Fundamentals of Nursing Final Exam
Review
-0-6 cm dilation
-Contractions 5-10 min apart - correct answerLatent phase of 1st stage of labor
-A chemical in the plasma that is activated due to cell injury
-Responsible for activating:
1) The Kinin system
2) The clotting cascade
3) The plasminogen system - correct answerThe Hageman Factor
-Breast tenderness
-Amenorrhea
-Nausea and vomiting
-Urinary frequency
-Breast enlargement
-Uterine enlargement noted by pt
-Fatigue
-Hyperpigmentation of skin
-Fetal movements
A. Presumptive signs
B. Probable signs
C. Positive signs
D. Both A & B
E. Both A & C
F. All of the above - correct answerA. Presumptive signs
-Causes vasodilation
-Alters capillary permeability
-Stimulates pain perception - correct answerHistamine
-Clear broth
-Coffee
-Tea
-Clear fruit juices
-Gelatin
-Popsicles
-Ice cream - correct answerExamples of clear liquid diet
-Establishment of trusting relationship
-Focus on education for overall wellness
-Detection and prevention of potential problems
,-Comprehensive health history, physical exam, and lab test - correct answerFirst
prenatal visit
-Failure to follow standard of care
-Failure to document
-Failure to be patient's advocate - correct answerMalpractice
-Important to a client's health and well-being
-Holistic care
-Important to clients
-Mandated by accreditors
-Helps to promote coping
-Positive relationship between this and health - correct answerSpiritual Care
-Irregular uterine contractions are felt, but the cervix is not affected
-Safest at home & not in hospital
-Usually felt in front of the abdomen - correct answerFalse/Latent/Early Labor
-Overall function: repair/removal of disease
-Acute and chronic - correct answerInflammation
-Positive pregnancy test
-Goodell's sign
-Chadwick's sign
-Hegar's sign
-Abdominal enlargement
-Braxton Hicks contractions
A. Probable signs
B. Presumptive signs
C. Positive signs
D. Both A & B
E. Both A & C
F. All of the above - correct answerA. Probable signs
-Regular diet w/modifications for texture
-Foods are chopped, ground, mashed, or soft - correct answerMechanically altered diet
-Relieves pain, reduces stress, enhances athletic performance, improves general well-
being
-Causes the relaxation response (lowers BP, HR, RR)
-Causes mechanical responses: physical effects from pressure applied to soft tissues -
correct answerMassage
-Teach patient with illness
-Improving quality of life
,-Family counseling
-Telehealth - correct answerTertiary Prevention
-Ultrasound verification of embryo or fetus
-Auscultation of fetal heart tones via Doppler
-Fetal movements felt by experienced clinician
These are all examples of what type of sign? - correct answerPositive signs
1-4 hours following delivery - correct answer4th Stage of Labor
1. A nurse assesses patients in a physician's office who are experiencing different levels
of health and illness. Which statements best define the concepts of health and illness?
Select all that apply.
A. Health and illness are the same for all people.
B. Health and illness are individually defined by each person.
C. People with acute illnesses are actually healthy.
D. People with chronic illnesses have poor health beliefs.
E. Health is more than the absence of illness.
F. Illness is the response of a person to a disease. - correct answerB, E, & F
1. Thirty-six hours after having surgery, a patient has a slightly elevated body
temperature and generalized malaise, as well as pain and redness at the surgical site.
Which intervention is most important to include in this patient's nursing care plan?
A. Document the findings and continue to monitor the patient.
B. Administer antipyretics, as ordered.
C. Increase the frequency of assessment to every hour and notify the patient's primary
care provider.
D. Increase the frequency of wound care and contact the primary care provider for an
antibiotic order. - correct answerThe assessment findings are normal for this stage of
healing following surgery. The patient is in the inflammatory phase of the healing
process, which involves a response by the immune system. This acute inflammation is
characterized by pain, heat, redness, and swelling at the site of the injury (surgery, in
this case). The patient also has a generalized body response, including a mildly
elevated temperature, leukocytosis, and generalized malaise.
1st Stage: When do you assess FHR? - correct answerLow-Risk: Every 30 min
High-risk: Every 15 min
1st Trimester Discomforts - correct answer-Urinary frequency or incontinence
-Fatigue
-Nausea and vomiting
-Breast tenderness
-Constipation
-Nasal stuffiness, bleeding gums, epistaxis
, -Cravings
-Leukorrhea
2 body tissues that do not need insulin for transport of glucose into the cells - correct
answerBrain and nerves
2nd Trimester Discomforts - correct answer-Backache
-Varicosities of the vulva and legs
-Hemorrhoids
-Flatulence with bloating
3. A patient who has a large abdominal wound suddenly calls out for help because she
feels as though something is falling out of her incision. Inspection reveals a gaping open
wound with tissue bulging outward. In which order should the nurse perform the
following interventions? Arrange from first to last.
A. Notify the physician immediately of the situation.
B. Cover the exposed tissue with sterile towels moistened with sterile NSS.
C. Place the patient in the low Fowler's position. - correct answerC, B, A Dehiscence
and evisceration is a postoperative emergency that requires prompt surgical repair. The
correct order of implementation by the nurse is to place the patient in the low Fowler's
position, cover the exposed tissue with sterile towels moistened with sterile NSS, and
notify the physician immediately of the situation.
3rd Trimester Discomforts - correct answer-Return of 1st trimester discomforts
-Shortness of breath and dyspnea
-Heartburn and indigestion
-Dependent edema
-Braxton Hicks contractions
6-8/9 cm dilation
-Contractions 2-5 min apart - correct answerActive phase of 1st stage of labor
6-8/9 cm dilation - correct answerActive phase of 1st stage of labor
8/9-complete dilation - correct answerTransition stage of 1st stage of labor
A birth without pain-relieving medications - correct answerNatural childbirth
A common site for infection in the elderly - correct answerUrinary tract
A female patient who is receiving chemotherapy for breast cancer tells the nurse, "The
treatment for this cancer is worse than the disease itself. I'm not going to come for my
therapy anymore." The nurse responds by using critical thinking skills to address this
patient problem. Which action is the first step the nurse would take in this process?
Review
-0-6 cm dilation
-Contractions 5-10 min apart - correct answerLatent phase of 1st stage of labor
-A chemical in the plasma that is activated due to cell injury
-Responsible for activating:
1) The Kinin system
2) The clotting cascade
3) The plasminogen system - correct answerThe Hageman Factor
-Breast tenderness
-Amenorrhea
-Nausea and vomiting
-Urinary frequency
-Breast enlargement
-Uterine enlargement noted by pt
-Fatigue
-Hyperpigmentation of skin
-Fetal movements
A. Presumptive signs
B. Probable signs
C. Positive signs
D. Both A & B
E. Both A & C
F. All of the above - correct answerA. Presumptive signs
-Causes vasodilation
-Alters capillary permeability
-Stimulates pain perception - correct answerHistamine
-Clear broth
-Coffee
-Tea
-Clear fruit juices
-Gelatin
-Popsicles
-Ice cream - correct answerExamples of clear liquid diet
-Establishment of trusting relationship
-Focus on education for overall wellness
-Detection and prevention of potential problems
,-Comprehensive health history, physical exam, and lab test - correct answerFirst
prenatal visit
-Failure to follow standard of care
-Failure to document
-Failure to be patient's advocate - correct answerMalpractice
-Important to a client's health and well-being
-Holistic care
-Important to clients
-Mandated by accreditors
-Helps to promote coping
-Positive relationship between this and health - correct answerSpiritual Care
-Irregular uterine contractions are felt, but the cervix is not affected
-Safest at home & not in hospital
-Usually felt in front of the abdomen - correct answerFalse/Latent/Early Labor
-Overall function: repair/removal of disease
-Acute and chronic - correct answerInflammation
-Positive pregnancy test
-Goodell's sign
-Chadwick's sign
-Hegar's sign
-Abdominal enlargement
-Braxton Hicks contractions
A. Probable signs
B. Presumptive signs
C. Positive signs
D. Both A & B
E. Both A & C
F. All of the above - correct answerA. Probable signs
-Regular diet w/modifications for texture
-Foods are chopped, ground, mashed, or soft - correct answerMechanically altered diet
-Relieves pain, reduces stress, enhances athletic performance, improves general well-
being
-Causes the relaxation response (lowers BP, HR, RR)
-Causes mechanical responses: physical effects from pressure applied to soft tissues -
correct answerMassage
-Teach patient with illness
-Improving quality of life
,-Family counseling
-Telehealth - correct answerTertiary Prevention
-Ultrasound verification of embryo or fetus
-Auscultation of fetal heart tones via Doppler
-Fetal movements felt by experienced clinician
These are all examples of what type of sign? - correct answerPositive signs
1-4 hours following delivery - correct answer4th Stage of Labor
1. A nurse assesses patients in a physician's office who are experiencing different levels
of health and illness. Which statements best define the concepts of health and illness?
Select all that apply.
A. Health and illness are the same for all people.
B. Health and illness are individually defined by each person.
C. People with acute illnesses are actually healthy.
D. People with chronic illnesses have poor health beliefs.
E. Health is more than the absence of illness.
F. Illness is the response of a person to a disease. - correct answerB, E, & F
1. Thirty-six hours after having surgery, a patient has a slightly elevated body
temperature and generalized malaise, as well as pain and redness at the surgical site.
Which intervention is most important to include in this patient's nursing care plan?
A. Document the findings and continue to monitor the patient.
B. Administer antipyretics, as ordered.
C. Increase the frequency of assessment to every hour and notify the patient's primary
care provider.
D. Increase the frequency of wound care and contact the primary care provider for an
antibiotic order. - correct answerThe assessment findings are normal for this stage of
healing following surgery. The patient is in the inflammatory phase of the healing
process, which involves a response by the immune system. This acute inflammation is
characterized by pain, heat, redness, and swelling at the site of the injury (surgery, in
this case). The patient also has a generalized body response, including a mildly
elevated temperature, leukocytosis, and generalized malaise.
1st Stage: When do you assess FHR? - correct answerLow-Risk: Every 30 min
High-risk: Every 15 min
1st Trimester Discomforts - correct answer-Urinary frequency or incontinence
-Fatigue
-Nausea and vomiting
-Breast tenderness
-Constipation
-Nasal stuffiness, bleeding gums, epistaxis
, -Cravings
-Leukorrhea
2 body tissues that do not need insulin for transport of glucose into the cells - correct
answerBrain and nerves
2nd Trimester Discomforts - correct answer-Backache
-Varicosities of the vulva and legs
-Hemorrhoids
-Flatulence with bloating
3. A patient who has a large abdominal wound suddenly calls out for help because she
feels as though something is falling out of her incision. Inspection reveals a gaping open
wound with tissue bulging outward. In which order should the nurse perform the
following interventions? Arrange from first to last.
A. Notify the physician immediately of the situation.
B. Cover the exposed tissue with sterile towels moistened with sterile NSS.
C. Place the patient in the low Fowler's position. - correct answerC, B, A Dehiscence
and evisceration is a postoperative emergency that requires prompt surgical repair. The
correct order of implementation by the nurse is to place the patient in the low Fowler's
position, cover the exposed tissue with sterile towels moistened with sterile NSS, and
notify the physician immediately of the situation.
3rd Trimester Discomforts - correct answer-Return of 1st trimester discomforts
-Shortness of breath and dyspnea
-Heartburn and indigestion
-Dependent edema
-Braxton Hicks contractions
6-8/9 cm dilation
-Contractions 2-5 min apart - correct answerActive phase of 1st stage of labor
6-8/9 cm dilation - correct answerActive phase of 1st stage of labor
8/9-complete dilation - correct answerTransition stage of 1st stage of labor
A birth without pain-relieving medications - correct answerNatural childbirth
A common site for infection in the elderly - correct answerUrinary tract
A female patient who is receiving chemotherapy for breast cancer tells the nurse, "The
treatment for this cancer is worse than the disease itself. I'm not going to come for my
therapy anymore." The nurse responds by using critical thinking skills to address this
patient problem. Which action is the first step the nurse would take in this process?
