Foundations of Nursing Mock Exam
Course Introduction
Foundations of Nursing introduces students to the fundamental concepts, skills, and professional standards that underpin the nursing discipline. The course explores the history and evolution of nursing, ethical and legal considerations, patient-centered care, and the roles and responsibilities of nurses within diverse healthcare environments. Emphasis is placed on communication, critical thinking, safety, and holistic approaches to patient assessment and basic care. Through a combination of theoretical learning and practical experience, students develop a solid foundation for providing effective, compassionate, and evidence-based nursing care across the lifespan.
Recommended Textbook
Fundamentals of Nursing Active Learning for Collaborative Practice 1st Edition by Yoost
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42 Chapters
1050 Verified Questions
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Page 2
Chapter 1: Nursing, Theory, and Professional Practice
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25 Verified Questions
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Sample Questions
Q1) A group of students are discussing the impact of non-nursing theories in clinical practice. The students would be correct if they chose which theory to prioritize patient care?
A) Erikson's Psychosocial Theory
B) Paul's Critical Thinking Theory
C) Maslow's Hierarchy of Needs
D) Rosenstock's Health Belief Model
Answer: C
Q2) Which nurse established the American Red Cross during the Civil War?
A) Dorothea Dix
B) Linda Richards
C) Lena Higbee
D) Clara Barton
Answer: D
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3
Chapter 2: Values, Beliefs, and Caring
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Sample Questions
Q1) The nurse is caring for a patient who is under arrest for murder. She is attempting to perform her duties while, at the same time, feeling a sense of repugnance toward the patient. The nurse is undergoing:
A) value clarification
B) value conflict
C) first-order beliefs
D) higher-order beliefs
Answer: B
Q2) Enduring ideas about what a person considers is desirable or has worth in life is known as a:
A) value.
B) first-order belief
C) higher order belief
D) stereotype
Answer: A
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4
Chapter 3: Communication
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Sample Questions
Q1) The nurse is caring for a patient with chronic lung disease. The patient demands a cigarette after eating breakfast. The nurse responds, "If that was me, I wouldn't be asking for a cigarette. That is what has made you so sick in the first place." This nontherapeutic communication response is an example of:
A) changing the subject.
B) giving advice.
C) a stereotypical response.
D) defensiveness.
Answer: B
Q2) The nursing student has been assigned to help feed patients at lunch time. Which of these nursing interventions would be most effective when assisting a blind patient to eat a meal?
A) Speak loudly to ensure that the patient understands.
B) Describe the food arrangement using the numbers on a clock.
C) Tell the patient what is on the plate, assuming he has lost the sense of smell.
D) Encourage the patient to eat faster so that the task will be done.
Answer: B
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Chapter 4: Critical Thinking in Nursing
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Sample Questions
Q1) A patient is admitted to a skilled nursing facility with a closed head injury. The nurse believes that the patient has been pocketing food in his cheeks during the noon meal although she has not found any food pocketed. The nurse refers the patient to the speech therapist for a swallowing evaluation. The nurse is using which critical thinking component in making this decision?
A) Inference
B) Deductive reasoning
C) Intuition
D) Inductive reasoning
Q2) A patient arrives at the urgent care clinic and complains of vague pains in the legs. The nurse asks the patient to describe this pain. This type of question meets the intellectual standard of precision. As with any skill, critical thinking questions:
A) are used to avoid repetition in providing care.
B) can be enhanced through practice.
C) should be based in thought and not spontaneity.
D) become dull when used routinely.
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6
Chapter 5: Introduction to the Nursing Process
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Sample Questions
Q1) The community health nurse is applying the nursing process to the care of patients with coronary artery disease. The nurse determines that most of the patients eat high-fat meals from the local fast-food restaurant and plans a nutrition workshop. The nurse is applying the nursing process characteristic of:
A) organization.
B) dynamics.
C) adaptability.
D) collaboration.
Q2) The charge nurse is discussing a patient's care plan during a team meeting. The team determines that the patient has not met the goal of "ambulating to the nurse's station twice a day" and decides to revise the plan. Which of the following characteristics of the nursing process most represents this decision?
A) Organization
B) Dynamics
C) Adaptability
D) Outcome orientation
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Chapter 6: Assessment
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Sample Questions
Q1) The unlicensed nursing assistive person (UAP) reports to the nurse that a patient is crying during a comedy show on television. The nurse's best response should be:
A) "Maybe the patient doesn't think the show is funny."
B) "Don't worry about it. Her daughter says this is normal."
C) "I will go visit her right away and see what is going on."
D) "Just document what you observe in your notes."
Q2) The patient interview consists of three phases: orientation (introductory), working, and termination. Each phase contributes to the development of trust and engagement between the nurse and the patient. During the orientation phase of the interview, the nurse should:
A) obtain demographic data using open-ended questions.
B) establish the name by which the patient prefers to be addressed.
C) gather general information using closed-ended questions.
D) stand by the bedside to ask the needed questions.
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8
Chapter 7: Nursing Diagnosis
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Sample Questions
Q1) A nurse completes a care plan for an assigned patient diagnosed with an inflammation of the pericardium. Which diagnosis written on the plan indicates a need for further instruction on using the nursing process?
A) Pericarditis
B) Acute pain
C) Risk for decreased cardiac output
D) Activity intolerance
Q2) When creating a nursing diagnosis, the related factor:
A) should be based on the medical diagnosis.
B) in unrelated to the pathophysiology with which the patient is dealing.
C) is the underlying etiology of the patient's situation.
D) does not reflect the nurse's understanding of pathophysiology.
Q3) The nurse has requested an order to place a patient on suicide watch. Which data noted in the health assessment led the nurse to this conclusion? (Select all that apply.)
A) Threats of killing oneself
B) Chronic pain
C) History of prior suicide attempt
D) Loneliness
E) Stable heart rhythm
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Page 9
Chapter 8: Planning
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Sample Questions
Q1) The nurse is caring for a patient who has had abdominal surgery but has developed a slight temperature. A patient-centered goal would be:
A) the patient's temperature will return to normal within 24 hours.
B) the nurse will medicate the patient for surgical pain every 4 hours.
C) skin integrity will be maintained until the patient is ambulatory.
D) the patient will ambulate 10 feet by post-op day 2.
Q2) The nurse is accurate when stating that adequate discharge planning:
A) "May decrease the incidence of patients required to return to the hospital."
B) "Increases complications and readmissions in most cases."
C) "Adapts to the situation as the patient's conditions changes."
D) "Should begin as soon as the patient is discharged home."
Q3) Goals are broad statements of purpose that describe the aim of nursing care. As such, goals:
A) are considered short term if achieved within a month of identification.
B) always have established time parameters, such as "long-term" or "short-term."
C) are mutually acceptable to the nurse, patient, and family.
D) can be vague to facilitate evaluation of achievement.
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Page 10
Chapter 9: Implementation and Evaluation
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Sample Questions
Q1) The nurse is learning to identify readiness to learn in patients. Which one of the following patients would the nurse identify correctly as ready to learn?
A) The patient requesting pain medication for treatment of severe discomfort
B) The patient with nausea and vomiting
C) The patient who learned 30 minutes ago that she has cancer of the pancreas
D) The patient who was recently diagnosed with diabetes mellitus and is scheduled to be discharged in 2 days
Q2) In implementing research-based interventions, the nurse realizes that:
A) implementation of evidence-based care is unique to the nursing profession.
B) evidence-based practice is based entirely in nursing research.
C) evidence-based care is focused on practices and not outcomes.
D) nurses must read recent literature and remain current in practice
Q3) The nursing process is an attempt to meet patient needs. As such, it:
A) is linear in nature.
B) is dynamic and cyclic.
C) requires care plans to be re-evaluated occasionally.
D) does not allow care plans to be modified.
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Chapter 10: Documentation, Electronic Health Records, and Reporting
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Sample Questions
Q1) Nurses must be aware of the danger of using abbreviations that may be misunderstood and compromise patient safety. The Joint Commission has compiled a list of do-not-use abbreviations, acronyms, and symbols to avoid the possibility of errors that may be life threatening. Of the following, which are acceptable? (Select all that apply.)
A) Daily
B) QD
C) qod
D)0.X mg
E) X mg
Q2) The nurse is charting using paper nursing notes. The nurse is aware that: A) attorneys are not allowed access to medical records during litigation. B) when mistakes are made in documentation, the nurse should scribble out the entry. C) only one nurse should document on a sheet so that it can be removed in case of error.
D) the medical record is the most reliable source of information in any legal action.
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12
Chapter 11: Ethical and Legal Considerations
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Sample Questions
Q1) Which statements are correct regarding informed consent and someone who requires an interpreter? (Select all that apply.)
A) A professional interpreter is needed.
B) A family member may interpret when convenient.
C) Detailed medical information remains a priority.
D) Professional interpreters are not effective in providing medical information.
E) If necessary, family members can make decisions regarding informed consent.
Q2) State legislatures give authority to administrative bodies, such as state boards of nursing, to:
A) create statutory laws.
B) establish regulatory laws.
C) try case law cases.
D) create laws based on social mores.
Q3) "First, do no harm" defines what ethical principle?
A) Beneficence
B) Justice
C) Fidelity
D) Nonmaleficence
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13
Chapter 12: Leadership and Management
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Sample Questions
Q1) The nurse manager of the emergency room believes that efficiency is the expected standard for her department. She also believes that efficiency lies in following established rules, policies, and guidelines. The only way to change procedures is to changes rules, policies, and guidelines. In order to run the emergency room with this philosophy, the nurse manager must take on the role of:
A) laissez-faire leader.
B) democratic leader.
C) bureaucratic leader.
D) autocratic leader.
Q2) The nurse has a question regarding scope of practice and delegation. Where should the nurse seek clarification? (Select all that apply.)
A) The state's Nurse Practice Act
B) Theory X management
C) Nurse's Code of Ethics
D) The NCSBN website
E) NCSBN journal articles
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14
Chapter 13: Evidence-Based Practice and Nursing Research
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Sample Questions
Q1) The nurse is reviewing a research study that includes data in the form of numbers. This study is likely what type of study?
A) Qualitative
B) Experimental
C) Quasi-experimental
D) Quantitative
Q2) The nurse researcher audiotaped interviews with subjects and would like to play these tapes during dissemination. What steps might this require?
A) Inform the participants that they cannot hear the tapes beforehand.
B) None, if the tape is of a group, since there is no expectation of anonymity.
C) None, since the tape is a direct "quote" and voice recognition is not controllable.
D) A release will need to be obtained from the subjects.
Q3) A human subject is defined as a living individual about whom an investigator conducting research obtains:
A) data without direct or indirect interaction or intervention.
B) information that is not expected to be made public.
C) no diagnostic information and does not manipulate the subjects environment.
D) information without any communication/contact during the research.
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15
Chapter 14: Health Literacy and Patient Education
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Sample Questions
Q1) The nurse is preparing to discharge a patient home. In providing instruction about the patients medications, the nurse should state:
A) "Before taking Metoprolol, you need to take your BP and rate."
B) "MS should be taken only when needed for pain."
C) "Take 1 baby aspirin by mouth every morning."
D) "Take your water pill bid and you should be fine."
Q2) The nurse is admitting a patient who has cystic fibrosis. During the admission interview, it is apparent that the patient is well versed in most aspects of his illness. When asked about where he learned so much, the patient responds, "I learned most of it myself. I looked things up on the Internet and read books. You have to know what's wrong with you to be sure that you're being treated right." This is an example of:
A) formal education.
B) psychomotor learning.
C) informal education.
D) affective learning.
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Chapter 15: Nursing Informatics
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22 Verified Questions
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Sample Questions
Q1) The nurse can see data relationships, can make judgments based on trends and patterns in the data, is skilled in information management and the use of computer technology, and is able to suggest areas for IT system improvement. The nurse's level of informatics competency can be described as:
A) beginner.
B) experienced.
C) specialist.
D) innovator.
Q2) The Technology Informatics Guiding Education Reform (TIGER) initiative identified a set of skills needed by all nurses practicing in the 21st century. The TIGER Vision Pillars include: (Select all that apply.)
A) management and leadership.
B) certification by HIMSS.
C) communication and Collaboration.
D) informatics design.
E) IT policy and culture.
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Chapter 16: Health and Wellness
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Sample Questions
Q1) The nurse is discussing immunizations for infants and children with new parents. The nurse should focus on:
A) providing scientific evidence to parents.
B) stressing that non-immunization is a crime.
C) acknowledging that immunizations are not needed.
D) informing the parents that they have no choice.
Q2) Self-concept refers to the way in which individuals perceive unchanging aspects of themselves, such as social character, cognitive abilities, physical appearance, and body image. As such, self-concept:
A) if negative, will allow the patient to compensate for weaknesses.
B) if positive, will cause the patient to see challenges as devastating.
C) is a concept that is derived from the patient internally.
D) depends on relationships with family and friends.
Q3) The nurse is developing a plan of care for a patient with a hip fracture. In order to prioritize the patient's care, the nurse should use:
A) the Health Belief Model.
B) Pender's Health Promotion Model.
C) Maslow's hierarchy of needs.
D) the Holistic Health Model.
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Page 18
Chapter 17: Human Development: Conception through Adolescence
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Sample Questions
Q1) A school-aged child is scheduled for a minor procedure and is very nervous. What response by the nurse is best?
A) Reassure the child the procedure is too minor to worry about.
B) Read the child a pamphlet about what to expect during the procedure.
C) Tell the child you will have the provider "put her to sleep" during the procedure.
D) Explain the procedure and what to expect in simple terms.
Q2) A high-school nurse is planning an educational presentation for juniors. What activities are most appropriate for the nurse plan to include? (Select all that apply.)
A) Video showing the aftermath of a drunk driving car crash
B) Confidential depression and suicide risk assessment
C) Same-age speaker sharing her story about the impact of HIV disease
D) Charts and graphs showing the physical changes of puberty
E) Bicycle helmet fitting station to see if child has outgrown the helmet
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Chapter 18: Human Development Young Adult to Older Adult
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Sample Questions
Q1) A young nursing student is assessing an older patient. The nurse questions whether or not to take a sexual history. What response by the faculty is best?
A) Since procreation is not an issue, you do not need to discuss this.
B) Only discuss this topic if you are comfortable in doing so.
C) Ask the patient if he or she wants to talk about sexuality.
D) Sexuality is a basic human need and needs to be assessed.
Q2) The nurse working in a family practice clinic has very limited time to assess patients for health concerns. When working with middle-aged patients, which problems does the nurse assess for as the priorities? (Select all that apply.)
A) Heart disease
B) Cancer
C) Sexually transmitted diseases
D) Stroke
E) Functional abilities
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Chapter 19: Vital Signs
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Q1) A nurse is told in the hand-off report that a patient is afebrile. What assessment finding correlates with this statement?
A) Blood pressure 152/98 mm Hg
B) Temperature 98.4° F (36.8° C)
C) Pulse 82 beats/min
D) Respirations 16 breaths/min
Q2) The nurse receives a handoff report on four patients. Which patient should the nurse assess first?
A) Pain rating 4/10 after pain medication
B) Blood pressure 102/62 mm Hg
C) Pulse 42 beats/min
D) Respiratory rate 18 breaths/min
Q3) A nurse is going to take a patient's oral temperature. The patient has been drinking coffee. What action by the nurse is best?
A) Have the patient drink room temperature water.
B) Return in 30 minutes to take the patient's temperature.
C) Take the patient's temperature rectally instead.
D) Document that temperature is unable to be obtained.
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Chapter 20: Health History and Physical Assessment
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Q1) The nurse examining a patient's skin correlates which conditions with which underlying pathology? (Select all that apply.)
A) Albinism: Full-thickness burns
B) Peripheral cyanosis: poor circulation
C) Purpura: clotting disorders
D) Jaundice: liver disease
E) Vitiligo: skin infestation
Q2) A nurse is assisting a patient who is having an examination of the female genitalia. What action by the nurse is best?
A) Get the provider; assist patient into lithotomy position.
B) Assist the patient into lithotomy position; get the provider.
C) Get the provider; assist patient into Sims position.
D) Assist the patient into Sims position; get the provider.
Q3) The student nurse asks if it matters whether a healthy eye or a diseased eye should be examined first. What response by the faculty is best?
A) Diseased eye first because it is the priority
B) Healthy eye first to prevent spread of disease
C) It does not matter as long as both eyes are examined
D) Start with the eye the patient wants you to start with
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Page 22
Chapter 21: Ethnicity and Cultural Assessment
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Q1) The student studying culture learns that which are characteristics of all cultures?
(Select all that apply.)
A) Integrated systems
B) Shared
C) Learned
D) Symbolic
E) Inherited
Q2) The nurse is caring for a patient from a culture that is unfamiliar. The patient nodded her head "yes" when asked if she will take her prescriptions as ordered, but the nurse discovers the patient does not take the medication, but uses herbs for treatment. What action by the nurse is best?
A) Warn the patient of the consequences on non-compliance.
B) Tell the patient how the medication will help the condition.
C) Ask the patient why herbal preparations are preferred.
D) Ask the patient to explain the meaning of the herbal products.
Q3) What does the nursing student learn about race?
A) It is biologically based.
B) It is a social construct.
C) It is chosen by the person.
D) It helps establish superiority.
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Chapter 22: Spiritual Health
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Sample Questions
Q1) A nurse is concerned about not consistently meeting the spiritual needs of patients. What action by the nurse is best?
A) Care for own spiritual needs
B) Begin a meditation practice
C) Consult the chaplain
D) Read books on the subject
Q2) A patient in the hospital is an adherent Muslim. Which of the five pillars of Islam can the nurse assist the patient in meeting?
A) Praying five times a day
B) Having privacy
C) Personal cleanliness
D) Giving alms
E) Maintaining modesty
Q3) A patient died suddenly in the emergency department. Which action by the nurse best provides the family connection with others?
A) Offering the family written information on grief support groups.
B) Asking the family if there is someone the nurse can call for them.
C) Having the hospital social worker or chaplain sit with the family.
D) Offering to stay with the family during this difficult time.
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Page 24
Chapter 23: Public Health, Community Base, and Home
Health Care
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Q1) A nurse is completing an OASIS assessment on a patient. What data would be most important for the nurse to assess?
A) Presence of grocery stores nearby
B) Safety concerns within the home
C) Number and kind of pets
D) Proximity to a health care facility
Q2) A nurse is assessing social determinants of health. Which does the nurse include in the assessment? (Select all that apply.)
A) Vaccination compliance
B) Family structure
C) Communication patterns
D) Roles for women
E) Education
Q3) A community was devastated by a tornado several months ago. What nursing diagnosis would be most appropriate for the nurse to consider?
A) Social isolation
B) Deficient community resources
C) Ineffective community coping
D) Deficient community health
25
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Chapter 24: Human Sexuality
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Sample Questions
Q1) The student learns that which are cycles in the female sexual response cycle? (Select all that apply.)
A) Excitement
B) Orgasm
C) Resolution
D) Detumescence
E) Plateau
Q2) A nurse is planning an educational event of safer sex. What topics does the nurse include? (Select all that apply.)
A) Proper use of condoms
B) Avoidance of risky behaviors
C) Need for routine examinations
D) Avoidance of homosexual activity
E) Symptoms of common STDs
Q3) The nursing student learns that the function of the hypothalamus is to do which of the following?
A) Cause lactation to begin
B) Produce spermatozoa
C) Release follicle-stimulating hormone
D) Release gonadotropin-releasing hormone
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Chapter 25: Safety
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Sample Questions
Q1) The increase focus in nursing on patient safety has resulted in a project funded by the Robert Wood Johnson Foundation called:
A) OSHA.
B) MSDS.
C) QSEN.
D) ADA.
Q2) The patient has a nursing diagnosis of risk for falls. Which goal is most important?
A) Patient will ambulate twice a day.
B) Patient will have no symptoms of infection.
C) Patient will perform activities of daily living.
D) Patient will have no injuries during hospital stay.
Q3) Which statement by the patient indicates a teaching need regarding safety in the home?
A) "I will put a night light in every room."
B) "I will not use an extension cord to plug in multiple items."
C) "I will wash my throw rugs in the bathroom regularly."
D) "I will keep all cleaning supplies out of reach of children."
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Chapter 26: Asepsis and Infection Control
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Sample Questions
Q1) For which situation is it inappropriate to use alcohol-based hand sanitizer?
A) Patient with pneumonia
B) Patient with C. difficile
C) Status post-appendectomy
D) Patient with HIV
Q2) The antigen-antibody reaction is an example of what type of immunity?
A) Humoral
B) Cellular
C) Innate
D) Passive
Q3) A patient admitted after abdominal surgery has a nursing diagnosis of risk for infection. Which is the most appropriate goal?
A) Patient will ambulate length of hallway this shift.
B) Patient will consume 20% of meals by the end of the week.
C) Patient's incision will be without signs or symptoms of infection at discharge.
D) Patient will verbalize need to stop antibiotics medication when symptom free.
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Chapter 27: Hygiene and Personal Care
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Sample Questions
Q1) Which tool is used to determine risk for impaired skin integrity?
A) Braden scale
B) Glasgow scale
C) Vanderbilt scale
D) MMSE scale
Q2) The nurse has assisted the patient to wash his hands, face, axillae, and perineal area. What type of bath should the nurse chart?
A) Sink bath
B) Complete bed bath
C) Partial bed bath
D) Shower
Q3) The nurse is assisting her patients with hygiene care. She knows that this includes the following: (Select all that apply.)
A) Bathing
B) Oral care
C) Perineal care
D) Foot care
E) Patient communication
F) None of the above
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Page 29
Chapter 28: Activity, Immobility, and Safe Movement
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Sample Questions
Q1) The nurse correctly teaches the patient to rise from a chair using crutches when the following interventions are used:
A) Patient starts from the back of the chair.
B) The weak leg is closest to the chair.
C) The hand on the strong side holds the handbar of the crutch.
D) The strong leg is closest to the chair.
Q2) The nurse is educating the family of a patient on falls risk precautions. Which of the following statements by the family indicates a need for further education?
A) "I should keep the wheelchair locked unless using it to move Mom."
B) "I should always leave the bathroom light on."
C) "I should use nonskid socks, not shoes."
D) "I should keep her cell phone close to her bed."
Q3) The nurse knows active assistive range of motion is:
A) when the patient is able to independently move all joints.
B) when the patient is able to partially move all joints.
C) when the caregiver must move the patient's joints.
D) when the patient is performing isotonic exercises.
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Chapter 29: Skin Integrity and Wound Care
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Sample Questions
Q1) The nurse knows that mechanical debridement involves all of the following except:
A) wet to dry dressings.
B) whirlpool baths.
C) damp to dry dressing.
D) enzymatic dressing.
Q2) The nurse is performing a wet/damp to dry dressing change when the patient begins to complain of severe pain. What should the nurse do first?
A) Notify the physician.
B) Notify the wound care nurse.
C) Stop the procedure.
D) Give the patient pain medication.
Q3) The nurse knows the most appropriate goal for a patient with a stage III pressure ulcer who has a nursing diagnosis of Impaired skin integrity is:
A) the wound will be completely healed in 72 hours.
B) the wound will show signs of healing within 2 weeks.
C) the patient will develop no new pressure ulcers.
D) the patient will ambulate twice a day.
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Chapter 30: Nutrition
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Sample Questions
Q1) The nurse is attempting to open an occluded PEG tube. Which of the following interventions requires re-education?
A) Flush the tube with a small amount of air
B) Flush the tube using a 50- to 60-mL syringe and 20 to 30 mL of warm water.
C) Reinsert the stylet to break up the clot.
D) Flush the tube with a carbonated beverage.
Q2) The nurse is educating her patient about who has just been placed on a renal diet. Which statement by the patient indicates a need for further education?
A) "I need to eat a low-sodium diet."
B) "I can have limited amounts of meat."
C) "I can drink unlimited cola if it is diet."
D) "I should avoid or limit bananas."
Q3) The nurse is performing an oral examination on a patient and notices a beefy-red tongue. She knows this is a characteristic finding in:
A) anorexia nervosa.
B) malnutrition.
C) bulimia.
D) pernicious anemia.
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Chapter 31: Cognitive and Sensory Alterations
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Q1) An appropriate goal for a patient with a diagnosis of social isolation is:
A) the patient will participate in cognitive exercises.
B) the patient will interact with other residents during activities.
C) the patient will communicate basic needs through use of photos.
D) the patient will remain within the unit while in long-term care.
Q2) The nurse is performing a health history to determine the patient's sensory status. Which questions will be best suited to elicit the information needed? (Select all that apply.)
A) "Do you ever lose your balance?"
B) "Do you wear glasses?"
C) "Do you read the newspaper?"
D) "Can you feel the difference between hot and cold water?"
E) "Do you wear a hearing aid?"
Q3) The nurse is providing discharge education to her patient with diabetes regarding foot care. Which of the following statements by the patient indicates a need for further education?
A) "I can go barefoot outside only in the summer."
B) "I should wear good fitting shoes."
C) "I cannot soak my feet in a hot tub."
D) "I can use lotion on my feet."
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Chapter 32: Stress and Coping
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Q1) The nurse is assessing level of stress in a patient from another culture. Which question is the most appropriate in helping the nurse understand the impact of the patient's belief system?
A) "Do you engage in prayer to help you during times of stress?"
B) "Do you go to church or other form of organized worship?"
C) "Do you have certain beliefs that are helpful during times of stress?"
D) "Do you want spiritual counseling while you are here?"
Q2) The nurse knows that when patients are experiencing stress, the following change can be seen in their signs and symptoms: (Select all that apply.)
A) Increase in heart rate
B) Increase in gastric motility
C) Pupil dilation
D) Decrease in blood pressure
E) Increase in respiratory rate
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34
Chapter 33: Sleep
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Q1) The nurse manager is concerned about her staff who are working the night shift. What interventions can she suggest to assist nurses in overcoming shift related sleep disturbances? (Select all that apply.)
A) Power nap before leaving for the first night shift.
B) Get a minimum of 4 hours of sleep.
C) Wear dark glasses when driving home from work.
D) Seek exposure to bright light when waking.
E) Maintain a regular sleeping schedule when working and on nights off.
Q2) The nurse is providing discharge education for a patient with narcolepsy. The following statement by the patient indicates a need for further education:
A) "Daytime naps are helpful."
B) "Taking the medication will cure it."
C) "High protein meals are helpful."
D) "I should avoid alcohol."
Q3) The nurse knows that with the onset of darkness and in preparation for sleep:
A) cortisol levels peak.
B) cortisol levels increase.
C) core body temperature increases.
D) melatonin levels increase.
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Page 35
Chapter 34: Diagnostic Testing
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Q1) The nurse is caring for a patient who will be undergoing flexible sigmoidoscopy testing to screen for colon cancer. What goal will the nurse include in the patient's plan of care?
A) Patient will verbalize understanding of pre-procedure preparation to be completed at home the day before the test.
B) Patient will feel comfortable about the upcoming test and have trust in the health care providers.
C) Patient will learn common side effects of the medications used to prepare the GI tract for endoscopy testing.
D) Patient will realize how important regular sigmoidoscopy testing is in the prevention of colon cancer.
Q2) The nurse is caring for a patient whose immune system is destroying red blood cells at a very rapid rate. Which test result will the nurse expect to see in the patient's chart as a result?
A) Bilirubin level 4 mg/dL
B) Platelet count 450,000/mm\(^{3}\)
C) Serum uric acid level 1.7 mg/dL
D) Partial thromboplastin time 45 seconds
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Page 36
Chapter 35: Medication Administration
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Q1) The nurse is caring for a patient who is taking many prescription medications for various health problems. Which direction from the nurse will help the patient avoid dangerous drug interactions?
A) Only take over-the-counter medications.
B) Have all of the prescriptions filled at the same pharmacy.
C) Avoid taking generic preparations of prescribed medications.
D) Only take the medications that the patient feels are necessary.
Q2) The nurse makes a medication error. Which action will the nurse take first?
A) Prepare an incident report so that the facility can determine the cause of the error.
B) Explain to the patient that a medication error has occurred, and notify the nurse manager.
C) Assess the patient for any adverse reactions and notify the prescriber.
D) Document the medication given, how the patient responded, and the corrective actions taken.
Q3) Which medication has the highest potential for abuse?
A) Methylphenidate (Ritalin) - schedule II
B) Alprazolam (Xanax) - schedule IV
C) Acetaminophen & codeine (Tylenol #3) - schedule III
D) Diphenoxylate & atropine (Lomotil) - schedule V
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Page 37
Chapter 36: Pain Management
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Sample Questions
Q1) What is the priority nursing assessment for a patient who his receiving postoperative epidural analgesia with hydromorphone (Dilaudid)?
A) Respiratory rate, depth, and pattern
B) Skin underneath the epidural dressing
C) Bladder scanning to check for urinary retention
D) Itching on the trunk and/or extremities
Q2) Which is the best pain medication option for a patient to manage severe long-term cancer pain at home?
A) Duragesic 50 mcg transdermal patch q 72 hours
B) Meperidine (Demerol) 50 mg IM q 6 hours
C) Hydromorphone (Dilaudid) 0.2 mg q 10 minutes IV via PCA pump
D) Hydromorphone (Dilaudid) 0.08 mg/hour infusion through epidural catheter
Q3) The nurse is checking on the patient after administering pain medication 30 minutes previously. Which assessment finding best indicates to the nurse that the pain medication was effective?
A) The patient is sleeping quietly.
B) The patient states that she has no pain.
C) The patient's respirations are slow and regular.
D) The patient's blood pressure has returned to baseline.
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Page 38
Chapter 37: Perioperative Nursing Care
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Q1) Which of the following patients would benefit from preoperative teaching about splinting of incisions to minimize discomfort? (Select all that apply.)
A) Patient having coronary bypass graft surgery
B) Patient having open breast biopsy
C) Patient having total hip replacement surgery
D) Patient having lumbar spine decompression surgery
E) Patient having surgery to repair retinal detachment
F) Patient having total abdominal hysterectomy
Q2) The nurse is caring for a patient who requires emergency surgery for injuries sustained in a motor vehicle accident. The patient was on his way back to work after having lunch with colleagues when the accident happened. What is the highest priority nursing diagnosis for this patient?
A) Risk for imbalanced body temperature
B) Risk for aspiration
C) Risk for perioperative positioning injury
D) Risk for delayed surgical recovery
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Chapter 38: Oxygenation and Tissue Perfusion
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Q1) The preceptor is working with a new nurse to suction a patient through his new tracheostomy. Which actions by the new nurse indicate need for additional teaching about the procedure? (Select all that apply.)
A) The suction is not applied to the catheter until it is being withdrawn.
B) The patient is placed in the supine position prior to suctioning.
C) The suction catheter is twirled side to side as it is being withdrawn.
D) Suction is applied continuously as the catheter is withdrawn.
E) The patient's oxygen is reapplied between suction attempts.
F) Water-soluble lubricant is applied to the suction catheter before insertion.
Q2) The nurse is caring for a patient with a history of left-sided congestive heart failure who is acutely short of breath. The nurse hears fine crackles throughout both lung fields and notes that the patient's pulse oximetry is only 88% on 4 L of oxygen. What is the
priority intervention of the nurse?
A) Administer the ordered intravenous diuretic.
B) Prepare for insertion of a chest tube.
C) Suction secretions from the patient's respiratory tract.
D) Have the patient use the ordered incentive spirometer.
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Chapter 39: Fluid, Electrolytes, and Acid-Base Balance
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Q1) The nurse is caring for a patient with a history of hyperparathyroidism who presents with a serum calcium level of 14.5 mg/dL. What is the highest priority nursing diagnosis for this patient?
A) Risk for injury related to weakened bones that may easily fracture
B) Deficient knowledge related to need for supplemental calcium in diet
C) Risk for constipation caused by decreased gastrointestinal motility
D) Activity intolerance related to muscle cramping and spasms
Q2) The nurse is caring for a patient who is to receive a transfusion of packed red blood cells. The patient has a 22-gauge IV in his arm with 0.9% normal saline infusing. What intervention will the nurse perform before obtaining the packed red blood cells from the blood bank?
A) Identify the blood group, type, and expiration date with another nurse.
B) Insert an 18- or 20-gauge angiocatheter into the patient's other arm.
C) Program the IV infusion pump so that the transfusion will complete within 4 hours.
D) Obtain a new microdrip tubing and extension tubing from the clean utility room.
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Chapter 40: Bowel Elimination
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Q1) The nurse is caring for a patient who has an ileostomy. Which nursing diagnosis has the highest priority for the patient?
A) Impaired skin integrity r/t localized skin irritation from liquid stool
B) Social isolation r/t potential leakage of stool from ostomy appliance
C) Knowledge deficit r/t care and maintenance of ostomy appliance
D) Disturbed body image r/t presence of stoma and altered elimination
Q2) The nurse is caring for a patient who periodically has small streaks of fresh red blood in his stool. The patient denies abdominal pain or loss of appetite. What is the most likely cause of this patient's bleeding?
A) Hemorrhoids
B) Bleeding gastric ulcer
C) Colon polyps
D) Perforated colon
Q3) The nurse is caring for a patient who is to have testing for fecal occult blood. What step will the nurse perform during this testing?
A) Keep the patient on a clear liquid diet for 72 hours.
B) Send the samples to the laboratory while they are still warm.
C) Inform the patient that several stool samples will be needed.
D) Use a sterile container when collecting the stool samples.
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Page 42
Chapter 41: Urinary Elimination
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Q1) The nurse is caring for a patient with an indwelling urinary catheter caused by severe prostate enlargement. Which is the priority nursing diagnosis for this patient?
A) Risk for infection r/t indwelling urinary catheter
B) Disturbed body image r/t presence of catheter
C) Risk for contamination r/t potential leakage of urine on clothing
D) Urinary retention r/t blockage of bladder outlet
Q2) The nurse is caring for a patient who has developed kidney failure. Which test finding leads the nurse to contact the nephrologist and arrange for emergency hemodialysis?
A) Serum potassium level 7.4 mEq/L
B) Serum creatinine level of 2.8 mg/dL
C) Large amounts of protein in the urine
D) 1500 mL of retained urine in the bladder
Q3) The nurse is caring for a patient who has urinary frequency. Which nursing diagnosis is the highest priority for this patient?
A) Risk for compromised human dignity r/t occasional incontinence
B) Risk-prone health behavior r/t living alone at home with nocturia
C) Risk for contamination r/t urine contact with perineal area skin
D) Risk for falls r/t hurried trips to the bathroom during the day and night
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43
Chapter 42: Death and Loss
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Q1) The nurse is caring for a female patient who died a few minutes previously. The patient's family comes in to the room and immediately starts to wash the body in preparation for burial. What is the most appropriate action of the nurse at this time?
A) Inform the patient's family that the body must be transported to the morgue.
B) Instruct the patient's family that hospital staff will provide post-mortem care.
C) Obtain needed signatures for organ donation and autopsy.
D) Offer to provide any needed supplies and provide privacy for the family.
Q2) The nurse is caring for a terminally ill patient whose children have come home to be with their mother during her last few days. They spend time looking through picture albums, watching old home movies, and remembering fun times spent together. Which term best describes the activity of the patient's children?
A) Anticipatory grieving
B) Bereavement
C) Caregiver role strain
D) Death anxiety
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