RN FUNDAMENTALS OF NURSING QUESTIONS & ANSWERS Plus Rationale | 2022 latest update
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RN FUNDAMENTALS OF NURSING
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RN FUNDAMENTALS OF NURSING
1. A facility has a system for transcribing medication orders to
a Kardex as well as a computerizedmedication administration
record (MAR). A physician writes the following order for a
client: "Prednisone 5 mg P.O. daily for 3 days." The order is
correctly transcri...
1 rn fundamentals of nursing 1 a facility has a system for transcribing medication orders to a kardex as well as a computerizedmedication administration record mar a physician writes the following
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RN FUNDAMENTALS OF NURSING client vomits and begins choking. Which of the following
actions is most appropriate for the nurse to take?
1. A facility has a system for transcribing medication orders to
a Kardex as well as a computerizedmedication administration a. Clear the client's airway.
record (MAR). A physician writes the following order for a b. Make the client comfortable.
client: "Prednisone 5 mg P.O. daily for 3 days." The order is c. Start cardiopulmonary resuscitation.
correctly transcribed on the Kardex. However, the nurse who d. Stop the feeding and remove the NG tube.
transcribes the order onto the MAR neglects to place the
limitation of 3 days on the prescription. On the 4th day after 8. The nurse is caring for a geriatric client with a pressure
the order was instituted, a nurse administers prednisone 5 mg ulcer on the sacrum. When teaching the client about
P.O. During an audit of the chart, the error is identified. The fundamentals in nursing on dietary intake, which foods should
person most responsible for the error is the: the nurse plan to emphasize?
a. nurse who transcribed the order incorrectly on the MAR a. Legumes and cheese
b. nurse who administered the erroneous dose. b. Whole grain products
c. pharmacist who filled the order and provided the c. Fruits and vegetables
erroneous dose. d. Lean meats and low-fat milk
d. facility because of its policy on transcription of
medications.
9. A client with chronic renal failure is admitted with a heart
rate of 122 beats/minute, a respiratory rate of 32
2. To evaluate a client's chief complaint, the nurse performs breaths/minute, a blood pressure of 190/110 mm Hg, neck
deep palpation. The purpose of deep palpation is to assess vein distention, and bibasilar crackles. Which nursing
which of the following? diagnosis takes highest priority for this client?
a. Skin turgor a. Fear
b. Hydration b. Urinary retention
c. Organs c. Excessive fluid volume
d. Temperature d. Self-care deficient: Toileting
3. One of the nursing fundamentals questions is about giving 10. A client's blood test results are as follows: white blood cell
an I.M. injection, the nurse should insert the needle into (WBC) count is 1,000/μl; hemoglobin (Hb) level, 14 g/dl;
the muscle at an angle of: hematocrit (HCT), 42%. Which of the following goals would be
most important for this client?
a. 15 degrees.
b. 30 degrees. a. Promote fluid balance
c. 45 degrees. b. Prevent infection.
d. 90 degrees. c. Promote rest.
d. Prevent injury.
4. A client, age 43, has no family history of breast cancer or
other risk factors for this disease. The nurse should instruct
her to have a mammogram how often
Answers and Rationale
a. Once, to establish a baseline
b. Once per year
1) B
c. Every 2 years
- The nurse administering the dose should have compared the
d. Twice per year
MAR with the Kardex and noted the discrepancy. The
transcribing nurse and pharmacist aren't void of
5. When prioritizing a client's plan of care based on Maslow's responsibility; however, the nurse administering the dose is
hierarchy of needs, the nurse's first priority would be: most responsible. The facility's policy does provide for a
system of checks and balances. Therefore, the facility isn't
a. allowing the family to see a newly admitted client. responsible for the error.
b. ambulating the client in the hallway.
c. administering pain medication 2) C
d. placing wrist restraints on the client. - The purpose of deep palpation, in which the nurse indents
the client's skin approximately 1½" (3.8 cm), is to assess
6. A 49-year-old client with acute respiratory distress watches underlying organs and structures, such as the kidneys and
everything the staff does and demands full explanations for spleen. Skin turgor, hydration, and temperature can be
all procedures and medications. Which of the following assessed by using light touch or light palpation
actions would best indicate that the client has achieved an
increased level of psychological comfort? 3) D
Nursing Fundamentals Questions Rationale: When giving an
a. Making decreased eye contact I.M. injection, the nurse inserts the needle into the muscle at
b. Asking to see family members a 90-degree angle, using a quick, dartlike motion. A 15-degree
c. Joking about the present condition angle is appropriate when administering an intradermal
,4) C a. Pulse rate greater than 100 beats per minute
- A client age 40 to 49 with no family history of breast b. Blood pressure of 140/90
cancer or other risk factors for this disease should have a c. Respiratory rate greater than 20 breaths per
mammogram every 2 years. After age 50, the client should minute
have a mammogram every year d. Frequent bowel sounds
5) C
2. The nurse listens to Mrs. Sullen‘s lungs and
- In Maslow's hierarchy of needs, pain relief is on the
notes a hissing sound or musical sound. The
first layer. Activity (option B) is on the second layer. Safety nurse documents this as:
(option D) is on the third layer. Love and belonging (option A)
are on the fourth layer. a. Wheezes
b. Rhonchi
6) D c. Gurgles
- Sleeping undisturbed for a period of time would indicate d. Vesicular
that the client feels more relaxed, comfortable, and trusting
and is less anxious. Decreasing eye contact, asking to see
family, and joking may also indicate that the client is more 3. The nurse in charge measures a patient‘s
relaxed. However, these also could be diversions. temperature at 101 degrees F. What is the
equivalent centigrade temperature?
7) A
- A living will states that no life-saving measures are to be a. 36.3 degrees C
b. 37.95 degrees C
used in terminal conditions. There is no indication that the
c. 40.03 degrees C
client is terminally ill. Furthermore, a living will doesn't apply
d. 38.01 degrees C
to nonterminal events such as choking on an enteral feeding
device. The nurse should clear the client's airway. Making the
client comfortable ignores the life-threatening event. 4. Which approach to problem solving tests any
Cardiopulmonary resuscitation isn't indicated, and removing number of solutions until one is found that works
the NG tube would exacerbate the situation for that particular problem?
8) D a. Intuition
- Although the client should eat a balanced diet with foods b. Routine
from all food groups, the diet should emphasize foods that c. Scientific method
supply complete protein, such as lean meats and low-fat milk, d. Trial and error
because protein helps build and repair body tissue, which
promotes healing. Fundamentals in nursing teaches that
legumes provide incomplete protein. Cheese contains 5. What is the order of the nursing process?
complete protein, but also fat, which should be limited to
30% or less of caloric intake. Whole grain products supply a. Assessing, diagnosing, implementing,
incomplete proteins and carbohydrates. Fruits and vegetables evaluating, planning
provide mainly carbohydrates. b. Diagnosing, assessing, planning,
implementing, evaluating
c. Assessing, diagnosing, planning, implementing,
9) C evaluating
- A client with renal failure can't eliminate sufficient fluid, d. Planning, evaluating, diagnosing, assessing,
increasing the risk of fluid overload and consequent implementing
respiratory and electrolyte problems. This client has signs of
excessive fluid volume and is acutely ill. Fear and a toileting
self-care deficit may be problems, but they take lower priority 6. During the planning phase of the nursing
because they aren't life-threatening. Urinary retention may process, which of the following is the outcome?
cause renal failure but is a less urgent concern than fluid
imbalance. a. Nursing history
b. Nursing notes
10) B c. Nursing care plan
- The client is at risk for infection because the WBC count is d. Nursing diagnosis
dangerously low. Hb level and HCT are within normal limits;
therefore, fluid balance, rest, and prevention of injury are
7. What is an example of a subjective data?
inappropriate.
a. Heart rate of 68 beats per minute
b. Yellowish sputum
c. Client verbalized, ―I feel pain when urinating.‖
Nursing Board Review: Fundamentals of
d. Noisy breathing
Nursing Practice Test Part 1
http://www.rnpedia.com/home/exams/philippine-board-
exam-nle/nursing-board-review-fundamentals-of-nursing- 8. Which expected outcome is correctly written?
practice-test-part-1
a. ―The patient will feel less nauseated in 24
,from a prepared list by discharge.‖ get urine.
d. ―The patient will have enough sleep.‖ d. Aspirate urine from the tubing port using a
sterile syringe.
9. Which of the following behaviors by Nurse Jane
Robles demonstrates that she understands well 16. A client is receiving 115 ml/hr of continuous
th elements of effecting charting? IVF. The nurse notices that the venipuncture site
is red and swollen. Which of the following
a. She writes in the chart using a no. 2 pencil. interventions would the nurse perform first?
b. She noted: appetite is good this afternoon.
c. She signs on the medication sheet after a. Stop the infusion
administering the medication. b. Call the attending physician
d. She signs her charting as follow: J.R c. Slow that infusion to 20 ml/hr
d. Place a clod towel on the site
10. What is the disadvantage of computerized
documentation of the nursing process? 17. The nurse enters the room to give a
prescribed medication but the patient is inside
a. Accuracy the bathroom. What should the nurse do?
b. Legibility
c. Concern for privacy a. Leave the medication at the bedside and leave
d. Rapid communication the room.
b. After few minutes, return to that patient‘s room
and do not leave until the patient takes the
11. The theorist who believes that adaptation and medication.
manipulation of stressors are related to foster c. Instruct the patient to take the medication and
change is: leave it at the bedside.
d. Wait for the patient to return to bed and just
a. Dorothea Orem leave the medication at the bedside.
b. Sister Callista Roy
c. Imogene King
d. Virginia Henderson 18. Which of the following is inappropriate
nursing action when administering NGT feeding?
12. Formulating a nursing diagnosis is a joint a. Place the feeding 20 inches above the pint if
function of: insertion of NGT.
b. Introduce the feeding slowly.
a. Patient and relatives c. Instill 60ml of water into the NGT after feeding.
b. Nurse and patient d. Assist the patient in fowler‘s position.
c. Doctor and family
d. Nurse and doctor
19. A female patient is being discharged after
thyroidectomy. After providing the medication
13. Mrs. Caperlac has been diagnosed to have teaching. The nurse asks the patient to repeat
hypertension since 10 years ago. Since then, she the instructions. The nurse is performing which
had maintained low sodium, low fat diet, to professional role?
control her blood pressure. This practice is viewed
as: a. Manager
b. Caregiver
a. Cultural belief c. Patient advocate
b. Personal belief d. Educator
c. Health belief
d. Superstitious belief
20. Which data would be of greatest concern to
the nurse when completing the nursing
14. Becky is on NPO since midnight as assessment of a 68-year-old woman hospitalized
preparation for blood test. Adreno-cortical due to Pneumonia?
response is activated. Which of the following is an
expected response? a. Oriented to date, time and place
b. Clear breath sounds
a. Low blood pressure c. Capillary refill greater than 3 seconds and
b. Warm, dry skin buccal cyanosis
c. Decreased serum sodium levels d. Hemoglobin of 13 g/dl
d. Decreased urine output
21. During a change-of-shift report, it would be
15. What nursing action is appropriate when important for the nurse relinquishing
obtaining a sterile urine specimen from an responsibility for care of the patient to
indwelling catheter to prevent infection? communicate. Which of the following facts to the
, a. That the patient verbalized, ―My headache is Vesicular breath sounds are low pitch, soft
gone.‖ intensity on expiration.
b. That the patient‘s barium enema performed 3
days ago was negative 3. (B) 37.95 degrees C
c. Patient‘s NGT was removed 2 hours ago To convert °F to °C use this formula, ( °F – 32 )
d. Patient‘s family came for a visit this morning. (0.55). While when converting °C to °F use this
formula, ( °C x 1.8) + 32. Note that 0.55 is 5/9
and 1.8 is 9/5.
22. Which statement is the most appropriate goal
for a nursing diagnosis of diarrhea? 4. (D) Trial and error
The trial and error method of problem solving
a. ―The patient will experience decreased isn‘t systematic (as in the scientific method of
frequency of bowel elimination.‖ problem solving) routine, or based on inner
b. ―The patient will take anti-diarrheal prompting (as in the intuitive method of problem
medication.‖ solving).
c. ―The patient will give a stool specimen for
laboratory examinations.‖ 5. (C) Assessing, diagnosing, planning,
d. ―The patient will save urine for inspection by implementing, evaluating
the nurse. The correct order of the nursing process is
assessing, diagnosing, planning, implementing,
evaluating.
23. Which of the following is the most important
purpose of planning care with this patient? 6. (C) Nursing care plan
The outcome, or the product of the planning
a. Development of a standardized NCP. phase of the nursing process is a Nursing care
b. Expansion of the current taxonomy of nursing plan.
diagnosis
c. Making of individualized patient care 7. (C) Client verbalized, “I feel pain when
d. Incorporation of both nursing and medical urinating.”
diagnoses in patient care Subjective data are those that can be described
only by the person experiencing it. Therefore,
only the patient can describe or verify whether he
24. Using Maslow‘s hierarchy of basic human is experiencing pain or not.
needs, which of the following nursing diagnoses
has the highest priority? 8. (C) “The patient will identify all the high-
salt food from a prepared list by
a. Ineffective breathing pattern related to pain, as discharge.”
evidenced by shortness of breath. Expected outcomes are specific, measurable,
b. Anxiety related to impending surgery, as realistic statements of goal attainment. The
evidenced by insomnia. phrases ―right amount‖, ―less nauseated‖ and
c. Risk of injury related to autoimmune ―enough sleep‖ are vague and not measurable.
dysfunction
d. Impaired verbal communication related to 9. (C) She signs on the medication sheet
tracheostomy, as evidenced by inability to speak. after administering the medication.
A nurse should record a nursing intervention (ex.
Giving medications) after performing the nursing
25. When performing an abdominal examination, intervention (not before). Recording should also
the patient should be in a supine position with the be done using a pen, be complete, and signed
head of the bed at what position? with the nurse‘s full name and title.
a. 30 degrees 10. (C) Concern for privacy
b. 90 degrees A patient‘s privacy may be violated if security
c. 45 degrees measures aren‘t used properly or if policies and
d. 0 degree procedures aren‘t in place that determines what
type of information can be retrieved, by whom,
and for what purpose.
Answer and Rationale : Fundamentals in
Nursing Practice Test Part 1 11. (B) Sister Callista Roy
Sister Roy‘s theory is called the adaptation theory
and she viewed each person as a unified
1. (C) Respiratory rate greater than 20 biophysical system in constant interaction with a
breaths per minute changing environment. Orem‘s theory is called
A respiratory rate of greater than 20 breaths per self-care deficit theory and is based on the belief
minute is tachypnea. A blood pressure of 140/90 that individual has a need for self-care actions.
is considered hypertension. Pulse greater than King‘s theory is the Goal attainment theory and
100 beats per minute is tachycardia. Frequent described nursing as a helping profession that
bowel sounds refer to hyper-active bowel sounds. assists individuals and groups in society to attain,
maintain, and restore health. Henderson
2. (A) Wheezes introduced the nature of nursing model and
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