RN FUNDAMENTALS OF NURSING
1. A facility has a system for transcribing medication orders to
a Kardex as well as a computerizedmedication
... [Show More] administration
record (MAR). A physician writes the following order for a
client: "Prednisone 5 mg P.O. daily for 3 days." The order is
correctly transcribed on the Kardex. However, the nurse who
transcribes the order onto the MAR neglects to place the
limitation of 3 days on the prescription. On the 4th day after
the order wasinstituted, a nurse administers prednisone 5 mg
P.O. During an audit of the chart, the error isidentified. The
person most responsible for the error is the:
a. nurse who transcribed the order incorrectly on the MAR
b. nurse who administered the erroneous dose.
c. pharmacist who filled the order and provided the
erroneous dose.
d. facility because of its policy on transcription of
medications.
2. To evaluate a client's chief complaint, the nurse performs
deep palpation. The purpose of deep palpation is to assess
which of the following?
a. Skin turgor
b. Hydration
c. Organs
d. Temperature
3. One of the nursing fundamentals questions is about giving
an I.M. injection, the nurse should insert the needle into
the muscle at an angle of:
a. 15 degrees.
b. 30 degrees.
c. 45 degrees.
d. 90 degrees.
4. A client, age 43, has no family history of breast cancer or
other risk factors for this disease. The nurse should instruct
her to have a mammogram how often
a. Once, to establish a baseline
b. Once per year
c. Every 2 years
d. Twice per year
5. When prioritizing a client's plan of care based on Maslow's
hierarchy of needs, the nurse's first priority would be:
a. allowing the family to see a newly admitted client.
b. ambulating the client in the hallway.
c. administering pain medication
d. placing wrist restraints on the client.
6. A 49-year-old client with acute respiratory distress watches
everything the staff does and demands full explanations for
all procedures and medications. Which of the following
actions would best indicate that the client has achieved an
increased level of psychological comfort?
a. Making decreased eye contact
b. Asking to see family members
c. Joking about the present condition
d. Sleeping undisturbed for 3 hours
7. A hospitalized client who has a living will is being fed
through a nasogastric (NG) tube. During a bolus feeding, the
client vomits and begins choking. Which of the following
actions is most appropriate for the nurse to take?
a. Clear the client's airway.
b. Make the client comfortable.
c. Start cardiopulmonary resuscitation.
d. Stop the feeding and remove the NG tube.
8. The nurse is caring for a geriatric client with a pressure
ulcer on the sacrum. When teaching the client about
fundamentalsin nursing on dietary intake, which foodsshould
the nurse plan to emphasize?
a. Legumes and cheese
b. Whole grain products
c. Fruits and vegetables
d. Lean meats and low-fat milk
9. A client with chronic renal failure is admitted with a heart
rate of 122 beats/minute, a respiratory rate of 32
breaths/minute, a blood pressure of 190/110 mm Hg, neck
vein distention, and bibasilar crackles. Which nursing
diagnosis takes highest priority for this client?
a. Fear
b. Urinary retention
c. Excessive fluid volume
d. Self-care deficient: Toileting
10. A client's blood test results are as follows: white blood cell
(WBC) count is 1,000/μl; hemoglobin (Hb) level, 14 g/dl;
hematocrit (HCT), 42%. Which of the following goals would be
most important for this client?
a. Promote fluid balance
b. Prevent infection.
c. Promote rest.
d. Prevent injury.
Answers and Rationale
1) B
- The nurse administering the dose should have compared the
MAR with the Kardex and noted the discrepancy. The
transcribing nurse and pharmacist aren't void of
responsibility; however, the nurse administering the dose is
most responsible. The facility's policy does provide for a
system of checks and balances. Therefore, the facility isn't
responsible for the error.
2) C
- The purpose of deep palpation, in which the nurse indents
the client's skin approximately 1½" (3.8 cm), is to assess
underlying organs and structures, such as the kidneys and
spleen. Skin turgor, hydration, and temperature can be
assessed by using light touch or light palpation
3) D
Nursing Fundamentals Questions Rationale: When giving an
I.M. injection, the nurse inserts the needle into the muscle at
a 90-degree angle, using a quick, dartlike motion. A 15-degree
angle is appropriate when administering an intradermal
injection. A 30-degree angle isn't used for any type of
injection. A 45- or 90-degree angle can be used when giving a
subcutaneous injection
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4) C
- A client age 40 to 49 with no family history of breast
cancer or other risk factors for this disease should have a
mammogram every 2 years. After age 50, the client should
have a mammogram every year
5) C
- In Maslow's hierarchy of needs, pain relief is on the
first layer. Activity (option B) is on the second layer. Safety
(option D) is on the third layer. Love and belonging (option A)
are on the fourth layer.
6) D
- Sleeping undisturbed for a period of time would indicate
that the client feels more relaxed, comfortable, and trusting
and is less anxious. Decreasing eye contact, asking to see
family, and joking may also indicate that the client is more
relaxed. However, these also could be diversions.
7) A
- A living will states that no life-saving measures are to be
used in terminal conditions. There is no indication that the
client is terminally ill. Furthermore, a living will doesn't apply
to nonterminal events such as choking on an enteral feeding
device. The nurse should clear the client's airway. Making the
client comfortable ignores the life-threatening event.
Cardiopulmonary resuscitation isn't indicated, and removing
the NG tube would exacerbate the situation
8) D
- Although the client should eat a balanced diet with foods
from all food groups, the diet should emphasize foods that
supply complete protein, such aslean meats and low-fat milk,
because protein helps build and repair body tissue, which
promotes healing. Fundamentals in nursing teaches that
legumes provide incomplete protein. Cheese contains
complete protein, but also fat, which should be limited to
30% or less of caloric intake. Whole grain products supply
incomplete proteins and carbohydrates. Fruits and vegetables
provide mainly carbohydrates.
9) C
- A client with renal failure can't eliminate sufficient fluid,
increasing the risk of fluid overload and consequent
respiratory and electrolyte problems. This client has signs of
excessive fluid volume and is acutely ill. Fear and a toileting
self-care deficit may be problems, but they take lower priority
because they aren't life-threatening. Urinary retention may
cause renal failure but is a less urgent concern than fluid
imbalance.
10) B
- The client is at risk for infection because the WBC count is
dangerously low. Hb level and HCT are within normal limits;
therefore, fluid balance, rest, and prevention of injury are
inappropriate.
Nursing Board Review: Fundamentals of
Nursing Practice Test Part 1
http://www.rnpedia.com/home/exams/philippine-boardexam-nle/nursing-board-review-fundamentals-of-nursingpractice-test-part-1
1. Jake is complaining of shortness of breath. The
nurse assesses his respiratory rate to be 30
breaths per minute and documents that Jake is
tachypneic. The nurse understands that
tachypnea means:
a. Pulse rate greater than 100 beats per minute
b. Blood pressure of 140/90
c. Respiratory rate greater than 20 breaths per
minute
d. Frequent bowel sounds
2. The nurse listens to Mrs. Sullen‘s lungs and
notes a hissing sound or musical sound. The
nurse documents this as:
a. Wheezes
b. Rhonchi
c. Gurgles
d. Vesicular
3. The nurse in charge measures a patient‘s
temperature at 101 degrees F. What is the
equivalent centigrade temperature?
a. 36.3 degrees C
b. 37.95 degrees C
c. 40.03 degrees C
d. 38.01 degrees C
4. Which approach to problem solving tests any
number of solutions until one is found that works
for that particular problem?
a. Intuition
b. Routine
c. Scientific method
d. Trial and error
5. What is the order of the nursing process?
a. Assessing, diagnosing, implementing,
evaluating, planning
b. Diagnosing, assessing, planning,
implementing, evaluating
c. Assessing, diagnosing, planning, implementing,
evaluating
d. Planning, evaluating, diagnosing, assessing,
implementing
6. During the planning phase of the nursing
process, which of the following is the outcome?
a. Nursing history
b. Nursing notes
c. Nursing care plan
d. Nursing diagnosis
7. What is an example of a subjective data?
a. Heart rate of 68 beats per minute
b. Yellowish sputum
c. Client verbalized, ―I feel pain when urinating.‖
d. Noisy breathing
8. Which expected outcome is correctly written?
a. ―The patient will feel less nauseated in 24
hours.‖
b. ―The patient will eat the right amount of food
daily.‖
c. ―The patient will identify all the high-salt food
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from a prepared list by discharge.‖
d. ―The patient will have enough sleep.‖
9. Which of the following behaviors by Nurse Jane
Robles demonstrates that she understands well
th elements of effecting charting?
a. She writes in the chart using a no. 2 pencil.
b. She noted: appetite is good this afternoon.
c. She signs on the medication sheet after
administering the medication.
d. She signs her charting as follow: J.R
10. What is the disadvantage of computerized
documentation of the nursing process?
a. Accuracy
b. Legibility
c. Concern for privacy
d. Rapid communication
11. The theorist who believes that adaptation and
manipulation of stressors are related to foster
change is:
a. Dorothea Orem
b. Sister Callista Roy
c. Imogene King
d. Virginia Henderson
12. Formulating a nursing diagnosis is a joint
function of:
a. Patient and relatives
b. Nurse and patient
c. Doctor and family
d. Nurse and doctor
13. Mrs. Caperlac has been diagnosed to have
hypertension since 10 years ago. Since then, she
had maintained low sodium, low fat diet, to
control her blood pressure. This practice is viewed
as:
a. Cultural belief
b. Personal belief
c. Health belief
d. Superstitious belief
14. Becky is on NPO since midnight as
preparation for blood test. Adreno-cortical
response is activated. Which of the following is an
expected response?
a. Low blood pressure
b. Warm, dry skin
c. Decreased serum sodium levels
d. Decreased urine output
15. What nursing action is appropriate when
obtaining a sterile urine specimen from an
indwelling catheter to prevent infection?
a. Use sterile gloves when obtaining urine.
b. Open the drainage bag and pour out the urine.
c. Disconnect the catheter from the tubing and
get urine.
d. Aspirate urine from the tubing port using a
sterile syringe.
16. A client is receiving 115 ml/hr of continuous
IVF. The nurse notices that the venipuncture site
is red and swollen. Which of the following
interventions would the nurse perform first?
a. Stop the infusion
b. Call the attending physician
c. Slow that infusion to 20 ml/hr
d. Place a clod towel on the site
17. The nurse enters the room to give a
prescribed medication but the patient is inside
the bathroom. What should the nurse do?
a. Leave the medication at the bedside and leave
the room.
b. After few minutes, return to that patient‘s room
and do not leave until the patient takes the
medication.
c. Instruct the patient to take the medication and
leave it at the bedside.
d. Wait for the patient to return to bed and just
leave the medication at the bedside.
18. Which of the following is inappropriate
nursing action when administering NGT feeding?
a. Place the feeding 20 inches above the pint if
insertion of NGT.
b. Introduce the feeding slowly.
c. Instill 60ml of water into the NGT after feeding.
d. Assist the patient in fowler‘s position.
19. A female patient is being discharged after
thyroidectomy. After providing the medication
teaching. The nurse asks the patient to repeat
the instructions. The nurse is performing which
professional role?
a. Manager
b. Caregiver
c. Patient advocate
d. Educator
20. Which data would be of greatest concern to
the nurse when completing the nursing
assessment of a 68-year-old woman hospitalized
due to Pneumonia?
a. Oriented to date, time and place
b. Clear breath sounds
c. Capillary refill greater than 3 seconds and
buccal cyanosis
d. Hemoglobin of 13 g/dl
21. During a change-of-shift report, it would be
important for the nurse relinquishing
responsibility for care of the patient to
communicate. Which of the following facts to the
nurse assuming responsibility for care of the
patient?
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a. That the patient verbalized, ―My headache is
gone.‖
b. That the patient‘s barium enema performed 3
days ago was negative
c. Patient‘s NGT was removed 2 hours ago
d. Patient‘s family came for a visit this morning.
22. Which statement is the most appropriate goal
for a nursing diagnosis of diarrhea?
a. ―The patient will experience decreased
frequency of bowel elimination.‖
b. ―The patient will take anti-diarrheal
medication.‖
c. ―The patient will give a stool specimen for
laboratory examinations.‖
d. ―The patient will save urine for inspection by
the nurse.
23. Which of the following is the most important
purpose of planning care with this patient?
a. Development of a standardized NCP.
b. Expansion of the current taxonomy of nursing
diagnosis
c. Making of individualized patient care
d. Incorporation of both nursing and medical
diagnoses in patient care
24. Using Maslow‘s hierarchy of basic human
needs, which of the following nursing diagnoses
has the highest priority?
a. Ineffective breathing pattern related to pain, as
evidenced by shortness of breath.
b. Anxiety related to impending surgery, as
evidenced by insomnia.
c. Risk of injury related to autoimmune
dysfunction
d. Impaired verbal communication related to
tracheostomy, as evidenced by inability to speak.
25. When performing an abdominal examination,
the patient should be in a supine position with the
head of the bed at what position?
a. 30 degrees
b. 90 degrees
c. 45 degrees
d. 0 degree
Answer and Rationale : Fundamentals in
Nursing Practice Test Part 1
1. (C) Respiratory rate greater than 20
breaths per minute
A respiratory rate of greater than 20 breaths per
minute is tachypnea. A blood pressure of 140/90
is considered hypertension. Pulse greater than
100 beats per minute is tachycardia. Frequent
bowel sounds refer to hyper-active bowel sounds.
2. (A) Wheezes
Wheezes are indicated by continuous, lengthy,
musical; heard during inspiration or expiration.
Rhonchi are usually coarse breath sounds.
Gurgles are loud gurgling, bubbling sound.
Vesicular breath sounds are low pitch, soft
intensity on expiratio [Show Less]