Nursing 101 Fundamentals of Nursing
Practice Exam 1, Part 2 (Carolinas
College of Health Sciences NCLEX
Questions that relate to Exam 1 in
Fundamentals of Nursing. Collected
from FoN NCLEX prep books,
Fundamentals Success, Potter and
Perry, and FoN NCLEX
/. During the change-of-shift report the night nurse states that a client mentioned having
a bad experience with surgery in the past. The nurse was called away and was unable
to continue the conversation with the client. The nurse tells the day shift nurse about the
comment and notes that the client appears anxious. When the day shift nurse visits the
client to clarify the client's bad experience with surgery, the nurse is exhibiting which
aspect of critical thinking?
A. Integrity
B. Discipline
C. Confidence
D. Perseverance
Discipline includes completing the task at hand, including assessments (which were not
completed on the previous shift). Integrity includes recognizing when one's opinions
conflict with those of others and finding a mutually satisfying solution. Confidence is
demonstrated in one's presentation and belief in one's knowledge and abilities.
Perseverance helps the critical thinker to find effective solutions to client care problems,
especially when they have been previously unresolved.
/.A client tells the nurse, "I'm not happy with the way the patient care technician did my
bath. He just seemed to be in a hurry and did not wash my back like I asked." The nurse
decides to go talk with the technician to learn his side of the story as well. This is an
example of:
A. Fairness
B. Curiosity
C. Risk taking
D. Responsibility
,Fairness involves analyzing all viewpoints to understand the situation completely before
making a decision. Curiosity gives the critical thinker the motivation to continue to ask
questions and learn more. Risk taking involves trying different ways to solve problems.
/.The surgical unit has initiated the use of a pain rating scale to assess the severity of
clients' pain during their postoperative recovery. The nurse assigned to a client can look
at the pain flow sheet to see the client's pain scores over the last 24 hours. Use of the
pain scale is an example of adherence to which intellectual standard? - Answer-.
Consistency
Using the same pain scale for all clients and ratings promotes consistency—each nurse
has the same measurement scale to compare assessments. Relevance refers to how
applicable the assessment is. An assessment has depth when it deals with less obvious
issues. Specificity refers to the ability of the assessment to provide information about
the particular problem of interest.
/.During the day the nurse spends time instructing a client in how to self-administer
insulin. After discussing the technique and demonstrating an injection, the nurse asks
the client to try it. After the client makes two attempts it is clear that the client does not
understand how to prepare the correct dose. The nurse discusses the situation with the
charge nurse and asks for suggestions. This is an example of:
A. Reflection
B. Risk taking
C. Problem solving
D. Client assessment
This is an example of problem solving because the nurse is taking a problem to a
supervisor for help in finding a different approach. Reflection is the process of
purposefully thinking back and recalling a situation to discover its purpose or meaning.
Risk taking involves trying a different approach. Client assessment is the first step in the
process of instruction.
/.A nurse uses an institution's procedure manual to confirm how to insert a Foley
catheter. The level of critical thinking the nurse is using is:
A. Commitment
B. Scientific method
C. Basic critical thinking
D. Complex critical thinking
At the basic level of critical thinking, a learner trusts the experts and follows a procedure
step by step. Complex critical thinkers separate themselves from authorities and
analyze and examine choices more independently. Commitment is the third level of
critical thinking in which the person anticipates the need to make choices without
assistance from others. The scientific method is a process of problem solving.
,/.A nurse refers to a client's postsurgical written plan of care, noting that the client has a
drainage device collecting wound drainage. The surgeon is to be notified when drainage
in the device exceeds 100 ml for the day. The nurse carefully notes the amount of
drainage currently in the device. This is an example of:
A. Planning
B. Evaluation
C. Assessment
D. Intervention
Assessment is the process of observing and collecting data. Planning is the step in
which the diagnosis is analyzed for problem resolution. Intervention consists of the
steps actually taken after planning. Evaluation measures the effectiveness of the plan.
/.The nurse asks a client how she feels about impending surgery for breast cancer.
Before initiating the discussion the nurse reviewed information about loss and grief in
addition to therapeutic communication principles. The critical thinking component
involved in the nurse's review of the literature is:
A) Experience
B) Problem solving
C) Knowledge application
D) Clinical decision making
The nurse sought appropriate information to be able to communicate more
knowledgeably with the client. Experience is acquired through clinical learning
situations. Problem solving is a series of steps to resolve a problem. Clinical decision
making is a process in which critical thinking steps are followed for problem resolution.
/.Which of the following is the most accurate information to give a nurse during change-
of-shift reporting?
A) Client refuses to take medications.
B) Client reports sharp pain in left anterior knee.
C) Client encouraged to consume more fluids.
D) Client expressed concern about pending surgery.
The information in option 2 represents objective data that the nurse can use as part of
baseline information. "Encouraged" and "more" are vague terms. "Concern" is also
vague; relating the exact concern would be more accurate. Option 1 may be true, but
accurate data would also report why the client refused medication.
/.On entering a client's room during change-of-shift rounds, the nurse notices that the
client and spouse have their backs turned to each other, and both have their arms
folded across their chests. The best action for the nurse to take at this time is to:
A) Introduce himself or herself and begin discharge teaching.
B) Proceed with the tasks the nurse was intending to perform.
C) Say nothing and leave quickly, closing the door behind.
, D) Ask the client and spouse if they need some time alone right now.
The situation suggests that the nurse entered during a stressful time. Offering privacy
would be appropriate. Because the situation indicates tension between the couple, this
is not the time to initiate teaching.
/.The nurse is assessing the urinary history of a middle-aged married woman. The nurse
asks her if she gets up at night. She replies, "Yes." What other question should the
nurse ask?
A) "How many times do you get up at night?"
B) "How long have you been getting up at night?"
C) "Why do you get up at night?"
D) "How easily do you go back to sleep after you get up?"
Perhaps it is the client's husband who is getting up in the middle of the night because of
a prostate problem, and this is why she is awakened. The nurse should not assume
nocturia without further assessment questions.
/.A client with diabetes mellitus who takes daily insulin injections is scheduled for
surgery the next day. The client is to take nothing by mouth (NPO status) after midnight.
The nurse questions whether insulin should be given the morning of surgery. This is an
example of:
A) Problem solving
B) Previous experience
C) Clinical practice guideline
D) Scientifically based clinical judgment
The nurse is demonstrating awareness of the effect of insulin, which is to lower blood
glucose level. Because the client will be NPO status for a long period of time, no
calories will be consumed. Giving the usual injection of insulin could cause the client to
experience hypoglycemia.
/.The client is a 65-year-old overweight woman with multiple medical diagnoses,
including diabetes mellitus type 2, hypertension, and residual right-sided weakness
resulting from a previous cerebrovascular accident. What tool should be used to plan
her care?
A) Care plan
B) Care map
C) Concept map
D) Critical thinking
A concept map is a visual representation of client problems and interventions that
shows their relationships to each other and allows easy synthesis of data about the
client.
Practice Exam 1, Part 2 (Carolinas
College of Health Sciences NCLEX
Questions that relate to Exam 1 in
Fundamentals of Nursing. Collected
from FoN NCLEX prep books,
Fundamentals Success, Potter and
Perry, and FoN NCLEX
/. During the change-of-shift report the night nurse states that a client mentioned having
a bad experience with surgery in the past. The nurse was called away and was unable
to continue the conversation with the client. The nurse tells the day shift nurse about the
comment and notes that the client appears anxious. When the day shift nurse visits the
client to clarify the client's bad experience with surgery, the nurse is exhibiting which
aspect of critical thinking?
A. Integrity
B. Discipline
C. Confidence
D. Perseverance
Discipline includes completing the task at hand, including assessments (which were not
completed on the previous shift). Integrity includes recognizing when one's opinions
conflict with those of others and finding a mutually satisfying solution. Confidence is
demonstrated in one's presentation and belief in one's knowledge and abilities.
Perseverance helps the critical thinker to find effective solutions to client care problems,
especially when they have been previously unresolved.
/.A client tells the nurse, "I'm not happy with the way the patient care technician did my
bath. He just seemed to be in a hurry and did not wash my back like I asked." The nurse
decides to go talk with the technician to learn his side of the story as well. This is an
example of:
A. Fairness
B. Curiosity
C. Risk taking
D. Responsibility
,Fairness involves analyzing all viewpoints to understand the situation completely before
making a decision. Curiosity gives the critical thinker the motivation to continue to ask
questions and learn more. Risk taking involves trying different ways to solve problems.
/.The surgical unit has initiated the use of a pain rating scale to assess the severity of
clients' pain during their postoperative recovery. The nurse assigned to a client can look
at the pain flow sheet to see the client's pain scores over the last 24 hours. Use of the
pain scale is an example of adherence to which intellectual standard? - Answer-.
Consistency
Using the same pain scale for all clients and ratings promotes consistency—each nurse
has the same measurement scale to compare assessments. Relevance refers to how
applicable the assessment is. An assessment has depth when it deals with less obvious
issues. Specificity refers to the ability of the assessment to provide information about
the particular problem of interest.
/.During the day the nurse spends time instructing a client in how to self-administer
insulin. After discussing the technique and demonstrating an injection, the nurse asks
the client to try it. After the client makes two attempts it is clear that the client does not
understand how to prepare the correct dose. The nurse discusses the situation with the
charge nurse and asks for suggestions. This is an example of:
A. Reflection
B. Risk taking
C. Problem solving
D. Client assessment
This is an example of problem solving because the nurse is taking a problem to a
supervisor for help in finding a different approach. Reflection is the process of
purposefully thinking back and recalling a situation to discover its purpose or meaning.
Risk taking involves trying a different approach. Client assessment is the first step in the
process of instruction.
/.A nurse uses an institution's procedure manual to confirm how to insert a Foley
catheter. The level of critical thinking the nurse is using is:
A. Commitment
B. Scientific method
C. Basic critical thinking
D. Complex critical thinking
At the basic level of critical thinking, a learner trusts the experts and follows a procedure
step by step. Complex critical thinkers separate themselves from authorities and
analyze and examine choices more independently. Commitment is the third level of
critical thinking in which the person anticipates the need to make choices without
assistance from others. The scientific method is a process of problem solving.
,/.A nurse refers to a client's postsurgical written plan of care, noting that the client has a
drainage device collecting wound drainage. The surgeon is to be notified when drainage
in the device exceeds 100 ml for the day. The nurse carefully notes the amount of
drainage currently in the device. This is an example of:
A. Planning
B. Evaluation
C. Assessment
D. Intervention
Assessment is the process of observing and collecting data. Planning is the step in
which the diagnosis is analyzed for problem resolution. Intervention consists of the
steps actually taken after planning. Evaluation measures the effectiveness of the plan.
/.The nurse asks a client how she feels about impending surgery for breast cancer.
Before initiating the discussion the nurse reviewed information about loss and grief in
addition to therapeutic communication principles. The critical thinking component
involved in the nurse's review of the literature is:
A) Experience
B) Problem solving
C) Knowledge application
D) Clinical decision making
The nurse sought appropriate information to be able to communicate more
knowledgeably with the client. Experience is acquired through clinical learning
situations. Problem solving is a series of steps to resolve a problem. Clinical decision
making is a process in which critical thinking steps are followed for problem resolution.
/.Which of the following is the most accurate information to give a nurse during change-
of-shift reporting?
A) Client refuses to take medications.
B) Client reports sharp pain in left anterior knee.
C) Client encouraged to consume more fluids.
D) Client expressed concern about pending surgery.
The information in option 2 represents objective data that the nurse can use as part of
baseline information. "Encouraged" and "more" are vague terms. "Concern" is also
vague; relating the exact concern would be more accurate. Option 1 may be true, but
accurate data would also report why the client refused medication.
/.On entering a client's room during change-of-shift rounds, the nurse notices that the
client and spouse have their backs turned to each other, and both have their arms
folded across their chests. The best action for the nurse to take at this time is to:
A) Introduce himself or herself and begin discharge teaching.
B) Proceed with the tasks the nurse was intending to perform.
C) Say nothing and leave quickly, closing the door behind.
, D) Ask the client and spouse if they need some time alone right now.
The situation suggests that the nurse entered during a stressful time. Offering privacy
would be appropriate. Because the situation indicates tension between the couple, this
is not the time to initiate teaching.
/.The nurse is assessing the urinary history of a middle-aged married woman. The nurse
asks her if she gets up at night. She replies, "Yes." What other question should the
nurse ask?
A) "How many times do you get up at night?"
B) "How long have you been getting up at night?"
C) "Why do you get up at night?"
D) "How easily do you go back to sleep after you get up?"
Perhaps it is the client's husband who is getting up in the middle of the night because of
a prostate problem, and this is why she is awakened. The nurse should not assume
nocturia without further assessment questions.
/.A client with diabetes mellitus who takes daily insulin injections is scheduled for
surgery the next day. The client is to take nothing by mouth (NPO status) after midnight.
The nurse questions whether insulin should be given the morning of surgery. This is an
example of:
A) Problem solving
B) Previous experience
C) Clinical practice guideline
D) Scientifically based clinical judgment
The nurse is demonstrating awareness of the effect of insulin, which is to lower blood
glucose level. Because the client will be NPO status for a long period of time, no
calories will be consumed. Giving the usual injection of insulin could cause the client to
experience hypoglycemia.
/.The client is a 65-year-old overweight woman with multiple medical diagnoses,
including diabetes mellitus type 2, hypertension, and residual right-sided weakness
resulting from a previous cerebrovascular accident. What tool should be used to plan
her care?
A) Care plan
B) Care map
C) Concept map
D) Critical thinking
A concept map is a visual representation of client problems and interventions that
shows their relationships to each other and allows easy synthesis of data about the
client.
