallowing. Which test would the nurse anticipate the health-care provider (HCP) will
order?
✓ strep culture
