NUR 155 FUNDAMENTALS OF NURSING EXAM– QUESTIONS
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1. A nurse is preparing to administer a medication to a hospitalized client. Which of the
following actions best demonstrates the application of the right route principle of
medication administration?
A. Checking the client's identification band against the medication administration record.
B. Verifying the delivery method specified in the prescriber's order matches the route
being used.
C. Confirming that the medication is given within 30 minutes before or after the scheduled time.
D. Documenting the medication administration immediately after the client swallows the pill.
The right route principle requires the nurse to ensure that the method of delivery specified in
the order corresponds to how the medication is administered. Checking the ID band ensures
the right client, timing relates to the right time, and charting relates to proper documentation.
2. An adult client admitted for dehydration is prescribed 0.9% sodium chloride
intravenous infusion at 125 mL/hr. What type of intravenous solution is 0.9% sodium
chloride?
A. Hypotonic solution
B. Hypertonic solution
C. Isotonic solution
D. Colloidal solution
0.9% sodium chloride is an isotonic solution that has an effective osmolality similar to
extracellular fluid, causing no net movement of water across the cell membrane. Hypotonic
solutions pull fluid into cells, hypertonic solutions pull fluid out of cells, and colloids contain
large molecules that do not pass through semipermeable membranes easily.
3. A nurse enters a client's room and finds the client unresponsive, pulseless, and not
breathing. After calling for emergency assistance and initiating cardiopulmonary
resuscitation, what is the priority action regarding automated external defibrillation?
,A. Apply the AED pads immediately upon availability and follow visual and voice
prompts.
B. Continue chest compressions for a full 10 minutes before interrupting for rhythm analysis.
C. Check for a palpable carotid pulse every two minutes while the device analyzes the rhythm.
D. Administer two rescue breaths before attaching the automated external defibrillation unit.
Early defibrillation combined with high-quality CPR significantly increases survival rates in
cardiac arrest. The automated external defibrillator pads should be applied as soon as the
device is available so the rhythm can be analyzed promptly. Interrupting CPR unnecessarily or
delaying pad placement worsens outcomes.
4. A nurse is assessing a client's surgical wound on the abdomen. The nurse notes
separation of the wound edges with protrusion of abdominal organs through the incision.
Which of the following is the immediate nursing priority?
A. Apply dry sterile gauze dressings tightly over the protruding organs to push them back into
place.
B. Cover the protruding viscera with sterile gauze moistened with sterile normal saline
and notify the provider.
C. Position the client flat on their back and encourage deep breathing and coughing exercises.
D. Administer a prescribed oral analgesic immediately to control the client's acute pain.
Evisceration is a medical emergency requiring immediate action to prevent drying and
necrosis of exposed organs. Covering the area with sterile saline-moistened gauze keeps tissue
viable, and notifying the provider initiates surgical intervention. Pushing organs back in is
contraindicated, and coughing increases intra-abdominal pressure.
5. A nurse is evaluating a client's understanding of a low-sodium diet prescribed for
hypertension. Which of the following statements by the client indicates an effective
understanding of the teaching?
A. "I can use as much table salt on my food as long as I do not cook with it."
B. "I should read nutrition labels and choose foods labeled low sodium."
C. "I need to eliminate all fresh fruits and vegetables from my daily meals."
D. "I can freely eat canned soups because they are healthy and convenient."
,Reading nutrition labels and choosing low-sodium items is a key self-management strategy for
controlling hypertension. Table salt is high in sodium, fresh fruits and vegetables are
naturally low in sodium, and canned soups are typically very high in hidden sodium.
6. A nurse is caring for an older adult client who is at high risk for developing pressure
injuries. Which of the following interventions should be included in the client's care plan?
A. Massaging bony prominences vigorously every two hours to stimulate blood flow.
B. Repositioning the client every four hours while maintaining a 90-degree side-lying position.
C. Keeping the head of the bed elevated at 45 degrees continuously to prevent aspiration.
D. Using a draw sheet to lift rather than pull the client when repositioning in bed.
Using a draw sheet minimizes shearing and friction forces that damage fragile skin and
underlying tissues. Massaging bony prominences is contraindicated because it damages deep
capillary beds, repositioning should occur at least every two hours, and a 30-degree lateral
position is preferred over a 90-degree position.
7. A nurse is preparing to administer an intramuscular injection into the ventrogluteal site
of an adult client. Which anatomical landmarks should the nurse use to locate this site
accurately?
A. Greater trochanter, anterior superior iliac spine, and iliac crest.
B. Midpoint of the lateral thigh between the greater trochanter and the lateral femoral condyle.
C. Lower edge of the scapula and the posterior axillary fold.
D. Two inches away from the umbilicus in the lower abdominal quadrant.
The ventrogluteal site is located by placing the palm on the greater trochanter, pointing the
index finger toward the anterior superior iliac spine, and spreading the middle finger along
the iliac crest. This avoids major nerves and blood vessels, making it a safe injection site.
8. An unlicensed assistive personnel is reporting vital signs for a newly admitted client.
Which of the following findings reported by the assistive personnel requires immediate
assessment by the registered nurse?
A. Blood pressure of 118/76 mmHg in a resting adult client.
B. Heart rate of 88 beats per minute with a regular rhythm.
C. Oral temperature of 38.5 degrees Celsius in a client with an infection.
, D. Respiratory rate of 28 breaths per minute with shallow depth.
A respiratory rate of 28 breaths per minute with shallow depth indicates tachypnea and
potential respiratory distress, requiring immediate nurse evaluation. The blood pressure and
heart rate are within normal limits, and a temperature of 38.5 degrees Celsius is expected in
an infectious process but is less immediately life-threatening than acute respiratory
compromise.
9. A nurse is performing a physical assessment on a client and auscultating bowel sounds.
After listening to all four quadrants for a full minute in each quadrant without hearing any
sounds, how should the nurse proceed?
A. Document normal bowel sounds in all four abdominal quadrants.
B. Continue listening in each quadrant for an additional four minutes before concluding
sounds are absent.
C. Immediately notify the healthcare provider of a surgical emergency.
D. Administer a prescribed stimulant laxative to stimulate peristalsis.
To confirm absent bowel sounds, the nurse must listen continuously for a full five minutes
across all four quadrants. Documenting normal sounds prematurely is an error, and notifying
the provider or giving laxatives requires complete and accurate assessment data first.
10. A nurse is caring for a client who is prescribed bed rest. Which of the following nursing
interventions is most effective in preventing venous thromboembolism in this client?
A. Applying sequential compression devices and encouraging active or passive leg
exercises.
B. Massaging the lower extremities firmly every shift to break up micro-clots.
C. Restricting fluid intake to decrease total blood volume and venous pressure.
D. Positioning the client in a high Fowler position with knees flexed over pillows.
Sequential compression devices and leg exercises promote venous return and prevent stasis,
which is the primary mechanism of deep vein thrombosis prevention. Massaging legs can
dislodge an existing clot, fluid restriction increases blood viscosity, and knee flexion impedes
venous return.
11. A nurse is preparing to insert an indwelling urinary catheter for an adult female client.
Which action is essential to maintain sterile technique during the procedure?
A. Opening the sterile catheter kit with the outer flaps opening toward the nurse's body.
AND ANSWERS | VERIFIED AND WELL DETAILED ANSWERS
PLUS RATIONALES | GUARANTEED PASS | LATEST EXAM
UPDATE | EXAM PREP | STUDY GUIDE | PRACTICE TEST|
DOWNLOAD INSTANT PDF
1. A nurse is preparing to administer a medication to a hospitalized client. Which of the
following actions best demonstrates the application of the right route principle of
medication administration?
A. Checking the client's identification band against the medication administration record.
B. Verifying the delivery method specified in the prescriber's order matches the route
being used.
C. Confirming that the medication is given within 30 minutes before or after the scheduled time.
D. Documenting the medication administration immediately after the client swallows the pill.
The right route principle requires the nurse to ensure that the method of delivery specified in
the order corresponds to how the medication is administered. Checking the ID band ensures
the right client, timing relates to the right time, and charting relates to proper documentation.
2. An adult client admitted for dehydration is prescribed 0.9% sodium chloride
intravenous infusion at 125 mL/hr. What type of intravenous solution is 0.9% sodium
chloride?
A. Hypotonic solution
B. Hypertonic solution
C. Isotonic solution
D. Colloidal solution
0.9% sodium chloride is an isotonic solution that has an effective osmolality similar to
extracellular fluid, causing no net movement of water across the cell membrane. Hypotonic
solutions pull fluid into cells, hypertonic solutions pull fluid out of cells, and colloids contain
large molecules that do not pass through semipermeable membranes easily.
3. A nurse enters a client's room and finds the client unresponsive, pulseless, and not
breathing. After calling for emergency assistance and initiating cardiopulmonary
resuscitation, what is the priority action regarding automated external defibrillation?
,A. Apply the AED pads immediately upon availability and follow visual and voice
prompts.
B. Continue chest compressions for a full 10 minutes before interrupting for rhythm analysis.
C. Check for a palpable carotid pulse every two minutes while the device analyzes the rhythm.
D. Administer two rescue breaths before attaching the automated external defibrillation unit.
Early defibrillation combined with high-quality CPR significantly increases survival rates in
cardiac arrest. The automated external defibrillator pads should be applied as soon as the
device is available so the rhythm can be analyzed promptly. Interrupting CPR unnecessarily or
delaying pad placement worsens outcomes.
4. A nurse is assessing a client's surgical wound on the abdomen. The nurse notes
separation of the wound edges with protrusion of abdominal organs through the incision.
Which of the following is the immediate nursing priority?
A. Apply dry sterile gauze dressings tightly over the protruding organs to push them back into
place.
B. Cover the protruding viscera with sterile gauze moistened with sterile normal saline
and notify the provider.
C. Position the client flat on their back and encourage deep breathing and coughing exercises.
D. Administer a prescribed oral analgesic immediately to control the client's acute pain.
Evisceration is a medical emergency requiring immediate action to prevent drying and
necrosis of exposed organs. Covering the area with sterile saline-moistened gauze keeps tissue
viable, and notifying the provider initiates surgical intervention. Pushing organs back in is
contraindicated, and coughing increases intra-abdominal pressure.
5. A nurse is evaluating a client's understanding of a low-sodium diet prescribed for
hypertension. Which of the following statements by the client indicates an effective
understanding of the teaching?
A. "I can use as much table salt on my food as long as I do not cook with it."
B. "I should read nutrition labels and choose foods labeled low sodium."
C. "I need to eliminate all fresh fruits and vegetables from my daily meals."
D. "I can freely eat canned soups because they are healthy and convenient."
,Reading nutrition labels and choosing low-sodium items is a key self-management strategy for
controlling hypertension. Table salt is high in sodium, fresh fruits and vegetables are
naturally low in sodium, and canned soups are typically very high in hidden sodium.
6. A nurse is caring for an older adult client who is at high risk for developing pressure
injuries. Which of the following interventions should be included in the client's care plan?
A. Massaging bony prominences vigorously every two hours to stimulate blood flow.
B. Repositioning the client every four hours while maintaining a 90-degree side-lying position.
C. Keeping the head of the bed elevated at 45 degrees continuously to prevent aspiration.
D. Using a draw sheet to lift rather than pull the client when repositioning in bed.
Using a draw sheet minimizes shearing and friction forces that damage fragile skin and
underlying tissues. Massaging bony prominences is contraindicated because it damages deep
capillary beds, repositioning should occur at least every two hours, and a 30-degree lateral
position is preferred over a 90-degree position.
7. A nurse is preparing to administer an intramuscular injection into the ventrogluteal site
of an adult client. Which anatomical landmarks should the nurse use to locate this site
accurately?
A. Greater trochanter, anterior superior iliac spine, and iliac crest.
B. Midpoint of the lateral thigh between the greater trochanter and the lateral femoral condyle.
C. Lower edge of the scapula and the posterior axillary fold.
D. Two inches away from the umbilicus in the lower abdominal quadrant.
The ventrogluteal site is located by placing the palm on the greater trochanter, pointing the
index finger toward the anterior superior iliac spine, and spreading the middle finger along
the iliac crest. This avoids major nerves and blood vessels, making it a safe injection site.
8. An unlicensed assistive personnel is reporting vital signs for a newly admitted client.
Which of the following findings reported by the assistive personnel requires immediate
assessment by the registered nurse?
A. Blood pressure of 118/76 mmHg in a resting adult client.
B. Heart rate of 88 beats per minute with a regular rhythm.
C. Oral temperature of 38.5 degrees Celsius in a client with an infection.
, D. Respiratory rate of 28 breaths per minute with shallow depth.
A respiratory rate of 28 breaths per minute with shallow depth indicates tachypnea and
potential respiratory distress, requiring immediate nurse evaluation. The blood pressure and
heart rate are within normal limits, and a temperature of 38.5 degrees Celsius is expected in
an infectious process but is less immediately life-threatening than acute respiratory
compromise.
9. A nurse is performing a physical assessment on a client and auscultating bowel sounds.
After listening to all four quadrants for a full minute in each quadrant without hearing any
sounds, how should the nurse proceed?
A. Document normal bowel sounds in all four abdominal quadrants.
B. Continue listening in each quadrant for an additional four minutes before concluding
sounds are absent.
C. Immediately notify the healthcare provider of a surgical emergency.
D. Administer a prescribed stimulant laxative to stimulate peristalsis.
To confirm absent bowel sounds, the nurse must listen continuously for a full five minutes
across all four quadrants. Documenting normal sounds prematurely is an error, and notifying
the provider or giving laxatives requires complete and accurate assessment data first.
10. A nurse is caring for a client who is prescribed bed rest. Which of the following nursing
interventions is most effective in preventing venous thromboembolism in this client?
A. Applying sequential compression devices and encouraging active or passive leg
exercises.
B. Massaging the lower extremities firmly every shift to break up micro-clots.
C. Restricting fluid intake to decrease total blood volume and venous pressure.
D. Positioning the client in a high Fowler position with knees flexed over pillows.
Sequential compression devices and leg exercises promote venous return and prevent stasis,
which is the primary mechanism of deep vein thrombosis prevention. Massaging legs can
dislodge an existing clot, fluid restriction increases blood viscosity, and knee flexion impedes
venous return.
11. A nurse is preparing to insert an indwelling urinary catheter for an adult female client.
Which action is essential to maintain sterile technique during the procedure?
A. Opening the sterile catheter kit with the outer flaps opening toward the nurse's body.
