Fundamental Exam 3

1. Before developing a procedure, a nurse reviews all current research-based

literature on insertion of an NG tube. What type of nursing will be practiced
based on this review?
a. Authoritative nursing
b. Institutional practice
c. Factual-based nursing
d. Evidence-based nursing
2. After assessing a patient, a nurse documents the state of awareness as
confused. The nurse is aware that which part of the brain controls awareness?
a. Cranial nerves
b. Hypothalamus
c. Medulla
d. Reticular activating system
3. The nurse is caring for a patient who is recovering from a traumatic brain
injury and frequently becomes disoriented to everything except her location.
Which nursing intervention would be effective in orienting a patient with
neurological deficit?
a. Keeping a day-by-day calendar at the patients bedside and have the
patient manage it.
b. Assessing the patients level of consciousness and documenting every
4 hours.
c. Placing a patient observer in the patients room for safety.
d. Informing the patient that she cannot be discharged unless she is
awake, alert, and oriented.
4. A nurse documents the following on a patient chart: Patient manifests acute
onset of disorganized thinking, impaired memory, and delusions and
hallucinations. What state of arousal/awareness does this describe?
a. Locked-in syndrome
b. Dementia
c. Delirium
d. Depression
5. A nurse implements a back massage as an intervention to relieve pain. The
nurse is aware that which theory serves as the motivation for this
intervention?
a. Large/small fiber theory
b. Prostaglandin stimulation
c. Gate control theory
d. Neuromodulation
6. The nurse would expect to see increased ventilations if a patient exhibits:
a. Decreased pH.
b. Decreased carbon dioxide levels.
c. Increased oxygen saturation.
d. Increased hemoglobin levels.
7. A nurse is formulating a clinical question in PICO format. What does the letter
P represent?
a. Explicit descriptions of the population of interest.
b. Specific identifications of the desired outcome.
c. Comparison to another similar treatment.

d. Clearly defined, focused literature review.

8. The nurse is caring for a patient in acute respiratory distress. The patient has
multiple monitoring systems on that constantly beep and make noise. The
patient is becoming agitated and frustrated over inability to sleep. Which
action by the nurse is most appropriate for this patient?
a. Administer and opioid medication to help the patient sleep.
b. Turn off the alarms on the monitoring devices.
c. Provide the patient with a therapeutic backrub.
d. Provide the patient with earplugs.
9. A patient calls the nurse because he is having incision pain and want a dose
of analgesic medication. When the nurse check the patients medications
administration record, she notes that his is prescribed the opioid,
hydromorphone (Dilaudid). Where should the nurse expect to retrieve this
drug for administration?
a. Stock supply mediation drawer.
b. Double-locked medication drawer.
c. Portable medication chart.
d. Cabinet in the patients room.
10.The nurse is caring for a patient who recently had surgery to repair a hernia.
The patients pain was 7 out of 10 before receiving pain medication. One hour
after receiving an oral opioid, the patient rates his pain at 3 out of 10. The
patient asks the nurse why he isnt receiving more pain medication. Which is
the nurses best response?
a. It can take 2 hours for oral pain medication to work, and your pain is
going down. Lets try boosting you up in bed and putting an ice pack
on the incision to see if that helps.
b. If the pain becomes severe, we may need to transfer you to and ICU.
c. This medication can be given only every 4 hours. It is not time for you
to have any other pain medication right now.
d. I will notify the health care provider to come perform an assessment
of your pain if it doesnt improve in 30 minutes.
11.The nurse is caring for a patient who has been diagnosed with a stroke. As
part of her ongoing care, the nurse should:
a. Place the patient on bed rest to prevent fatigue.
b. Provide a complete bed bath to promote patient comfort.
c. Encourage the patient to perform as many self-care activities as
possible.
d. Understand that the patient will not eat anything owing to a decreased
energy need.
12.A patient has a severe abdominal injury with damage to the liver and colon
from a motorcycle crash. The nurse is aware that what type of pain will
predominate?
a. Neuropathic pain
b. Visceral pain
c. Psychogenic pain
d. Cutaneous pain

13.The nurse is preparing to position an immobile patient. Before doing so, the
nurse must understand that:
a. Following body mechanics principles alone will prevent back injury.
b. Body mechanics alone are not sufficient to prevent injuries
c. Body mechanics are not as important when patient handling
equipment is used.
d. Manual lifting is the easier method and should be tried first.
14.The hospital policy states that when starting an IV catheter, the nurse must
first prepare the potential IV site with alcohol and dress it using a gauze
dressing. The nurse has done a literature review and believes that evidencebased practice dictates the uses of transparent dressing to prevent catheter
dislodgment. What should the nurse do?
a. Being to use transparent dressing instead of gauze dressings.
b. Continue following hospital policy without saying anything.
c. Bring findings to the policy and procedures committee.
d. Use transparent dressings on half of her IV starts and gauze on the
other.
15.The student nurse is preparing to document a suspicious area over a bony
prominence. Which description would be most appropriate?
a. Nonblanching area over left trochanter 0.8 cm X 1.2 cm.
b. Suspicious area over left trochanter.
c. Reddened area on left hip.
d. Reddened, nonblanching area approximately 1 cm X 1 cm.
16.A patient with type 1 diabetes has impaired sensation in her lower
extremities. What teaching would be necessary to reduce her risk of injury?
a. rub lotion on the skin of your legs and feet twice a day,
b. Take your insulin twice a day as we have discussed.
c. Always test the temperature of bath water before stepping in.
d. Remember to follow your diet so you continue to lose weight this
month.
17.The nurse anticipates administering opioid fentanyl patch to which patient?
a. A 30 year old adult with cellulitis.
b. An 80 year old patient with a broken hip.
c. A 50 year old patient with prostate cancer.
d. A 15 year old adolescent with a broken femur.
18.A postop patient has not voided for 8 hours (since surgery). He is restless and
complains of abdominal pain. How and what would the nurse assess before
administering pain medication?
a. Percuss abdomen for sounds of tympany.
b. Palpate abdomen for distended bladder.
c. Check electronic medical record for last bowel movement.
d. Auscultate abdomen for bowel sounds.
19.A nurse is caring for a person who is delusional. What is important for the
nurse to do while communicating with the patient?
a. Reinforce reality for delusional patients.
b. Maintain eye contact at all times.
c. Avoid arguing about erroneous statements.
d. Touch the patient gently while taking.

20.A patient who has had a recent BKA tells the nurse that he feels as though his
ties are cramping. What would the nurse say in return?
a. I think it might be good to refer you to a psychiatrist.
b. That is called phantom pain, and it is not unusual.
c. Oh, that is all in your mind. Just forget it.
d. Well, this is really strange. I will notify the doctor.
21.A nurse is caring for a patient who recently had spinal surgery. The nurse
knows that patients usually experience acute pain following this type of
surgery. The patient refuses to get up and walk and is not moving around in
the bed. However, the patient is stoic and denies experiencing pain at this
time. What most likely explains this patients behavior and response to
surgery?
a. The surgery successfully cured the patients pain.
b. The patients culture is possibly influencing the patients experience of
pain.
c. The nurse is allowing personal beliefs to influence pain management at
this time.
d. The patient is experiencing urinary retention because of manipulation
of the spine during surgery; this is preventing the patient from
experiencing pain.
22.Which of the following are conditions that must be met for a person to receive
the necessary data to experience the world? Select all that apply?
a. A particular area in the brain must receive and translate the impulse
into a sensation.
b. A stimulus must be present.
c. A receptor or sense organ must receive the stimulus and convert it to a
nerve impulse.
d. The person must physically and mentally recognize the stimulus and
accept or reject it in the brain.
e. The nerve impulse must be conducted along a nervous pathway from
the receptor or sense organ to the brain.
f. The stimulus must be recognized by the cardiovascular system and
sent to the brain.
23.Which of the following are characteristics of the stage of infection known as
full stage of illness? Select all that apply.
a. The presence of specific signs and symptoms indicates the full stage of
illness.
b. The type of infection determines the length of the illness and the
severity of the manifestations.
c. During the full stage of illness, the organisms are growing and
multiplying.
d. Early signs and symptoms of disease are present, but these are often
vague and nonspecific.
e. It is the interval between the pathogens invasion of the body and the
appearance of symptoms of infection.

Answers
1. D
2. D
3. A
4. C
5. C
6. A
7. A
8. D
9. B
10.A
11.C
12.B
13.B
14.C
15.A
16.C
17.C
18.B
19.A
20.B
21.B
22.A, B, C, E
23.A, B