FUNDAMENTAL OF NURSING TEST EXAM  WITH COMPLETE SOLUTIONS

FUNDAMENTAL OF NURSING TEST EXAM 
WITH COMPLETE SOLUTIONS

Name:
Date:
1. Which statement regarding heart sounds is correct?
a.S1 and s2 sound equally loud over the entire cardiac area.
b.S1 and sound fainter at the apex than at the base.
c.S and 2 sound fainter at the base than at the apex.
d. S1 is loudest at the apex, and S2 is loudest at the base. 
Rationale: The S1 sound — the “lub” sound — is loudest at the apex of the heart. It sounds 
longer, lower, and louder there thanthe S2 — the “dub” sound — is loudest at the base. It
sounds shorter, sharper, higher, and louder there than the S1.
2. A client has a nursing diagnosis of Ineffective airway clearance related to poor coughing.
When planning this
client’s care, the nurse should include which intervention?
a.Increasing fluids to 2,500 ml/day
b. Teaching the client how to deep-breathe and cough 
c.Improving airway clearance
d.Suctioning the client every 2 hours
RATIONALE: Interventions should address the etiology of the client's problem — poor 
coughing. Teaching deep breathing and coughing addresses this etiology. Increasing fluids may
improve the client’s condition, but this intervention doesn't address poor coughing. Improving 
airway clearance is too vague to be considered an appropriate intervention. Suctioning isn't 
indicated unless other measures fail to clear the airway.
3. A nurse is using the computer when a client calls for pain medication. Which action by the
nurse is the best?
a. Staying logged on, leaving the terminal on, and administering the medication immediately
b. telling the client that he’ll have to wait 15 minutes while she completes the entry
c. Asking a coworker to log out for her and administering the medicine right away
d. Logging out of the computer, then administering the pain medication 
RATIONALE: A nurse should meet a client’s request for pain medication as quickly as possible 
after she logs out of the computer.A nurse shouldn't ask a client to wait for as long as 15 
minutes for requested pain medication. If the nurse leaves the terminal without logging out, 
others may view confidential information or use her password. Asking a coworker to log her 
out isn't safe computer practice.
4. Elizabeth Kubler-Ross identified five stages of death and dying. Loss, grief, and intense 
sadness are symptoms ofwhich stage?
a.Denial and isolation
b. Depression 
c.Anger
d.Bargaining
RATIONALE: According to Kübhler-Ross, the five stages of death and dying are denial and 
isolation, anger, bargaining, depression, and acceptance. In denial, the client denies aspects of 
the illness and death. Loss, grief, and intense sadness indicatedepression. In anger, the client 
has hostility that may be directed to family members, God, heath care workers, and others. In
bargaining, the client asks God for more time, and in return promises to do something good.
5. To help minimize calcium loss from a hospitalized client's bones, the nurse should:
a. reposition the client every 2 hours.
b. encourage the client to walk in the hall 
c.provide the client daily products at frequent intervals
d. provide supplemental feedings between meals.
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RATIONALE: Calcium absorption diminishes with reduced physical activity because of 
decreased bone stimulation. Therefore, encouraging the client to increase physical activity 
such as by walking the hall, helps minimize calcium loss. Turning or repositioning the client 
every 2 hours wouldn’t increase activity sufficiently to minimize bone loss, Providing dairy 
products and supplemental feedings wouldn't lessen calcium loss - even if the dairy products 
and feedings contained extra calcium — becausethe additional calcium doesn’t increase bone 
stimulation or osteoblast activity.
6. What is the most appropriate nursing diagnosis for the client with acute pancreatitis?
a.Deficient fluid volume 
b.Excess fluid volume
c.Decreased cardiac output
d. Ineffective gastrointestinal tissue perfusion
RATIONALE: Clients with acute pancreatitis often experience deficient fluid volume, which can 
lead to hypovolemicshock. Vomiting, hemorrhage (in hemorrhagic pancreatitis), and plasma 
leaking into the peritoneal cavity may cause the volume deficit. Hypovolemic shock will cause 
a decrease in cardiac output. Gastrointestinal tissue perfusion will be ineffective if
hypovolemic shock occurs, but this wouldn't be the primary nursing diagnosis.
7. One aspect of implementation related to drug therapy is:
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a. developing a plan of care
b. documenting drugs given. 
c. establishing outcome criteria.
d. setting realistic client goals.
RATIONALE: Athough documentation isn't a step in the nursing process, the nurse is legally 
required to documentactivities related to drug therapy, including the time of administration,
the quantity, and the client's reaction.
Developing a plan of care, establishing outcome criteria, and setting realistic client goals 
are parts of planningrather than implementation.
8. A nurse notes that a client’s I.V. insertion site is red, swollen, and warm to the touch. which
action should the
nurse take first?
a. Discontinue the I.V. infusion. 
b. Apply a warm, moist compress to the I.V. site.
c. Assess the I.V. infusion for patency.
d. Apply an ice pack to the I.V. site.
RATIONALE: Because redness, swelling, and warmth at an I.V. site are signs of infection, the 
nurse should discontinue the infusion immediately and restart at another site. After doing this, 
the nurse should apply warmth tothe original site. Checking infusion patency isn't warranted 
because assessment findings suggest infection and inflammation, not infiltration. Heat, not
cold is the appropriate treatment for inflammation.
9. A nurse is caring for a client with a history of falls. The nurse's first priority when caring 
for a client at risk for fallsis:
a. placing the call light for easy access.
b. keeping the bed in the lowest possible position. 
c.instructing the client not to get out of the bed without assistance
d. keeping the bedpan available so that the client doesn’t have to get out of bed.
RATIONALE: Keeping the bed at the lowest possible position the first priority for clients at risk 
for falling. Keeping the call light easy accessible is important but isn’t a top priority. 
Instructing the client not to get out of bed may noteffectively prevent falls — for example, if 
the client is confused. Even when the client needs assistance to get out ofbed, the nurse
should place the bed in the lowest position. The client may not require a bedpan.
10. A nurse is caring for a client who is exhibiting signs and symptoms characteristic of a
myocardial infarction (MI). which statement describes priorities the nurse should establish
while performing the physical assessment?
a. Assess the client's level of pain and administer prescribed analgesics. 
b. Assess the client’s level of anxiety and provide emotional support.
c. Prepare the client for pulmonary artery catheterization.
d. Ensure that the client's family is kept informed of his status.
RATIONALE: The cardinal symptom of MI is persistent, crushing substernal pain or pressure. 
The nurse should first assess the client's pain and prepare to administer nitroglycerin or 
morphine for pain control. The client must be medically stabilized before pulmonary artery 
catheterization can be used as a diagnostic procedure. Anxiety and a feeling of impending 
doom are characteristic of MI, but the priority is to stabilize the client medically. Although the
client and his family should be kept informed at every step of the recovery process, this action 
isn’t the priority when treating a client with a suspected MI.
11. A nurse is monitoring a client for adverse reactions during barbiturate therapy. What is 
the major disadvantageof barbiturate use?
a. Prolonged half-life
b. Poor absorption
c. Potential for drug dependence 
d. Potential for hepatotoxicity
RATIONALE: Clients can become dependent on barbiturates, especially with prolonged use. 
Because of the rapid distribution of some barbiturates, no correlation exists between 
duration of action and half-life. Barbiturates areabsorbed well and don't cause 
hepatotoxicity, but because barbiturates are metabolized in the liver, existing hepatic
damage does require cautious use of these drugs.
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12. A nurse is caring for a client who required chest tube insertion for a
pneumothorax. To assess for pneumothorax resolution, the nurse anticipates that
the client will require:
a. monitoring of arterial oxygen saturation ,
b. arterial blood gas (ABG) studies.
c. chest auscultation.
d. a chest x-ray. 
Rationale: Chest x-ray confirms diagnosis by revealing air or fluid in the pleural space. SaO2 
values may initially decrease with a pneumothorax but typically return to normal within 24
hours. ABG studies may show hypoxemia,
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possibly with respiratory acidosis and hypercapnia not related to a pneumothorax. Chest
auscultation will determine overall lung status, but it's difficult to determine if the chest has
reexpanded sufficiently.
13. During her morning assessment, a nurse notes that a client has severe dyspnea, his 
respirations are 34 breaths/minute and labored. Oxygen saturation is 79% on 3L of 
oxygen. The nurse remembers that the client'schart includes his living will, When
considering best practice, the nurse should:
a. withhold all potentially life-prolonging treatments in accordance with the client's living will
b. increase the oxygen flow rate to 4L, but avoid initiating other interventions
c. call the client’s family and ask what they think is best.
d. initiate potentially life-prolonging treatment unless the client refuses. 
RATIONALE: A living will doesn't go into effect unless the client is unable to make his own 
decisions. A nurse shouldn't withhold care for an alert client unless he specifically refuses 
care. The nurse should give all appropriate care while also maintaining the client's right to 
refuse treatment. Increasing the oxygen flow rate might be an appropriate response, but isn't 
the best action at this time. The family isn't responsible for determining care at thistime.
14. A client is to receive a glycerin suppository. Which nursing action is appropriate 
when administering asuppository?
a. Removing the suppository from the refrigerator 30 minutes before insertion
b. Applying a lubricant to the suppository 
c. Dissolving the suppository in 3 ml of warm water
d. Instructing the client to bear down during insertion
RATIONALE: A suppository must be lubricated before insertion. Because suppositories melt at 
body temperature, they usually require refrigeration until administration. It isn’t appropriate to
dissolve a suppository in warm water. It should remain in a solid state. Instructing the client 
to bear down would cause the anal sphincter to contract, making insertion difficult.
15. A physician orders regular insulin 10 units LV. along with 50 ml of dextrose 50% for a 
client with acute renalfailure. What problem is this client most likely experiencing?
a. Hypercalcemia
b. Hypernatremia
c. Hyperglycemia
d. Hyperkalemia 
Rationale: Administering regular IV concomitantly with 50 ml of dextrose 50% helps shift
potassium from the extracellular fluid into the cell, which normalizes serum potassium
levels in the client with hyperkalemia. This combination doesn't he reverse the effects of
hypercalcemia, hypenatremia, or hyperglycemia.
16. A nurse identifies a client’s responses to actual or potential health problems during which
step of the nursing
process?
a. Assessment
b. Diagnosis 
c. Planning
d. Evaluation
RATIONALE: The nurse identifies human responses to actual or potential health problems 
during the diagnosis stepof the nursing process, which encompasses the nurse’s ability to 
formulate a nursing diagnosis. During the assessment step, the nurse systematically collects 
data about the client or his family. During the planning step, shedevelops strategies to resolve 
or decrease the client’s problem. During the evaluation step, the nurse determines the
effectiveness of the care plan.
17. In a client with a urine specific gravity of 1.040, a subnormal serum osmolality, and a 
serum sodium level of128 mEq/L, the nurse should question an order for which I.V. fluid?
a. dextrose 5% in half-normal saline solution.
b. normal saline solution.
c. dextrose 5% on water (D5W) 
d. lactated Ringer’s solution.
RATIONALE: An elevated urine specific gravity, a subnormal serum osmolality, and a subnormal 
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serum sodium levelindicate that the client is excreting too many solutes. Because the client is 
in a hypotonic state, the nurse shouldn't give him a hypotonic I.V. solution. D5W, also referred to 
as free water, is hypotonic when given I.V. and can further hemodilute the clent. Dextrose 5% 
half-normal saline solution is hypertonic, normal saline solution is isotonic, and lactated
Ringer's solution is isotonic. For this client, each of these three choices are more acceptable
than D5w.
18. A 10-year-old child with rheumatic fever must have his heart rate measured while he's
awake and while he’s
sleeping. Why are two readings necessary?
a. To obtain a heart rate that isn't affected by medication
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b. To eliminate interference from the jerky movements of chorea
c. To ensure that the child can't consciously raise or lower his heart rate
d. To compensate for activity's effects on the child’s heart rate 
RATIONALE: Tachycardia may be a sign of heart failure. The nurse can detect mild 
tachycardia more easily whenthe child is asleep than when he's awake because activity can 
increase his heart rate. Medications given for rheumatic fever and rheumatic heart disease, 
such as digoxin (Lanoxin), exert their influence both day and night.Chorea, a symptom of 
rheumatic fever, is the loss of voluntary muscle control. It doesn't affect pulse because the
child would be sitting quietly while the nurse measured his heart rate and wouldn't be 
involved in purposeful movement. A 10-year-old child probably doesn't know how to
consciously raise or lower his heart rate.
19. A nurse preparing to administer a sustained-release capsule to a client. Which is 
an appropriate nursingintervention?
a. Administering the capsule whole with a glass of water 
b. Crushing the capsule and mixing the medication with applesauce
c. Opening the capsule, shaking the contents into water, and administering it to the client
d. Having the client chew the capsule before swallowing
20. After receiving an I.M. injection, a client complains of burning pain at the injection site.
which nursing action would be most appropriate at this time?
a. Applying a cold compress to decrease swelling
b. Applying a warm compress to dilate the blood vessels 
c. Massaging the area to promote absorption of the drug
d. Instructing the client to tighten his gluteal muscles to promote better absorption of the drug
RATIONAI.E: Applying heat increases blood flow to the area, which, in turn, increases 
medication absorption. Colddecreases pain but allows the medication to remain in the 
muscle longer. Massage is a good intervention, but applying a warm compress is better. 
Tightening the gluteal muscles may cause additional burning if the drug irritates muscular
tissues.