Fundamentals Exam 2

FUNDAMENTAL EXAM 2
1. While performing an assessment, the nurse hears crackles in bilateral lower

lung lobes. The nurse adds a nursing diagnosis of impaired gas exchange. What
purpose does a nursing diagnoses serve? (Select all that apply.)
– Nursing diagnoses allow for greater autonomy in the nursing field.
- Nursing diagnoses allow for greater accountability to the nursing profession.
- Nursing diagnoses provide clear identification of the body of nursing knowledge.
2. A nurse is admitting a client who is immunocompromised and

receiving chemotherapy treatment. Which type of safety measures
should the nurse initiate?
Neuropathic precaution
3. A nurse assesses an oral temperature of an adult client. The

temperature is 96.3f. What term would the nurse use to report this
temperature?
Answer: Hypothermia: abnormal low body temperature
AFEBRILE means NOT FEVERISH

4. A nurse is working in a long-term care facility and delegates patient
care to unlicensed assistive personnel (UAP). which patient care
could the nurse most likely delegate (select all that apply)?
Answer:
Assisting patient with toileting
Assisting patient during mealtimes
Transferring a patient to the bedside commode.
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5. A nurse has just completed organizing and planning a new admitted clients
individualized care plan. What is the nurse next action?
Answer: Analyze assessment data to determine priorities for care.
6. How does wheezing in the airway affect perfusion in the body tissues?
Answer: When the airways are dilated, there is increased oxygen inspired and increased tissue
perfusion.
7. A 68-year-old patient five days post op following a major abdominal surgery

states ‘I don’t need to washup, I haven’t done anything to get dirty’. Which
nursing diagnosis is most appropriate for this patient.
Answer: Bathing self-care deficit.
8. A nurse is planning care for a client who has decreased level of consciousness
(LOC) following an accidental fall. What is an appropriate nursing
intervention?
Answer: Place the client in a room close to the nursing station with the call light easily accessible
and the bed alarm on.
9. After 4 days working with the same client and care plan, the nurse notes no
improvement in the condition or size of the wound and begins to revise the
plan. What phase of nursing process does care plan revision fall into?
Answer: Evaluation
10. Which of the following factors can affect risk for infection? (select all that
apply)
Answer: Age
Skin integrity
Drainage tube in place
Indwelling device
11. Any increase in the amount or consistency of sputum in the lungs will reduce
the diffusion of oxygen and carbon dioxide in the alveoli?
Answer: Diffusion.
12. What statement will a nurse include in a lesson of proper hand hygiene?
Rub all surfaces of your hands with an alcohol rub for at least 15-20 (20-30) seconds or until dry.
13. An individual is most infectious during what stage of infection.

Answer: Prodromal stage
14. The nurse discusses teaching with a patient going home on oxygen therapy. The
client demonstrates a lack of understanding after stating which of the
following?
Answer: I can use electrical equipment near oxygen administration.
15. The nurse is preparing to assess the cardiopulmonary system with inspection,
palpation, percussion, and auscultation. The patient complains of chest pain.
What priority assessments are needed next?
Answer: Palpate the chest wall for tenderness and instruct patient to inhale deeply to rule out
muscular pain.
16. The nurse would identify which body system as not directly involved in the
process of normal gas exchange?
Answer: Hepatic system
17. What is true of acute wounds?

Answer: Acute wounds usually heal within days to weeks.
18. A nurse working on an orthopedic unit is caring for four clients. What client is
at greatest risk for skin breakdown?
Answer: An older adult who has a hip fracture with poorly managed pain.
19. What desired outcome is most appropriate for a client with the nursing
diagnosis of impaired gas exchange.
Answer: Client will have oxygen saturation greater than 95% after activity.
20. A client is having difficulty climbing stairs and says it is difficult to catch their
breath. The nurse notes that the client is breathing rapidly at a rate of 35 breaths
per minute having nasal flaring and mouth is wide open. How will the nurse
document this client’s response to activity?
Answer: Tachypnea with activity.
21. A client had surgery on her right arm to remove a cyst. The surgical wound was
closed with ID sutures. This surgical wound is healing by what process?
Answer: Primary intention.
22. Which of the following are beneficial effects of fever?

Answer:
Destruction of disease-causing microorganisms.
23. What is not an approved method of rewarming a hypothermic patient?

Answer: Stimulating the hypothalamus with laser hydrolysis.
24. A nurse is planning care for an older adult client who is at risk for developing
pressure ulcers. What intervention should the nurse use to help maintain the
integrity of the client’s skin? (select all that apply)
Remove soiled clothing.
Keep skin clean and dry.
Apply barrier cream.
Reposition client every 2hrs
25. Your patient suddenly chetches his chest and collapses to the floor while
walking the halls, he becomes unresponsive. What is the first action you should
take?
Answer: Check the patient for a pulse.
26. When developing care plan nurses are person centered rather than task centered.
Guiding principle of person-centered care include: (select all that apply)
Answer:
Care is customized to reflect the client’s needs values and choices.
The Client is the source of control for their care.
Family and friends are considered as essential part of the care team.
27. During the planning phase of the nursing process, what is an appropriate
expected outcome for the nursing diagnosis of impaired gas exchange?
Answer: Client will tolerate oxygen wearing while maintaining oxygen saturations >94%.
28. A nurse is caring for an obese comatose obese client. What intervention reduces
friction and shear injury?
Answer: Using an electric ceiling lift to reposition client every 2 hours.
29. A nurse identifies a client as having a risk for impaired skin integrity. The
client’s position is changed every two hours as directed in the care plan. How
should the nurse evaluate the effectiveness of the intervention?
Answer: Examine the condition of the client’s skin using inspection and palpation.
30. When should a nurse wear eye protection (select all that apply)?
Answer:
While irrigate a wound with saline.
Collecting a sputum specimen from a client with pneumonia
31. A nurse is educating a married client on modifiable ways to lower the risk of
infections. The nurse should include what behaviors?
Answer: Smoking cessation.
32. A nurse is admitting a client who has influenza. What transmission-based

precaution should the nurse initiate?
Answer: Droplet.
33. What does the acronym Rice represent?

Answer: rest, ice, compression, elevation
34. An instructional strategy where leaners identify graphically display and link key
concepts is called?
Answer: Concept mapping
35. A nurse is assessing for cyanosis in the client who has dark skin. What site
should the nurse examine to identify cyanosis in the client?
Answer: Soles of the feet / palms of hands
36.The nurse is assessing an ischial pressure ulcer on a client. Objective data

reveals an ulcer that is 3cm X 2cm and involves partial thickness loss of the
epidermis. The nurse also notes an area of redness around the pressure ulcer. What
would the nurse document this wound as?
Answer: A stage II pressure ulcer with surrounding erythema
37.The nurse uses critical thinking in the evaluation phase of the nursing
process. What is an appropriate nursing action upon finding a pressure
ulcer that is larger than the previous measurement? (select all that apply).
Answer:
Evaluate client’s ability to reposition self in bed.

Modify interventions using evidence-based practice.
Collaborate with the interprofessional health care team to improve nutrition hydration and skin
care.
38.While assessing the client the nurse hears diminished lung sounds on
auscultation, counts a high rate of 22 and regular and obtains an oxygen
saturation of 89% on room air. what nursing diagnosis is best supported
by this assessment data?
Answer: Impaired gas exchange
39.You are caring a client who had knee replacement 2 days ago. The client
suddenly states, ‘I have tingling in my toes on the left foot’. What is the
first thing the nurse should assess?
Answer: Bilateral PEDAL pulses
*NOTE CHECK QUIZLET to verify answer.
40.While bathing a client the nurse notes a firm red area on the right chest,
the nurse should document this finding as:
Answer: Erythema: reddening of the skin
41. Which of the following assessment tools can be used to specifically identify clients at
risk of ulcer development?
Braden scale
42.A Client is admitted for treatment of poorly healing infected led ulcers.
What is the importance of obtaining the clients nutritional history?
Answer: wound healing and infection prevention are directly affected by poor nutrition.
43.After providing an influenza vaccination to a client, you accidentally

stick yourself with the needle. What action should be taken first?
Answer: Wash the area of the puncture thoroughly with soap and warm water.
44.You are the nurse caring for a client who has a stool culture positive for
clostridium difficile, prior to entering the room to complete the
assessment. What personal protective equipment (PPE) is required?
Answer: Clean gloves, isolation gown, hand washing with soap
45.What statement identifies the purpose of nursing diagnostic statements?

Answer: Nursing diagnosis identify actual problems and potential problems.
46.Physiological changes associated with aging place the elder adult clients
at risk for what nursing problem?
Answer: Impaired Skin Integrity.
47.While performing a health history questionnaire, a patient confirms that

he occasionally coughs up mucous. What additional questions will the
nurse follow up with? (select all that apply).
Answer: How much do you spit out?
What color is the mucous and is it ever blood-tinged?
Are there certain times of the day or environments where you cough up more mucous?
48. A client was admitted to a medical surgical unit with an antecubital fossa wound
infected with methicillin-resistant staphylococcus aureus (MRSA). What type of
isolation precaution is appropriate for this client?
Answer: Contact precautions with bleach, private room, gloves gowns, handwashing with
soap and water, clean with bleach products
49. What is a sign or symptom of early hypoxia?
Answer:
Restlessness Elevated
50. Pulse oximetry is a non-invasion test that measures the ------oxyhemoglobin saturation of
blood.
Answer: arterial
51. You are the nurse instructing client with chronic obstructive pulmonary disease (COPD)to
breath out slowly and gently, like blowing out a candle to prolong exhalation. What
techniques is this teaching?
Answer: pursed lip breathing
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FUNDAMENTAL EXAM 2

1. While performing an assessment, the nurse hears crackles in bilateral lower

2. A nurse is admitting a client who is immunocompromised and

3. A nurse assesses an oral temperature of an adult client. The

AFEBRILE means NOT FEVERISH

7. A 68-year-old patient five days post op following a major abdominal surgery

13. An individual is most infectious during what stage of infection.

17. What is true of acute wounds?

22. Which of the following are beneficial effects of fever?

23. What is not an approved method of rewarming a hypothermic patient?

32. A nurse is admitting a client who has influenza. What transmission-based

33. What does the acronym Rice represent?

36.The nurse is assessing an ischial pressure ulcer on a client. Objective data

Evaluate client’s ability to reposition self in bed.

43.After providing an influenza vaccination to a client, you accidentally

45.What statement identifies the purpose of nursing diagnostic statements?

47.While performing a health history questionnaire, a patient confirms that

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