Fundamental Nursing Final Exam 3
Questions and Correct Answers
1. A client has been admitted to a post-surgical unit with a patient-controlled analgesia
(PCA) system. Which statement is true of this medication delivery system?
A) The client can adjust the dose as needed.
B) The dose is delivered only when the nurse administers it.
C) The dose that is delivered when the client activates the machine is preset.
D) The PCA system does not require monitoring.
Correct Answer: C) The dose that is delivered when the client activates the machine is
preset.
Explanation: PCA allows the client to self-administer pain medication within preset safety limits
to prevent overdose. The dose is predetermined by the healthcare provider.
2. Which nursing intervention would be appropriate for preventing urinary tract infection?
A) Encouraging fluid restriction
B) Perineal cleaning after each incontinent episode
C) Delaying catheterization as long as possible
D) Using scented soaps for hygiene
Correct Answer: B) Perineal cleaning after each incontinent episode
Explanation: Proper perineal hygiene reduces bacterial growth and prevents UTIs.
3. You are caring for a 49-year-old client with a sudden increase in blood pressure
(200/110). Using ISBARR, what is the "B" (Background)?
A) The client's name and age
B) Blood pressure of 200/110
C) The client's medication list
D) The nurse's concerns
Correct Answer: B) Blood pressure of 200/110
Explanation: In ISBARR, "B" stands for Background, which includes relevant clinical data
(e.g., vital signs).
4. A client is receiving physical therapy following knee surgery. This is an example of what
type of care?
A) Primary
,B) Secondary
C) Tertiary
D) Restorative
Correct Answer: C) Tertiary
Explanation: Tertiary care involves rehabilitation and recovery after an illness or surgery.
5. The nurse is caring for a patient with a stage III pressure ulcer. Which type of healing
will the nurse focus on?
A) Primary intention
B) Secondary intention
C) Tertiary intention
D) Regeneration
Correct Answer: B) Secondary intention
Explanation: Stage III pressure ulcers heal by secondary intention, where the wound fills with
granulation tissue over time.
6. A client suddenly feels light-headed and dyspneic. What objective data would the nurse
anticipate finding?
A) Hypotension
B) Tachypnea
C) Bradycardia
D) Hypothermia
Correct Answer: B) Tachypnea
Explanation: Dyspnea (shortness of breath) often leads to rapid breathing (tachypnea).
7. What is an appropriate outcome for a client who needs nursing assistance with voiding?
A) The client will remain dry at all times.
B) The client will empty the bladder completely at least every four hours while awake with
nursing assistance.
C) The client will avoid all fluids to prevent incontinence.
D) The client will use a bedpan independently.
Correct Answer: B) The client will empty the bladder completely at least every four hours
while awake with nursing assistance.
Explanation: This is a measurable and realistic goal for a client needing voiding assistance.
8. What nursing organizational statement defines the social context of nursing and the
standards of professional nursing practice?
, A) The Joint Commission Standards
B) The ANA Nursing’s Social Policy Statement
C) The CDC Infection Control Guidelines
D) The HIPAA Privacy Rule
Correct Answer: B) The ANA Nursing’s Social Policy Statement
Explanation: This document outlines nursing’s role in healthcare and professional standards.
9. Which of the following are culturally sensitive considerations? (Select all that apply)
A) Recognizing that culture is an important component of individuality.
B) Recognizing that each person holds various beliefs about pain.
C) Respecting the patient's right to respond to pain in their own manner.
D) Assuming all patients from the same culture have identical needs.
Correct Answers: A, B, C
Explanation: Culturally sensitive care involves respecting individual differences, pain beliefs,
and personal responses.
10. A female resident in a long-term care facility is embarrassed about her incontinence.
What nursing intervention could aid in reducing incontinence episodes?
A) Restricting all fluids
B) Teaching Kegel exercises at regular intervals daily
C) Using adult diapers without discussion
D) Limiting mobility
Correct Answer: B) Teaching Kegel exercises at regular intervals daily
Explanation: Kegel exercises strengthen pelvic floor muscles, reducing incontinence.
11. A bed-bound client complains of lower abdominal pain and pelvic pressure. Bowel
sounds are present in all four quadrants, and the last bowel movement was yesterday.
What should be assessed next?
A) Check for fecal impaction
B) Ask the patient when they last voided
C) Administer a laxative
D) Increase fluid intake
Correct Answer: B) Ask the patient when they last voided
Explanation: Pelvic pressure and lower abdominal pain may indicate urinary retention, which
should be assessed first.
Questions and Correct Answers
1. A client has been admitted to a post-surgical unit with a patient-controlled analgesia
(PCA) system. Which statement is true of this medication delivery system?
A) The client can adjust the dose as needed.
B) The dose is delivered only when the nurse administers it.
C) The dose that is delivered when the client activates the machine is preset.
D) The PCA system does not require monitoring.
Correct Answer: C) The dose that is delivered when the client activates the machine is
preset.
Explanation: PCA allows the client to self-administer pain medication within preset safety limits
to prevent overdose. The dose is predetermined by the healthcare provider.
2. Which nursing intervention would be appropriate for preventing urinary tract infection?
A) Encouraging fluid restriction
B) Perineal cleaning after each incontinent episode
C) Delaying catheterization as long as possible
D) Using scented soaps for hygiene
Correct Answer: B) Perineal cleaning after each incontinent episode
Explanation: Proper perineal hygiene reduces bacterial growth and prevents UTIs.
3. You are caring for a 49-year-old client with a sudden increase in blood pressure
(200/110). Using ISBARR, what is the "B" (Background)?
A) The client's name and age
B) Blood pressure of 200/110
C) The client's medication list
D) The nurse's concerns
Correct Answer: B) Blood pressure of 200/110
Explanation: In ISBARR, "B" stands for Background, which includes relevant clinical data
(e.g., vital signs).
4. A client is receiving physical therapy following knee surgery. This is an example of what
type of care?
A) Primary
,B) Secondary
C) Tertiary
D) Restorative
Correct Answer: C) Tertiary
Explanation: Tertiary care involves rehabilitation and recovery after an illness or surgery.
5. The nurse is caring for a patient with a stage III pressure ulcer. Which type of healing
will the nurse focus on?
A) Primary intention
B) Secondary intention
C) Tertiary intention
D) Regeneration
Correct Answer: B) Secondary intention
Explanation: Stage III pressure ulcers heal by secondary intention, where the wound fills with
granulation tissue over time.
6. A client suddenly feels light-headed and dyspneic. What objective data would the nurse
anticipate finding?
A) Hypotension
B) Tachypnea
C) Bradycardia
D) Hypothermia
Correct Answer: B) Tachypnea
Explanation: Dyspnea (shortness of breath) often leads to rapid breathing (tachypnea).
7. What is an appropriate outcome for a client who needs nursing assistance with voiding?
A) The client will remain dry at all times.
B) The client will empty the bladder completely at least every four hours while awake with
nursing assistance.
C) The client will avoid all fluids to prevent incontinence.
D) The client will use a bedpan independently.
Correct Answer: B) The client will empty the bladder completely at least every four hours
while awake with nursing assistance.
Explanation: This is a measurable and realistic goal for a client needing voiding assistance.
8. What nursing organizational statement defines the social context of nursing and the
standards of professional nursing practice?
, A) The Joint Commission Standards
B) The ANA Nursing’s Social Policy Statement
C) The CDC Infection Control Guidelines
D) The HIPAA Privacy Rule
Correct Answer: B) The ANA Nursing’s Social Policy Statement
Explanation: This document outlines nursing’s role in healthcare and professional standards.
9. Which of the following are culturally sensitive considerations? (Select all that apply)
A) Recognizing that culture is an important component of individuality.
B) Recognizing that each person holds various beliefs about pain.
C) Respecting the patient's right to respond to pain in their own manner.
D) Assuming all patients from the same culture have identical needs.
Correct Answers: A, B, C
Explanation: Culturally sensitive care involves respecting individual differences, pain beliefs,
and personal responses.
10. A female resident in a long-term care facility is embarrassed about her incontinence.
What nursing intervention could aid in reducing incontinence episodes?
A) Restricting all fluids
B) Teaching Kegel exercises at regular intervals daily
C) Using adult diapers without discussion
D) Limiting mobility
Correct Answer: B) Teaching Kegel exercises at regular intervals daily
Explanation: Kegel exercises strengthen pelvic floor muscles, reducing incontinence.
11. A bed-bound client complains of lower abdominal pain and pelvic pressure. Bowel
sounds are present in all four quadrants, and the last bowel movement was yesterday.
What should be assessed next?
A) Check for fecal impaction
B) Ask the patient when they last voided
C) Administer a laxative
D) Increase fluid intake
Correct Answer: B) Ask the patient when they last voided
Explanation: Pelvic pressure and lower abdominal pain may indicate urinary retention, which
should be assessed first.
