NURSING FUNDAMENTA77119781-500-Item-Coaching
FUNDAMENTALS IN NURSING
Situation 1. The nursing process provides a framework for a nurse's responsibility and accountability. It requires critical thinking.
1. The patient states, “My chest hurts and my left arm feels numb.” What is the type and source of this data?
A. Subjective data from a primary source
B. Subjective data from a secondary source
C. Objective data from a primary source
D. Objective data from a secondary source
Answer: A
Rationale: Subjective data is apparent only to the person affected and cannot be measured, seen, felt, or heard by the
nurse. It may be called “covert data.” It includes the patient's thoughts, beliefs, feelings, perceptions, and sensations. The
patient is always considered the primary source.
(Hogan et. al., Prentice Hall Reviews and Rationales Series for Nursing: Fundamentals of Nursing)
2. The nurse is measuring the patient's urine output and straining the urine to assess for stones. Which of the following
should the nurse record as objective data?
A. The patient stated, “I feel like I have passed a stone.”
B. The patient's urine output was 550 mL
C. The patient is complaining of abdominal pain
D. The patient stated, “I didn't see any stones in my urine.”
Answer: B
Rationale: Measurable data is objective data.
(Hogan et. al., Prentice Hall Reviews and Rationales Series for Nursing: Fundamentals of Nursing)
3. Which of the following demonstrates that the nurse is participating critical thinking?
A. The nurse admits she does not know how to do a procedure and requests help
B. The nurse makes her point with clever and persuasive remarks to win an argument
C. The nurse accepts without question the values acquired in nursing school
D. The nurse finds a quick and logical answer, even to complex questions
Answer: A
Rationale: Critical thinking is self-directed and supports what an individual knows and makes clear what she does not know.
It is important for nurses to recognize when they lack the knowledge they need to provide safe care for a client. Nurses
must utilize their resources to acquire the knowledge and support they need to fulfill a nursing responsibility safely.
. (Hogan et. al., Prentice Hall Reviews and Rationales Series for Nursing: Fundamentals of Nursing)
4. What is the problem with the following outcome goal, “Patient will state pain is less than or equal to 3 on a 0 to 10 pain
scale”?
A. None, goal is written correctly
B. It is not measurable
C. No target time is given
D. Patient behavior is missing
Answer: C
Rationale: Outcome goals should be SMART (specific, measurable, appropriate, realistic, and timely). There is no time
estimate for goal attainment. Thus, option A is incorrect.
(Hogan et. al., Prentice Hall Reviews and Rationales Series for Nursing: Fundamentals of Nursing)
5. When evaluating an adult patient's blood pressure reading. The nurse considers the patient's age. This is an example of
which of the following?
A. Comparing data against standards
B. Clustering data
C. Determining gaps in the data
D. Differentiating cues and inferences
Answer: A
Rationale: Analysis of the client data (blood pressure reading) requires knowledge of the normal blood pressure range for
an adult. The nurse compares client data against standards to identify significant cues. (Hogan et. al., Prentice Hall Reviews
and Rationales Series for Nursing: Fundamentals of Nursing)
Situation 2. Jason has a nursing diagnosis of ineffective airway clearance related to excessive secretions and is at risk for infection
because of retained secretions. Part of Nurse Melai’s nursing care plan is to loosen and remove excessive secretions in the airway.
6. Nurse Melai listens to Jason’s bilateral sounds and finds that congestion is in the upper lobes of the lungs. The appropriate
position to drain the anterior and posterior apical segment of the lungs when the nurse does percussion would be:
A. Patient lying on his back then flat on his abdomen on Trendelenburg position
B. Patient seated upright in bed or on a chair then leaning forward in sitting position then flat on his back and on
his abdomen
C. Patient lying flat in his back and then flat on his abdomen
,NURSING FUNDAMENTA77119781-500-Item-Coaching
under the buttocks for anterior segment of upper lobe affectation.
,NURSING FUNDAMENTA77119781-500-Item-Coaching
7. When documenting the outcome of Jason’s treatment Nurse Melai should include the following in her recording, except:
A. Color, amount, consistency of sputum
B. Character of breath sounds and respiratory rate before and after procedure
C. Amount of fluid intake of the patient before and after the procedure
D. Significant changes in vital signs
Answer: C
Rationale: Though patients receiving Chest Physiotherapy are encouraged to increase oral fluid intake, this intervention is
not too specific for documentation of pertinent data related to the procedure.
8. When assessing Jason for chest percussion or chest vibration and postural drainage, Nurse Melai would focus on the
following, except:
A. Amount of fluid taken during the last meal before treatment
B. Respiratory rate, breath sounds and location of congestion
C. Teaching the patient’s relatives to perform the procedure
D. Doctor’s order regarding position restrictions and the patient’s tolerance for lying flat
Answer: C
Rationale: Options A, B and D are all assessable, C is an intervention that is not allowed. Chest Physiotherapy is a
dependent nursing intervention that cannot be just delegated to the patient’s relatives. Even for home/community based
care or long term care of patients; CPT is done during home visits by a home care nurse and not delegated to the relatives.
9. Nurse Melai prepares Jason for postural drainage and percussion. Which of the following is a special consideration when
doing the procedure?
A. Respiratory rate of 16-20 per minute
B. Patient can tolerate sitting and lying positions
C. Patient has no sign of infection
D. Time of the last food and fluid intake of the patient
Answer: D
Rationale: The time of last food and fluid intake of the client is very important for the nurse to assess. The best time to
perform chest physiotherapy is 1 hour before meals or 2-3 hours after meals to prevent food and fluid regurgitation or
vomiting.
10. The purpose of chest percussion and vibration is to loosen secretions in the lungs. The difference between the procedures
is:
A. Percussion uses only one hand while vibration uses both hands
B. Percussion delivers cushioned blows to the chest with cupped palms while vibration gently shakes secretion
loose on the exhalation cycle
C. In both percussion and vibration the hands are on top of each other and hand action is in tune with the client’s
breathing rhythm
D. Percussion slaps the chest to loosen secretions while vibration shakes the secretions with inhalation of air
Answer: B
Rationale: Option B is the correct comparison.
Situation 3. The vital signs are body temperature, pulse, respirations, and blood pressure. These signs, which should be looked at
in total, are checked to monitor the functions of the body. They reflect changes in function that otherwise might not be observed.
11. For a patient with a previous blood pressure of 140/80 and pulse of 64, approximately how long should the nurse take to
release the blood pressure cuff in order to obtain an accurate reading?
A. 10 to 20 seconds C. 30 to 45 seconds
B. 1 to 1.5 minutes D. 3 to 3.5 minutes
Answer: C
Rationale: If the cuff is inflated to about 30 mm Hg over the previous systolic pressure, which would be 170. To ensure that
the diastolic has been determined, the cuff should be released slowly until the mid-60s mm Hg (and then completely) for
someone with a previous reading of 80. The cuff should be deflated at a rate of 2 to 3 mm per second. Thus, a range of 90
mm Hg will require 30 to 45 seconds. (Kozier & Erb's Fundamentals of Nursing, 8th Edition)
12. A patient with pyrexia will most likely demonstrate:
A. Dyspnea C. Increased pulse rate
B. Precordial pain D. Elevated blood pressure
Answer: C
Rationale: The pulse increases to meet increased tissue demands for oxygen in the febrile
state. (Mosby, 18th Edition)
13. Which of the following patients meet the criteria for selection of the apical site for assessment of the pulse rather than a
radial pulse?
A. A patient is in shock
B. The pulse changes with body position changes
, NURSING FUNDAMENTA77119781-500-Item-Coaching
14. The absence of which pulse may not be a significant finding when a patient is admitted to the hospital?
A. Pedal C. Apical
B. Femoral D. Radial
Answer: A
Rationale: Because the pedal pulse cannot be detected in 10% to 20% of the population, its absence is not necessarily a
significant finding. However, the presence or absence of the pedal pulse should be documented upon admission so that
changes can be identified during the hospital stay. (Kozier & Erb's Fundamentals of Nursing, 8th Edition)
15. All of the following can cause tachycardia, except:
a. Sympathetic nervous system stimulation
b. Parasympathetic nervous system stimulation
c. Fever
d. Exercise
Answer: B
Rationale: Parasympathetic nervous system stimulation of the heart decreases the heart rate as well as the force of
contraction, rate of impulse conduction and blood flow through the coronary vessels.
(Kozier & Erb's Fundamentals of Nursing, 8th Edition)
Situation 4. Diagnostic and laboratory tests (commonly called lab tests) are tools that provide information about the client.
Frequently, tests are used to help confirm a diagnosis, monitor an illness, and provide valuable information about the client's
response to treatment.
16. A patient is admitted to the hospital with complaints of nausea, vomiting, diarrhea, and severe abdominal pain. Which of
the following would immediately alert the nurse that the patient has gastrointestinal tract bleeding?
A. Complete blood count C. Vital signs
B. Guaiac test D. Abdominal girth
Answer: B
Rationale: To assess for GI tract bleeding when frank blood is absent, the nurse has two options: She can test for occult
blood in vomitus, if present, or in stool - through Guaiac (Hemoccult) test.
(Kozier & Erb's Fundamentals of Nursing, 8th Edition)
17. Before scheduling a patient for endoscopic retrograde cholangiopancreatography (ERCP), the nurse should assess the
patient's:
A. Urine output C. Serum glucose
B. Bilirubin leve D. Blood pressure
Answer: B
Rationale: ERCP or endoscopic retrograde cholangiopancreatography involves the insertion of a cannula into the pancreatic
and common bile ducts during an endoscopy. The test is not performed if the client's bilirubin is greater than 3 to 5 mg/dL
because cannulization may cause edema, which would increase obstruction of bile flow.
(Mosby, 18th Edition)
18. The laboratory tests that would indicate that the liver of a patient with cirrhosis is compromised and neomycin enemas
might be helpful would be:
A. Ammonia level C. Culture and sensitivity
B. White blood count D. Alanine aminotransferase level
Answer: A
Rationale: Increased ammonia levels indicate that the liver is unable to detoxify protein byproducts. Neomycin reduces the
amount of ammonia-forming bacteria in the intestines.
(Mosby, 18th Edition)
19. The most important test used to determine whether a transplanted kidney is working is:
A. Renal ultrasound C. White blood cell count
B. Serum creatinine level D. Twenty-four hour output
Answer: B
Rationale: Serum creatinine concentration measures the kidney's ability to excrete metabolic wastes. Creatinine, a
nitrogenous product of protein breakdown, is elevated in renal insufficiency.
(Mosby, 18th Edition)
20. The best blood test for the nurse to use to evaluate fluid loss resulting from burns is the:
A. Blood urea nitrogen C. Hematocrit
B. Blood pH D. Sedimentation rate
Answer: C
Rationale: An increased hematocrit level indicates hemoconcentration secondary to fluid loss.
Option A is incorrect because although blood urea nitrogen (BUN) may be used to indicate dehydration from burns,
FUNDAMENTALS IN NURSING
Situation 1. The nursing process provides a framework for a nurse's responsibility and accountability. It requires critical thinking.
1. The patient states, “My chest hurts and my left arm feels numb.” What is the type and source of this data?
A. Subjective data from a primary source
B. Subjective data from a secondary source
C. Objective data from a primary source
D. Objective data from a secondary source
Answer: A
Rationale: Subjective data is apparent only to the person affected and cannot be measured, seen, felt, or heard by the
nurse. It may be called “covert data.” It includes the patient's thoughts, beliefs, feelings, perceptions, and sensations. The
patient is always considered the primary source.
(Hogan et. al., Prentice Hall Reviews and Rationales Series for Nursing: Fundamentals of Nursing)
2. The nurse is measuring the patient's urine output and straining the urine to assess for stones. Which of the following
should the nurse record as objective data?
A. The patient stated, “I feel like I have passed a stone.”
B. The patient's urine output was 550 mL
C. The patient is complaining of abdominal pain
D. The patient stated, “I didn't see any stones in my urine.”
Answer: B
Rationale: Measurable data is objective data.
(Hogan et. al., Prentice Hall Reviews and Rationales Series for Nursing: Fundamentals of Nursing)
3. Which of the following demonstrates that the nurse is participating critical thinking?
A. The nurse admits she does not know how to do a procedure and requests help
B. The nurse makes her point with clever and persuasive remarks to win an argument
C. The nurse accepts without question the values acquired in nursing school
D. The nurse finds a quick and logical answer, even to complex questions
Answer: A
Rationale: Critical thinking is self-directed and supports what an individual knows and makes clear what she does not know.
It is important for nurses to recognize when they lack the knowledge they need to provide safe care for a client. Nurses
must utilize their resources to acquire the knowledge and support they need to fulfill a nursing responsibility safely.
. (Hogan et. al., Prentice Hall Reviews and Rationales Series for Nursing: Fundamentals of Nursing)
4. What is the problem with the following outcome goal, “Patient will state pain is less than or equal to 3 on a 0 to 10 pain
scale”?
A. None, goal is written correctly
B. It is not measurable
C. No target time is given
D. Patient behavior is missing
Answer: C
Rationale: Outcome goals should be SMART (specific, measurable, appropriate, realistic, and timely). There is no time
estimate for goal attainment. Thus, option A is incorrect.
(Hogan et. al., Prentice Hall Reviews and Rationales Series for Nursing: Fundamentals of Nursing)
5. When evaluating an adult patient's blood pressure reading. The nurse considers the patient's age. This is an example of
which of the following?
A. Comparing data against standards
B. Clustering data
C. Determining gaps in the data
D. Differentiating cues and inferences
Answer: A
Rationale: Analysis of the client data (blood pressure reading) requires knowledge of the normal blood pressure range for
an adult. The nurse compares client data against standards to identify significant cues. (Hogan et. al., Prentice Hall Reviews
and Rationales Series for Nursing: Fundamentals of Nursing)
Situation 2. Jason has a nursing diagnosis of ineffective airway clearance related to excessive secretions and is at risk for infection
because of retained secretions. Part of Nurse Melai’s nursing care plan is to loosen and remove excessive secretions in the airway.
6. Nurse Melai listens to Jason’s bilateral sounds and finds that congestion is in the upper lobes of the lungs. The appropriate
position to drain the anterior and posterior apical segment of the lungs when the nurse does percussion would be:
A. Patient lying on his back then flat on his abdomen on Trendelenburg position
B. Patient seated upright in bed or on a chair then leaning forward in sitting position then flat on his back and on
his abdomen
C. Patient lying flat in his back and then flat on his abdomen
,NURSING FUNDAMENTA77119781-500-Item-Coaching
under the buttocks for anterior segment of upper lobe affectation.
,NURSING FUNDAMENTA77119781-500-Item-Coaching
7. When documenting the outcome of Jason’s treatment Nurse Melai should include the following in her recording, except:
A. Color, amount, consistency of sputum
B. Character of breath sounds and respiratory rate before and after procedure
C. Amount of fluid intake of the patient before and after the procedure
D. Significant changes in vital signs
Answer: C
Rationale: Though patients receiving Chest Physiotherapy are encouraged to increase oral fluid intake, this intervention is
not too specific for documentation of pertinent data related to the procedure.
8. When assessing Jason for chest percussion or chest vibration and postural drainage, Nurse Melai would focus on the
following, except:
A. Amount of fluid taken during the last meal before treatment
B. Respiratory rate, breath sounds and location of congestion
C. Teaching the patient’s relatives to perform the procedure
D. Doctor’s order regarding position restrictions and the patient’s tolerance for lying flat
Answer: C
Rationale: Options A, B and D are all assessable, C is an intervention that is not allowed. Chest Physiotherapy is a
dependent nursing intervention that cannot be just delegated to the patient’s relatives. Even for home/community based
care or long term care of patients; CPT is done during home visits by a home care nurse and not delegated to the relatives.
9. Nurse Melai prepares Jason for postural drainage and percussion. Which of the following is a special consideration when
doing the procedure?
A. Respiratory rate of 16-20 per minute
B. Patient can tolerate sitting and lying positions
C. Patient has no sign of infection
D. Time of the last food and fluid intake of the patient
Answer: D
Rationale: The time of last food and fluid intake of the client is very important for the nurse to assess. The best time to
perform chest physiotherapy is 1 hour before meals or 2-3 hours after meals to prevent food and fluid regurgitation or
vomiting.
10. The purpose of chest percussion and vibration is to loosen secretions in the lungs. The difference between the procedures
is:
A. Percussion uses only one hand while vibration uses both hands
B. Percussion delivers cushioned blows to the chest with cupped palms while vibration gently shakes secretion
loose on the exhalation cycle
C. In both percussion and vibration the hands are on top of each other and hand action is in tune with the client’s
breathing rhythm
D. Percussion slaps the chest to loosen secretions while vibration shakes the secretions with inhalation of air
Answer: B
Rationale: Option B is the correct comparison.
Situation 3. The vital signs are body temperature, pulse, respirations, and blood pressure. These signs, which should be looked at
in total, are checked to monitor the functions of the body. They reflect changes in function that otherwise might not be observed.
11. For a patient with a previous blood pressure of 140/80 and pulse of 64, approximately how long should the nurse take to
release the blood pressure cuff in order to obtain an accurate reading?
A. 10 to 20 seconds C. 30 to 45 seconds
B. 1 to 1.5 minutes D. 3 to 3.5 minutes
Answer: C
Rationale: If the cuff is inflated to about 30 mm Hg over the previous systolic pressure, which would be 170. To ensure that
the diastolic has been determined, the cuff should be released slowly until the mid-60s mm Hg (and then completely) for
someone with a previous reading of 80. The cuff should be deflated at a rate of 2 to 3 mm per second. Thus, a range of 90
mm Hg will require 30 to 45 seconds. (Kozier & Erb's Fundamentals of Nursing, 8th Edition)
12. A patient with pyrexia will most likely demonstrate:
A. Dyspnea C. Increased pulse rate
B. Precordial pain D. Elevated blood pressure
Answer: C
Rationale: The pulse increases to meet increased tissue demands for oxygen in the febrile
state. (Mosby, 18th Edition)
13. Which of the following patients meet the criteria for selection of the apical site for assessment of the pulse rather than a
radial pulse?
A. A patient is in shock
B. The pulse changes with body position changes
, NURSING FUNDAMENTA77119781-500-Item-Coaching
14. The absence of which pulse may not be a significant finding when a patient is admitted to the hospital?
A. Pedal C. Apical
B. Femoral D. Radial
Answer: A
Rationale: Because the pedal pulse cannot be detected in 10% to 20% of the population, its absence is not necessarily a
significant finding. However, the presence or absence of the pedal pulse should be documented upon admission so that
changes can be identified during the hospital stay. (Kozier & Erb's Fundamentals of Nursing, 8th Edition)
15. All of the following can cause tachycardia, except:
a. Sympathetic nervous system stimulation
b. Parasympathetic nervous system stimulation
c. Fever
d. Exercise
Answer: B
Rationale: Parasympathetic nervous system stimulation of the heart decreases the heart rate as well as the force of
contraction, rate of impulse conduction and blood flow through the coronary vessels.
(Kozier & Erb's Fundamentals of Nursing, 8th Edition)
Situation 4. Diagnostic and laboratory tests (commonly called lab tests) are tools that provide information about the client.
Frequently, tests are used to help confirm a diagnosis, monitor an illness, and provide valuable information about the client's
response to treatment.
16. A patient is admitted to the hospital with complaints of nausea, vomiting, diarrhea, and severe abdominal pain. Which of
the following would immediately alert the nurse that the patient has gastrointestinal tract bleeding?
A. Complete blood count C. Vital signs
B. Guaiac test D. Abdominal girth
Answer: B
Rationale: To assess for GI tract bleeding when frank blood is absent, the nurse has two options: She can test for occult
blood in vomitus, if present, or in stool - through Guaiac (Hemoccult) test.
(Kozier & Erb's Fundamentals of Nursing, 8th Edition)
17. Before scheduling a patient for endoscopic retrograde cholangiopancreatography (ERCP), the nurse should assess the
patient's:
A. Urine output C. Serum glucose
B. Bilirubin leve D. Blood pressure
Answer: B
Rationale: ERCP or endoscopic retrograde cholangiopancreatography involves the insertion of a cannula into the pancreatic
and common bile ducts during an endoscopy. The test is not performed if the client's bilirubin is greater than 3 to 5 mg/dL
because cannulization may cause edema, which would increase obstruction of bile flow.
(Mosby, 18th Edition)
18. The laboratory tests that would indicate that the liver of a patient with cirrhosis is compromised and neomycin enemas
might be helpful would be:
A. Ammonia level C. Culture and sensitivity
B. White blood count D. Alanine aminotransferase level
Answer: A
Rationale: Increased ammonia levels indicate that the liver is unable to detoxify protein byproducts. Neomycin reduces the
amount of ammonia-forming bacteria in the intestines.
(Mosby, 18th Edition)
19. The most important test used to determine whether a transplanted kidney is working is:
A. Renal ultrasound C. White blood cell count
B. Serum creatinine level D. Twenty-four hour output
Answer: B
Rationale: Serum creatinine concentration measures the kidney's ability to excrete metabolic wastes. Creatinine, a
nitrogenous product of protein breakdown, is elevated in renal insufficiency.
(Mosby, 18th Edition)
20. The best blood test for the nurse to use to evaluate fluid loss resulting from burns is the:
A. Blood urea nitrogen C. Hematocrit
B. Blood pH D. Sedimentation rate
Answer: C
Rationale: An increased hematocrit level indicates hemoconcentration secondary to fluid loss.
Option A is incorrect because although blood urea nitrogen (BUN) may be used to indicate dehydration from burns,
