Nur101 Complete Fundamentals of Nursing Practice
Exam 1, Part 1 QUESTIONS AND CORRECT DETAILED
ANSWERS (VERIFIED ANSWERS)
.
Which data would be of greatest concern to the nurse when completing the nursing assessment of a 68-
year-old woman hospitalized due to Pneumonia?
A. Oriented to date, time and place
B. Clear breath sounds
C. Capillary refill greater than 3 seconds and buccal cyanosis
D. Hemoglobin of 13 g/dl
C. Capillary refill greater than 3 seconds and buccal cyanosis
Capillary refill greater than 3 seconds and buccal cyanosis indicate decreased oxygen to the tissues
which requires immediate attention/intervention. Oriented to date, time and place, hemoglobin of 13
g/dl are normal data.
.
What is the order of the nursing process?
A. Assessing, diagnosing, implementing, evaluating, planning
B. Diagnosing, assessing, planning, implementing, evaluating
C. Assessing, diagnosing, planning, implementing, evaluating
D. Planning, evaluating, diagnosing, assessing, implementing
C. Assessing, diagnosing, planning, implementing, evaluating
The correct order of the nursing process is assessing, diagnosing, planning, implementing, evaluating.
,.
Which of the following is the most important purpose of planning care with a patient?
A. Development of a standardized NCP.
B. Expansion of the current taxonomy of nursing diagnosis
C. Making of individualized patient care
D. Incorporation of both nursing and medical diagnoses in patient care
C. Making of individualized patient care
To be effective, the nursing care plan developed in the planning phase of the nursing process must
reflect the individualized needs of the patient.
.
What nursing action is appropriate when obtaining a sterile urine specimen from an indwelling catheter
to prevent infection?
A. Use sterile gloves when obtaining urine
B. Open the drainage bag and pour out the urine
C. Disconnect the catheter from the tubing and get urine
D. Aspirate urine from the tubing port using a sterile syringe
D. Aspirate urine from the tubing port using a sterile syringe
The nurse should aspirate the urine from the port using a sterile syringe to obtain a urine specimen.
Opening a closed drainage system increase the risk of urinary tract infection.
.
Jake is complaining of shortness of breath. The nurse assesses his respiratory rate to be 30 breaths per
minute and documents that Jake is tachypneic. The nurse understands that tachypnea means:
,A. Pulse rate greater than 100 beats per minute
B. Blood pressure of 140/90
C. Respiratory rate greater than 20 breaths per minute
D. Frequent bowel sounds
C. Respiratory rate greater than 20 breaths per minute
A respiratory rate of greater than 20 breaths per minute is tachypnea. A blood pressure of 140/90 is
considered hypertension. Pulse greater than 100 beats per minute is tachycardia. Frequent bowel
sounds refer to hyper-active bowel sounds.
Formulating a nursing diagnosis is a joint function of:
A. Patient and relatives
B. Nurse and patient
C. Doctor and family
D. Nurse and doctor
B. Nurse and patient
Although diagnosing is basically the nurse's responsibility, input from the patient is essential to
formulate the correct nursing diagnosis.
The nurse listens to Mrs. Sullen's lungs and notes a hissing sound or musical sound. The nurse
documents this as:
A. Wheezes
B. Rhonchi
C. Gurgles
D. Vesicular
A. Wheezes
, Wheezes are indicated by continuous, lengthy, musical; heard during inspiration or expiration. Rhonchi
are usually coarse breath sounds. Gurgles are loud gurgling, bubbling sound. Vesicular breath sounds are
low pitch, soft intensity on expiration.
.
Becky is on NPO since midnight as preparation for blood test. Adreno-cortical response is activated.
Which of the following is an expected response?
A. Low blood pressure
B. Warm, dry skin
C. Decreased serum sodium levels
D. Decreased urine output
D. Decreased urine output
Adreno-cortical response involves release of aldosterone that leads to retention of sodium and water.
This results to decreased urine output.
.
When performing an abdominal examination, the patient should be in a supine position with the head of
the bed at what position?
A. 30 degrees
B. 90 degrees
C. 45 degrees
D. 0 degree
D. 0 degree
The patient should be positioned with the head of the bed completely flattened to perform an
abdominal examination. If the head of the bed is elevated, the abdominal muscles and organs can be
bunched up, altering the findings.
Exam 1, Part 1 QUESTIONS AND CORRECT DETAILED
ANSWERS (VERIFIED ANSWERS)
.
Which data would be of greatest concern to the nurse when completing the nursing assessment of a 68-
year-old woman hospitalized due to Pneumonia?
A. Oriented to date, time and place
B. Clear breath sounds
C. Capillary refill greater than 3 seconds and buccal cyanosis
D. Hemoglobin of 13 g/dl
C. Capillary refill greater than 3 seconds and buccal cyanosis
Capillary refill greater than 3 seconds and buccal cyanosis indicate decreased oxygen to the tissues
which requires immediate attention/intervention. Oriented to date, time and place, hemoglobin of 13
g/dl are normal data.
.
What is the order of the nursing process?
A. Assessing, diagnosing, implementing, evaluating, planning
B. Diagnosing, assessing, planning, implementing, evaluating
C. Assessing, diagnosing, planning, implementing, evaluating
D. Planning, evaluating, diagnosing, assessing, implementing
C. Assessing, diagnosing, planning, implementing, evaluating
The correct order of the nursing process is assessing, diagnosing, planning, implementing, evaluating.
,.
Which of the following is the most important purpose of planning care with a patient?
A. Development of a standardized NCP.
B. Expansion of the current taxonomy of nursing diagnosis
C. Making of individualized patient care
D. Incorporation of both nursing and medical diagnoses in patient care
C. Making of individualized patient care
To be effective, the nursing care plan developed in the planning phase of the nursing process must
reflect the individualized needs of the patient.
.
What nursing action is appropriate when obtaining a sterile urine specimen from an indwelling catheter
to prevent infection?
A. Use sterile gloves when obtaining urine
B. Open the drainage bag and pour out the urine
C. Disconnect the catheter from the tubing and get urine
D. Aspirate urine from the tubing port using a sterile syringe
D. Aspirate urine from the tubing port using a sterile syringe
The nurse should aspirate the urine from the port using a sterile syringe to obtain a urine specimen.
Opening a closed drainage system increase the risk of urinary tract infection.
.
Jake is complaining of shortness of breath. The nurse assesses his respiratory rate to be 30 breaths per
minute and documents that Jake is tachypneic. The nurse understands that tachypnea means:
,A. Pulse rate greater than 100 beats per minute
B. Blood pressure of 140/90
C. Respiratory rate greater than 20 breaths per minute
D. Frequent bowel sounds
C. Respiratory rate greater than 20 breaths per minute
A respiratory rate of greater than 20 breaths per minute is tachypnea. A blood pressure of 140/90 is
considered hypertension. Pulse greater than 100 beats per minute is tachycardia. Frequent bowel
sounds refer to hyper-active bowel sounds.
Formulating a nursing diagnosis is a joint function of:
A. Patient and relatives
B. Nurse and patient
C. Doctor and family
D. Nurse and doctor
B. Nurse and patient
Although diagnosing is basically the nurse's responsibility, input from the patient is essential to
formulate the correct nursing diagnosis.
The nurse listens to Mrs. Sullen's lungs and notes a hissing sound or musical sound. The nurse
documents this as:
A. Wheezes
B. Rhonchi
C. Gurgles
D. Vesicular
A. Wheezes
, Wheezes are indicated by continuous, lengthy, musical; heard during inspiration or expiration. Rhonchi
are usually coarse breath sounds. Gurgles are loud gurgling, bubbling sound. Vesicular breath sounds are
low pitch, soft intensity on expiration.
.
Becky is on NPO since midnight as preparation for blood test. Adreno-cortical response is activated.
Which of the following is an expected response?
A. Low blood pressure
B. Warm, dry skin
C. Decreased serum sodium levels
D. Decreased urine output
D. Decreased urine output
Adreno-cortical response involves release of aldosterone that leads to retention of sodium and water.
This results to decreased urine output.
.
When performing an abdominal examination, the patient should be in a supine position with the head of
the bed at what position?
A. 30 degrees
B. 90 degrees
C. 45 degrees
D. 0 degree
D. 0 degree
The patient should be positioned with the head of the bed completely flattened to perform an
abdominal examination. If the head of the bed is elevated, the abdominal muscles and organs can be
bunched up, altering the findings.
