Nursing Fundamentals
3 MAXE
NF Foundations of Professional Nursing Practice
CARING · COMPETENCE · COMPASSION
FUNDAMENTALS
Nursing Fundamentals — Exam 3
A B D O M I N A L A SS E SS M E N T, W O U N D S , I M M O B I L I TY, R E S P I R ATO R Y & C A R D I A C A SS E SS M E N T
INSTITUTION Nursing Fundamentals Program COURSE CODE NURS 101 — Fundamentals
PROGRAM Associate / Bachelor of Science in Nursing ACADEMIC YEAR
EXAM TITLE Exam 3 — Fundamentals of Nursing TOTAL QUESTIONS 100+ Questions (Complete)
COURSE TITLE Fundamentals of Nursing FORMAT Multiple Choice — Select the Single Best
Answer
EXAMINATION INSTRUCTIONS
▸ Select the single best answer for each question.
▸ All questions from the provided study material are included with correct answers and clinical rationales.
ABDOMEN, WOUNDS, IMMOBILITY, RESPIRATORY & CARDIAC Questions 1 – 100+
1. The correct sequence for abdominal assessment is:
A. Palpation, Percussion, Auscultation, Inspection.
B. Inspection, Auscultation, Percussion, Palpation — auscultation before palpation prevents altering bowel sounds.
C. Auscultation, Inspection, Palpation, Percussion.
D. Percussion, Palpation, Inspection, Auscultation.
CORRECT ANSWER B — Inspect → Auscultate → Percuss → Palpate. Auscultation follows inspection because percussion
and palpation can stimulate bowel sounds.
RATIONALE Patient should relax in supine/dorsal recumbent position with arms at sides, knees slightly bent on small
pillows. Arms under head tighten abdominal muscles, hindering palpation.
2. Visceral pain is characterized by:
A. Sharp, well-localized pain over the involved structure.
B. Pain from solid organs (liver, spleen, kidneys, pancreas, ovaries, uterus) — usually at midline, corresponds to organ
level, difficult to localize.
C. Pain that only occurs with movement.
D. Pain that is always referred to the shoulder.
CORRECT ANSWER B — Visceral pain = dull, poorly localized, midline. Parietal pain = sharp, well-localized, aggravated by
movement. Referred pain = distant from source but same spinal level.
RATIONALE Infection = invasion by pathogenic microorganism that reproduces and multiplies. Colonization = presence
and multiplication without tissue invasion or damage.
, 3. Medical asepsis differs from surgical asepsis in that medical asepsis:
A. Eliminates ALL microorganisms including spores.
B. Reduces the number of microorganisms and prevents their spread (clean technique).
C. Is only used in the operating room.
D. Requires a sterile field.
CORRECT ANSWER B — Medical asepsis = clean technique (hand hygiene, barriers, environmental cleaning). Surgical
asepsis = sterile technique (eliminates ALL organisms including spores).
RATIONALE Ways to maintain asepsis: aseptic technique, hand hygiene, barrier techniques, routine environmental
cleaning, disinfection, sterilization.
4. A Stage I pressure ulcer presents as:
A. Partial-thickness loss with blister.
B. Intact skin with non-blanchable redness.
C. Full-thickness loss with visible fat.
D. Full-thickness loss with exposed bone.
CORRECT ANSWER B — Stage 1 = intact skin, non-blanchable erythema. Stage 2 = partial-thickness/blister. Stage 3 = full-
thickness, fat visible. Stage 4 = bone/tendon/muscle exposed.
RATIONALE Unstageable = slough/eschar covers wound base. Deep tissue injury = purple/maroon discoloration or blood-
filled blister from underlying damage.
5. The phases of wound healing in correct order are:
A. Maturation, Proliferation, Inflammatory.
B. Inflammatory (1-5 days), Proliferation/Granulation (5-21 days, fibroblasts/collagen), Maturation/Epithelialization
(remodeling, scar ~80% original strength).
C. Proliferation, Inflammatory, Maturation.
D. All phases occur simultaneously.
CORRECT ANSWER B — Inflammatory (1-5 days) → Proliferation/Granulation (5-21 days) → Maturation/Remodeling
(begins week 2-3, scar 80% strength).
RATIONALE Signs of infection: inflammation, warmth, erythema, fever, foul odor, severe/increasing pain, large amount of
exudate. Primary healing = well-approximated edges, minimal scar. Secondary = granulation from bottom.
Tertiary = delayed primary closure.
6. Serous exudate is described as:
A. Thick, yellow/green, malodorous (pus).
B. Watery, serum-like, straw colored — seen in clean wounds.
C. Bright red (active bleeding).
D. Pale red, watery mixture.
CORRECT ANSWER B — Serous = clear, watery, straw-colored. Sanguineous = bloody. Serosanguineous = pale red/watery.
Purulent = thick, malodorous, yellow/green (pus). Purosanguineous = red-tinged pus.
RATIONALE Wound complications: hemorrhage (internal/external), infection (within 2-3 days post-op), evisceration
(organs protrude — cover with sterile saline-soaked gauze, knees flexed, prepare for OR), fistula (abnormal
passage between two body parts).
3 MAXE
NF Foundations of Professional Nursing Practice
CARING · COMPETENCE · COMPASSION
FUNDAMENTALS
Nursing Fundamentals — Exam 3
A B D O M I N A L A SS E SS M E N T, W O U N D S , I M M O B I L I TY, R E S P I R ATO R Y & C A R D I A C A SS E SS M E N T
INSTITUTION Nursing Fundamentals Program COURSE CODE NURS 101 — Fundamentals
PROGRAM Associate / Bachelor of Science in Nursing ACADEMIC YEAR
EXAM TITLE Exam 3 — Fundamentals of Nursing TOTAL QUESTIONS 100+ Questions (Complete)
COURSE TITLE Fundamentals of Nursing FORMAT Multiple Choice — Select the Single Best
Answer
EXAMINATION INSTRUCTIONS
▸ Select the single best answer for each question.
▸ All questions from the provided study material are included with correct answers and clinical rationales.
ABDOMEN, WOUNDS, IMMOBILITY, RESPIRATORY & CARDIAC Questions 1 – 100+
1. The correct sequence for abdominal assessment is:
A. Palpation, Percussion, Auscultation, Inspection.
B. Inspection, Auscultation, Percussion, Palpation — auscultation before palpation prevents altering bowel sounds.
C. Auscultation, Inspection, Palpation, Percussion.
D. Percussion, Palpation, Inspection, Auscultation.
CORRECT ANSWER B — Inspect → Auscultate → Percuss → Palpate. Auscultation follows inspection because percussion
and palpation can stimulate bowel sounds.
RATIONALE Patient should relax in supine/dorsal recumbent position with arms at sides, knees slightly bent on small
pillows. Arms under head tighten abdominal muscles, hindering palpation.
2. Visceral pain is characterized by:
A. Sharp, well-localized pain over the involved structure.
B. Pain from solid organs (liver, spleen, kidneys, pancreas, ovaries, uterus) — usually at midline, corresponds to organ
level, difficult to localize.
C. Pain that only occurs with movement.
D. Pain that is always referred to the shoulder.
CORRECT ANSWER B — Visceral pain = dull, poorly localized, midline. Parietal pain = sharp, well-localized, aggravated by
movement. Referred pain = distant from source but same spinal level.
RATIONALE Infection = invasion by pathogenic microorganism that reproduces and multiplies. Colonization = presence
and multiplication without tissue invasion or damage.
, 3. Medical asepsis differs from surgical asepsis in that medical asepsis:
A. Eliminates ALL microorganisms including spores.
B. Reduces the number of microorganisms and prevents their spread (clean technique).
C. Is only used in the operating room.
D. Requires a sterile field.
CORRECT ANSWER B — Medical asepsis = clean technique (hand hygiene, barriers, environmental cleaning). Surgical
asepsis = sterile technique (eliminates ALL organisms including spores).
RATIONALE Ways to maintain asepsis: aseptic technique, hand hygiene, barrier techniques, routine environmental
cleaning, disinfection, sterilization.
4. A Stage I pressure ulcer presents as:
A. Partial-thickness loss with blister.
B. Intact skin with non-blanchable redness.
C. Full-thickness loss with visible fat.
D. Full-thickness loss with exposed bone.
CORRECT ANSWER B — Stage 1 = intact skin, non-blanchable erythema. Stage 2 = partial-thickness/blister. Stage 3 = full-
thickness, fat visible. Stage 4 = bone/tendon/muscle exposed.
RATIONALE Unstageable = slough/eschar covers wound base. Deep tissue injury = purple/maroon discoloration or blood-
filled blister from underlying damage.
5. The phases of wound healing in correct order are:
A. Maturation, Proliferation, Inflammatory.
B. Inflammatory (1-5 days), Proliferation/Granulation (5-21 days, fibroblasts/collagen), Maturation/Epithelialization
(remodeling, scar ~80% original strength).
C. Proliferation, Inflammatory, Maturation.
D. All phases occur simultaneously.
CORRECT ANSWER B — Inflammatory (1-5 days) → Proliferation/Granulation (5-21 days) → Maturation/Remodeling
(begins week 2-3, scar 80% strength).
RATIONALE Signs of infection: inflammation, warmth, erythema, fever, foul odor, severe/increasing pain, large amount of
exudate. Primary healing = well-approximated edges, minimal scar. Secondary = granulation from bottom.
Tertiary = delayed primary closure.
6. Serous exudate is described as:
A. Thick, yellow/green, malodorous (pus).
B. Watery, serum-like, straw colored — seen in clean wounds.
C. Bright red (active bleeding).
D. Pale red, watery mixture.
CORRECT ANSWER B — Serous = clear, watery, straw-colored. Sanguineous = bloody. Serosanguineous = pale red/watery.
Purulent = thick, malodorous, yellow/green (pus). Purosanguineous = red-tinged pus.
RATIONALE Wound complications: hemorrhage (internal/external), infection (within 2-3 days post-op), evisceration
(organs protrude — cover with sterile saline-soaked gauze, knees flexed, prepare for OR), fistula (abnormal
passage between two body parts).
