FUNDAMENTALS OF NURSING FULL
EXAM
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 abo...
FUNDAMENTALS OF NURSING FULL EXAM 2023 \2024 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 - CORRECT ANSWER -D. Discipline 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 fi nding 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 - CORRECT ANSWER -A. Fairness Fairness involves analyzing all viewpoints to understand the situation completely before making a decision. Curiosity give s 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 t heir 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? - CORRECT ANSWER -D. Consist ency 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 de monstrating 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 suggest ions. This is an example of: A. Reflection B. Risk taking C. Problem solving D. Client assessment - CORRECT ANSWER -C. Problem Solving This is an example of problem solving because the nurse is taking a problem to a supervisor for help in finding a differe nt 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 - CORRECT ANSWER -C. Basic cri tical 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. As sessment D. Intervention - CORRECT ANSWER -C. Assessment 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 pla nning. 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 commu nication 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 - CORRECT ANSWER -C. Knowledge application The nurse sought appr opriate 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 critica l 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) Cl ient encouraged to consume more fluids. D) Client expressed concern about pending surgery. - CORRECT ANSWER -B. Client reports sharp pain in elft anterior knee 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 duri ng 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 an d 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. - CORRECT ANSWER -D. Ask the client and spouse if they need smoe 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?" - CORRECT ANSWER -C. "Why do you get up at night?" 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 awake ned. 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. Th e 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 - CORRECT ANSWER -D. Scientifially 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 acciden t. What tool should be used to plan her care? A) Care plan B) Care map C) Concept map D) Critical thinking - CORRECT ANSWER -C. Concept map 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. A client newly admitted to the hospital begins to have chest pain. Before calling the physician, the nurse should gather what additional data? (Select all that apply.) A) Pain intensity B) Location of pain C) Character of pain D) Radiation of pain E) Meaning of pain to the client F) Family history of myocardial infarctions - CORRECT ANSWER -A, B, C, D, and E The nurse should gather the data the physician will need to determine whether the chest pain represents a myocardial infarction. Family history is important in comprehensive pain assessment; however, taking time to obtain this information is inappropriate in this critical situation. The purpose of assessment is to: A) Make a diagnostic conclusion. B) Delegate nursing responsibility. C) Teach the client about his or her health. D) Establish a database concerning the client. - CORRECT ANSWER -D. Establish a database concerning the client The purpose of assessment is to establish a database about the client's perceived needs, health problems, and responses to these problems. The data also reveal related
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