FUNDAMENTALS OF NURSING FINAL EXAM – QUESTIONS AND
ANSWERS |
VERIFIED AND WELL DETAILED ANSWERS PLUS RATIONALES |
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1. A nurse is assessing a newly admitted adult client who reports generalized fatigue, dry
skin, and a preference for warm clothing in a moderate environment. Which foundational
nursing concept should guide the nurse's initial physiological assessment?
A. Thermoregulation and metabolic rate
B. Fluid volume deficit and electrolyte balance
C. Peripheral perfusion and tissue oxygenation
D. Neurological integration and cognitive processing
ANSWER: A. Thermoregulation and metabolic rate
Clients exhibiting cold intolerance, dry skin, and fatigue frequently experience alterations in
basal metabolic rate and thermoregulation, classic indicators commonly associated with
hypothyroidism, requiring focused endocrine and integumentary evaluation.
2. A nurse is preparing to administer a sublingual medication to an older adult client.
Which physiological characteristic of aging must the nurse consider when evaluating the
absorption route?
A. Decreased sublingual mucosal vascularity and diminished salivary flow can impair rapid drug
dissolution and absorption.
B. Increased gastric pH accelerates the passive diffusion of weak organic acids across the
mucosal membrane.
C. Accelerated hepatic first-pass metabolism instantly neutralizes sublingual agents before
systemic circulation.
D. Enhanced oral mucosa permeability increases peak plasma concentrations twofold within
minutes.
,ANSWER: A. Decreased sublingual mucosal vascularity and diminished salivary flow can
impair rapid drug dissolution and absorption.
Aging is accompanied by mucosal thinning, reduced capillary blood flow, and xerostomia (dry
mouth), which directly hinder the dissolution and transmucosal absorption of sublingual
medications, altering expected onset times.
3. A nurse enters a client's room and finds the client gasping, clutching their chest, and
reporting sudden, severe substernal chest pain radiating to the left arm. What is the nurse's
immediate priority action according to the nursing process?
A. Stop all current activity, place the client in a comfortable semi-Fowler's position, and assess
vital signs while staying with the client.
B. Leave the room immediately to retrieve the crash cart and notify the primary healthcare
provider.
C. Instruct the client to perform controlled deep breathing exercises and administer a prescribed
oral antacid.
D. Document the exact time of symptom onset in the electronic health record before initiating
interventions.
ANSWER: A. Stop all current activity, place the client in a comfortable semi-Fowler's
position, and assess vital signs while staying with the client.
In emergency scenarios involving suspected acute coronary syndrome, the priority assessment
and intervention are to reduce myocardial oxygen demand by halting activity, positioning for
optimal lung expansion, assessing vital signs, and ensuring emergency support is alerted
without abandoning the client.
4. A nurse is caring for a client with a stage 2 pressure injury on the sacrum. Which
description best characterizes this level of tissue damage?
A. Partial-thickness skin loss involving the epidermis and/or dermis, presenting as a shallow
open ulcer with a red-pink wound bed.
B. Full-thickness tissue loss with visible subcutaneous fat, bone, tendon, or muscle exposed.
C. Intact skin with localized area of persistent non-blanching deep red to maroon discoloration.
D. Full-thickness skin loss where the base of the ulcer is obscured by slough or eschar in the
wound bed.
,ANSWER: A. Partial-thickness skin loss involving the epidermis and/or dermis, presenting
as a shallow open ulcer with a red-pink wound bed.
According to the National Pressure Injury Advisory Panel (NPIAP), a stage 2 pressure injury
involves partial-thickness loss of dermis presenting as a shallow open ulcer with a pink-red
wound bed, without slough or exposed deep structures.
5. A nurse is calculating the intake and output for a client over an 8-hour shift. The client
consumed 240 mL of water, 120 mL of broth, 150 mL of gelatin, and received 1,000 mL of
normal saline intravenously. What total fluid intake should the nurse record in milliliters?
A. 1510
B. 1290
C. 510
D. 1610
ANSWER: A. 1510
To calculate total fluid intake, sum all oral liquids (240 mL water + 120 mL broth + 150 mL
gelatin = 510 mL) and add all parenteral infusions (1,000 mL IV normal saline), resulting in a
total intake of 1,510 mL.
6. A nurse is performing an abdominal assessment on a client reporting lower quadrant
discomfort. What is the correct sequence of assessment techniques the nurse must follow?
A. Inspection, auscultation, percussion, palpation
B. Palpation, percussion, auscultation, inspection
C. Auscultation, inspection, palpation, percussion
D. Inspection, palpation, auscultation, percussion
ANSWER: A. Inspection, auscultation, percussion, palpation
Abdominal assessment requires auscultation to precede percussion and palpation because
vigorous tactile manipulation can alter bowel motility and distort true bowel sounds, rendering
auscultation unreliable.
7. A nurse is caring for an adult client who exhibits signs of cultural assimilation after
immigrating to a new country. Which behavioral observation supports this sociological
concept?
, A. The client adopts the language, values, and dietary habits of the dominant host culture
while gradually losing aspects of their native heritage.
B. The client strictly maintains traditional healthcare practices exclusively within their
immediate ethnic community.
C. The client experiences profound psychological distress and disorientation when
navigating public institutions.
D. The client rejects all modern medical interventions in favor of indigenous spiritual
healing rituals.
ANSWER: A. The client adopts the language, values, and dietary habits of the dominant
host culture while gradually losing aspects of their native heritage.
Cultural assimilation describes the process by which an individual or group from a minority
culture progressively sheds their original cultural markers and adopts the behavioral patterns,
language, and norms of the dominant culture.
8. A nurse is planning care for a client prescribed strict bed rest. Which nursing
intervention is most effective in preventing deep vein thrombosis (DVT)?
A. Applying sequential compression devices (SCDs) and encouraging active ankle and foot
exercises every hour while awake.
B. Massaging the lower extremities vigorously every two hours to stimulate deep muscular
blood flow.
C. Keeping the client's knees tightly crossed in bed to prevent venous pooling in the distal
calves.
D. Restricting oral fluid intake to minimize plasma volume and venous pressure.
ANSWER: A. Applying sequential compression devices (SCDs) and encouraging active
ankle and foot exercises every hour while awake.
Mechanical prophylaxis via SCDs combined with active range-of-motion exercises promotes
venous return through the skeletal muscle pump, significantly reducing venous stasis and the
risk of thrombus formation.
9. A nurse is evaluating a client's understanding of a low-sodium therapeutic diet for
hypertension. Which food selection made by the client indicates effective learning?
A. Fresh steamed broccoli with skinless baked chicken breast
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 assessing a newly admitted adult client who reports generalized fatigue, dry
skin, and a preference for warm clothing in a moderate environment. Which foundational
nursing concept should guide the nurse's initial physiological assessment?
A. Thermoregulation and metabolic rate
B. Fluid volume deficit and electrolyte balance
C. Peripheral perfusion and tissue oxygenation
D. Neurological integration and cognitive processing
ANSWER: A. Thermoregulation and metabolic rate
Clients exhibiting cold intolerance, dry skin, and fatigue frequently experience alterations in
basal metabolic rate and thermoregulation, classic indicators commonly associated with
hypothyroidism, requiring focused endocrine and integumentary evaluation.
2. A nurse is preparing to administer a sublingual medication to an older adult client.
Which physiological characteristic of aging must the nurse consider when evaluating the
absorption route?
A. Decreased sublingual mucosal vascularity and diminished salivary flow can impair rapid drug
dissolution and absorption.
B. Increased gastric pH accelerates the passive diffusion of weak organic acids across the
mucosal membrane.
C. Accelerated hepatic first-pass metabolism instantly neutralizes sublingual agents before
systemic circulation.
D. Enhanced oral mucosa permeability increases peak plasma concentrations twofold within
minutes.
,ANSWER: A. Decreased sublingual mucosal vascularity and diminished salivary flow can
impair rapid drug dissolution and absorption.
Aging is accompanied by mucosal thinning, reduced capillary blood flow, and xerostomia (dry
mouth), which directly hinder the dissolution and transmucosal absorption of sublingual
medications, altering expected onset times.
3. A nurse enters a client's room and finds the client gasping, clutching their chest, and
reporting sudden, severe substernal chest pain radiating to the left arm. What is the nurse's
immediate priority action according to the nursing process?
A. Stop all current activity, place the client in a comfortable semi-Fowler's position, and assess
vital signs while staying with the client.
B. Leave the room immediately to retrieve the crash cart and notify the primary healthcare
provider.
C. Instruct the client to perform controlled deep breathing exercises and administer a prescribed
oral antacid.
D. Document the exact time of symptom onset in the electronic health record before initiating
interventions.
ANSWER: A. Stop all current activity, place the client in a comfortable semi-Fowler's
position, and assess vital signs while staying with the client.
In emergency scenarios involving suspected acute coronary syndrome, the priority assessment
and intervention are to reduce myocardial oxygen demand by halting activity, positioning for
optimal lung expansion, assessing vital signs, and ensuring emergency support is alerted
without abandoning the client.
4. A nurse is caring for a client with a stage 2 pressure injury on the sacrum. Which
description best characterizes this level of tissue damage?
A. Partial-thickness skin loss involving the epidermis and/or dermis, presenting as a shallow
open ulcer with a red-pink wound bed.
B. Full-thickness tissue loss with visible subcutaneous fat, bone, tendon, or muscle exposed.
C. Intact skin with localized area of persistent non-blanching deep red to maroon discoloration.
D. Full-thickness skin loss where the base of the ulcer is obscured by slough or eschar in the
wound bed.
,ANSWER: A. Partial-thickness skin loss involving the epidermis and/or dermis, presenting
as a shallow open ulcer with a red-pink wound bed.
According to the National Pressure Injury Advisory Panel (NPIAP), a stage 2 pressure injury
involves partial-thickness loss of dermis presenting as a shallow open ulcer with a pink-red
wound bed, without slough or exposed deep structures.
5. A nurse is calculating the intake and output for a client over an 8-hour shift. The client
consumed 240 mL of water, 120 mL of broth, 150 mL of gelatin, and received 1,000 mL of
normal saline intravenously. What total fluid intake should the nurse record in milliliters?
A. 1510
B. 1290
C. 510
D. 1610
ANSWER: A. 1510
To calculate total fluid intake, sum all oral liquids (240 mL water + 120 mL broth + 150 mL
gelatin = 510 mL) and add all parenteral infusions (1,000 mL IV normal saline), resulting in a
total intake of 1,510 mL.
6. A nurse is performing an abdominal assessment on a client reporting lower quadrant
discomfort. What is the correct sequence of assessment techniques the nurse must follow?
A. Inspection, auscultation, percussion, palpation
B. Palpation, percussion, auscultation, inspection
C. Auscultation, inspection, palpation, percussion
D. Inspection, palpation, auscultation, percussion
ANSWER: A. Inspection, auscultation, percussion, palpation
Abdominal assessment requires auscultation to precede percussion and palpation because
vigorous tactile manipulation can alter bowel motility and distort true bowel sounds, rendering
auscultation unreliable.
7. A nurse is caring for an adult client who exhibits signs of cultural assimilation after
immigrating to a new country. Which behavioral observation supports this sociological
concept?
, A. The client adopts the language, values, and dietary habits of the dominant host culture
while gradually losing aspects of their native heritage.
B. The client strictly maintains traditional healthcare practices exclusively within their
immediate ethnic community.
C. The client experiences profound psychological distress and disorientation when
navigating public institutions.
D. The client rejects all modern medical interventions in favor of indigenous spiritual
healing rituals.
ANSWER: A. The client adopts the language, values, and dietary habits of the dominant
host culture while gradually losing aspects of their native heritage.
Cultural assimilation describes the process by which an individual or group from a minority
culture progressively sheds their original cultural markers and adopts the behavioral patterns,
language, and norms of the dominant culture.
8. A nurse is planning care for a client prescribed strict bed rest. Which nursing
intervention is most effective in preventing deep vein thrombosis (DVT)?
A. Applying sequential compression devices (SCDs) and encouraging active ankle and foot
exercises every hour while awake.
B. Massaging the lower extremities vigorously every two hours to stimulate deep muscular
blood flow.
C. Keeping the client's knees tightly crossed in bed to prevent venous pooling in the distal
calves.
D. Restricting oral fluid intake to minimize plasma volume and venous pressure.
ANSWER: A. Applying sequential compression devices (SCDs) and encouraging active
ankle and foot exercises every hour while awake.
Mechanical prophylaxis via SCDs combined with active range-of-motion exercises promotes
venous return through the skeletal muscle pump, significantly reducing venous stasis and the
risk of thrombus formation.
9. A nurse is evaluating a client's understanding of a low-sodium therapeutic diet for
hypertension. Which food selection made by the client indicates effective learning?
A. Fresh steamed broccoli with skinless baked chicken breast
