FUNDAMENTALS

OF
NURSING PRACTICE
TESTBANK








Barbara Timbey



Test questions
1. When the nursing care plan indicates that a clients is to be weighted regularly,
which is most important to consider?
a. When the client was weighed before
b. When the client took a drink of fluid
c. How much the client has eaten so far today
d. Whether the client feels like being weighed
2. When a client asks how a transfusion of packed red blood cells differ from the
usual whole blood transfusion, the nurse is most correct in explaining that a unit
of packed red blood cells
a. Has the same number of red blood cells in less fluid volume
b. Contains more red blood cells in the same amount of fluid volume
c. Is less likely to cause an allergic transfusion reaction
d. Will stimulate the bone marrow to make more red blood cell
3. When a health nurse visits the home of a family being treated for
pediculosis(head lice), which of the following items should the nurse discourage
a. Pediculocide shampoo
b. Fine-toothed comb
c. Hair conditioner
d. Warm tap water
4. When a client develop pruritus(itching skin), which nursing measure is best for
relieving the clients discomfort
a. Use a medicated bath with oatmeal or cornstarch
b. Apply extra wool blankets to the bed for warmth
c. Give frequent shower or tub baths
d. Rub the skin dry after bathing
5. When observing an unlicensed nursing assistant make an occupied, which action
indicates a need for further learning?
a. The assistant loosens all the linen under the client
b. The assistant wear gloves to remove soiled linen
c. The assistant keep the bed in low position
d. The assistant rolls the client to the far side of the bed
6. When making an unoccupied bed of a client who has been incontinent of stool,
which action is essential?
a. The nurse discards all linen
b. The nurse don clean disposable gloves
c. The nurse uses fitted bottom sheet
d. The nurse puts a blanket over the top sheet





7. During the orientation of an unlicensed nursing assistant, which of the nurses
descriptions of a restraint alternative is most accurate?
a. It fasten behind the client
b. It is made f cloth or nylon
c. The client must be able to release the device
d. The client must give consent for its application
8. When providing health teaching to caregivers of older adults, the nurse is most
correct in identifying which of the following as the greatest safety issue
a. Chemical poisoning
b. Thermal burns
c. Electrical shock
d. Accidental falls
9. Which of the following nursing action is best to implement initially when
discovering an alert person who has ingested too much prescribed medication
a. Induce vomiting
b. Administer an antacid
c. Transport the person to the emergency department
d. Calls the persons personal physician immediately
10. If ta nurse determines that a physical restraint is necessary to maintain a clients
safety which of the following is essential
a. Obtaining a medical order for its use
b. Notifying the nursing supervisor
c. Administering a mild sedative
d. Charging the client for the equipment
11. When a nurse observes that a client with upper abdominal pain is curled in a fetal
position and rocking back and forth, which action would help most to further
assess the clients pain
a. Determine if the client can stop moving
b. Ask the client to rate the pain from 0 to 10
c. Observe if the client is perspiring heavily
d. Give the client a prescribed pain relieving drug
12. A nurse can expect that acute pain may have which of the following effects on
the clients vital signs?
a. Temperature may be elevated
b. Pulse rate may be rapid
c. Blood pressure may fall
d. Respiratory rate may be slow
13. When a client return from surgery, which sign is an early indication that the
clients oxygenation status is compromised
a. Clients dressing is bloody
b. Client become restless
c. Clients heart rate is irregular
d. Client indicates he is thirsty
A. Rationale
1. A
To evaluate trends in weight that may reflect deficient or excess fluid volumes,
the nurse weighs the client at the same time daily using the same scale each
time. The amount of clothing is similar at each weighing. If the time of weighing is
consistent, the amount of food or liquids that the client has been consuming is
not likely to vary considerably. It is important to collaborate with the client but
obtaining the weight is not omitted or postponed for frivolous reason
2. A
A unit of packed blood cells contains similar number of blood cells in less fluid
volume. A unit of packed red blood cells is prepared by removing approximately
two thirds of the plasma from 1 unit of whole blood. Administration of packed red
blood cell is preferred for client who need a blood transfusion but for whom
additional water within the circulatory system is hazardous. Typically the
candidate for packed blood cells is someone prone to excess fluid volume.
Packed red blood cell pose the same risk for an allergic transfusion reaction as
whole blood. Neither a transfusion of packed red blood cell nor whole blood
stimulate the bone marrow to produce more red blood
3. C
Hair conditioner is not recommended for those infected with head lice because it
coat the hair and protect the nits attached to the shafts of hair. Pediculocide
shampoos are effective, but some contain strong neurotoxic or carcinogenic
chemical that may be harmful for client who are pregnant, nursing, younger than
2 years, or who have open wounds, epilepsy, or asthma. Manual removal with
fine toothed combing tool is best for removal of nit and live lice. The water
temperature is of no consequence as long as it is not so hot as to burn the scalp
4. A
Soaking or immersing in water with substance like oatmeal or cornstarch relieves
itching. Rough fibers, like wool, irritate the skin and contribute to itching. Bathing
or showering frequently with soap removes skin oils and adds to or causes
itching. Rubbing the skin creates skin irritation and contributes t itching and skin
discomfort


5. A
Keeping the bed in low position while making an occupied bed predisposes to
muscle strain and back injury. Loosening the linen, wearing gloves to avoid
contact with blood fluids and rolling the client to the far side are appropriate
action
6. B
Gloves are essential barrier garment for avoiding contact with blood and body
fluids. The nurse may choose to reuse any linen that is not soiled. A flat or fitter
sheet can be used. The application of a blanket is based on the clients
preference
7. C
A restraint alternative is one which the client can release himself or herself
independently. It can be made from either nylon or cloth. Restraint fastens
behind the client does not facilitate being released without assistance. Although it
is beneficial to communicate with the client to maintain safety and cooperation,
their use may be implemented as nursing cooperation
8. C
Falls, more than any other injury are most common accident that older adults
experience
9. A
If an alert person has ingested an excessive amount of a non-caustic, non-
corrosive, non-petroleum substance, the first step in preventing complication is to
induce vomiting. Notify emergency medical services, who will transport the client
and medical care will be given. Emergency department will perform lavage and
activated charcoal. Antacid is not indicated in poisoning
10. A
According to omnibus budget reconciliation act(1897) which applies to the use of
restraints in long term facilities and most healthcare agency, that a nurse must
obtain a medical order for using a restraint and must be renewed every 24 hours
11. B
Asking the client to rate the pain using a numerical scale helps the nurse assess
its intensity. Noting whether or not the client can stop moving is not the best
assessment technique because a cooperative client may make an effort to stop
moving despite the continuation of severe pain. Perspiration may be triggered by
other factor, and may not be the best assessment. Administering analgesic is an
intervention
12. B
A client in acute pain is most likely to have rapid pulse rate, rapid respiratory rate
and rising blood pressure. Pain is least likely to influence body temperature
13. A
Of the choices provided, restlessness is the most indicative sign of early hypoxia.
Thirst is a sign of fluid volume deficit, client with compromised oxygenation are
more likely to manifest tachycardia rather than irregular heart rhythm.
reference
Timby B. (2005), Fundamental nursing skills and concepts 8
th
edition. P-
282,284,321,350,377,398,425-426,836-837