FUNDAMENTALS OF NURSING

(ANSWER KEY – RATIONALE)

1. To help minimize calcium loss from a hospitalized client's bones, the nurse should:
a. reposition the client every 2 hours.
b. encourage the client to walk in the hall
c. provide the client daily products at frequent intervals
d. provide supplemental feedings between meals.

RATIONALE: Calcium absorption diminishes with reduced physical activity because of decreased bone stimulation.
Therefore, encouraging the client to increase physical activity such as by walking the hall, helps minimize calcium
loss. Turning or repositioning the client every 2 hours wouldn’t increase activity sufficiently to minimize bone loss,
Providing dairy products and supplemental feedings wouldn't lessen calcium loss - even if the dairy products and
feedings contained extra calcium — because the additional calcium doesn’t increase bone stimulation or osteoblast
activity.

2. A nurse notes that a client’s I.V. insertion site is red, swollen, and warm to the touch. which action should the
nurse take first?
a. Discontinue the I.V. infusion.
b. Apply a warm, moist compress to the I.V. site.
c. Assess the I.V. infusion for patency.
d. Apply an ice pack to the I.V. site.

RATIONALE: Because redness, swelling, and warmth at an I.V. site are signs of infection, the nurse should
discontinue the infusion immediately and restart at another site. After doing this, the nurse should apply warmth to
the original site. Checking infusion patency isn't warranted because assessment findings suggest infection and
inflammation, not infiltration. Heat, not cold is the appropriate treatment for inflammation.

3. During her morning assessment, a nurse notes that a client has severe dyspnea, his respirations are 34
breaths/minute and labored. Oxygen saturation is 79% on 3L of oxygen. The nurse remembers that the client's chart
includes his living will, When considering best practice, the nurse should:
a. withhold all potentially life-prolonging treatments in accordance with the client's living will
b. increase the oxygen flow rate to 4L, but avoid initiating other interventions
c. call the client’s family and ask what they think is best.
d. initiate potentially life-prolonging treatment unless the client refuses.

RATIONALE: A living will doesn't go into effect unless the client is unable to make his own decisions. A nurse
shouldn't withhold care for an alert client unless he specifically refuses care. The nurse should give all appropriate
care while also maintaining the client's right to refuse treatment. Increasing the oxygen flow rate might be an
appropriate response, but isn't the best action at this time. The family isn't responsible for determining care at this
time.

4. A nurse identifies a client’s responses to actual or potential health problems during which step of the nursing
process?
a. Assessment
b. Diagnosis
c. Planning
d. Evaluation

RATIONALE: The nurse identifies human responses to actual or potential health problems during the diagnosis step
of the nursing process, which encompasses the nurse’s ability to formulate a nursing diagnosis. During the
assessment step, the nurse systematically collects data about the client or his family. During the planning step, she
develops strategies to resolve or decrease the client’s problem. During the evaluation step, the nurse determines the
effectiveness of the care plan.
5. A nurse determines that a client has 20/40 vision. Which statement about this client’s vision is true?
a. The client can read the entire vision chart at a distance of 40 feet.
b. The client can read from a distance of 20 feet what a person with normal vision can read at a
distance of 40 feet.
c. The client can read the vision chart from a distance of 20 feet with the right eye and from 40 feet with the left
eye.
d. The client can read at a distance of 40 feet what a person with normal vision can read at a distance of 20 feet.

RATIONALE: The numerator, which is always 20, is the distance in feet between the vision chart and the client. The
denominator indicates from what distance a person with normal vision can read the chart.

6. When examining a client who has abdominal pain, a nurse should assess:
a. any quadrant first.
b. the symptomatic quadrant first.
c. the symptomatic quadrant last.
d. the symptomatic quadrant either second or third.

Rationale: The nurse should systematically assess all areas of the abdomen, if time and the client's condition permit,
concluding with the symptomatic area. Otherwise, the nurse may elicit pain in the symptomatic area, causing the
muscles in other areas to tighten. This tightening would interfere with further assessment.

7. A nurse caring for a client who has suffered a severe stroke. During routine assessment, the nurse notices
Cheyne-Stokes respirations. Cheyne-Stokes respirations are:
a. progressively deeper breaths followed by shallower breaths with apneic periods.
b. rapid, deep breaths with abrupt pauses between each breath.
c. rapid, deep breaths and irregular breathing without pauses.
d. shallow breaths with an increased respiratory rate.

RATIONALE: Cheyne-Stokes respirations are breaths that become progressively deeper followed by shallower
respirations with apneic periods. Biot’s respirations are rapid, deep breaths with abrupt pauses between each breath,
and equal depth between each breath. Kussmaul’s respirations are rapid, deep breaths without pauses. Tachypnea is
abnormally rapid respirations.

8. When positioned properly, the top of a central venous catheter should lie in the:
a. superior vena cava.
b. basilic vein.
c. jugular vein.
d. subclavian vein.

RATIONALE: When positioned correctly, the top of a central venous catheter lies in the superior vena cava, inferior
vena cava, or right atrium — that is, in the central venous circulation. Blood flows unimpeded around the tip,
allowing the rapid infusion of large amounts of fluid directly into circulation. The basilic, jugular, and subclavian veins
are common insertion sites for central venous catheters.

9. The ear canal of an infant or young child:

a. slants upward.
b. slants downward.
c. is horizontal.
d. slants backward.

Rationale: The ear canal slants up in a younger child and down in an older child or adult.

10. When a central venous catheter dressing becomes moist or loose, what should a nurse do first?
a. Draw a circle around the moist spot and note the date and time.
b. Notify the physician.
c. Remove the catheter, check for catheter integrity, and send the tip for culture.
d. Remove the dressing, clean the site, and apply a new dressing.

Rationale: A nurse maintaining a central venous catheter should change the dressing every 72 hours or when it
becomes soiled, moist, or loose. After removing the soiled dressing, the nurse should use sterile technique to clean
around the site in accordance with facility policy. After the cleaning solution has dried, the nurse should cover the
site with a transparent semipermeable dressing. A nurse who notes drainage on a wound dressing should draw a
circle around the moist spot and note the date and time. She should notify the physician if she observes any
catheter-related complications. Only a nurse with the appropriate qualifications may remove a central venous
catheter, and a moist or loose dressing isn’t a reason to remove the catheter.
References: Smeltzer, S.C., and Bare, B. Brunner&Suddarth’s Texthook of MedicalSurgical Nursing, 11th ed.
Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1005

11. Which of the following patients is at greater risk for contracting an infection?
A. A patient with leukopenia
B. A patient receiving broad-spectrum antibiotics
C. A postoperative patient who has undergone orthopedic surgery
D. A newly diagnosed diabetic patient

Rationale: Leukopenia is a decreased number of leukocytes (white blood cells), which are important in
resisting infection. None of the other situations would put the patient at risk for contracting an infection; taking
broad-spectrum antibiotics might actually reduce the infection risk.

Reference: Potter, P. & Perry, A. (2009). Fundamentals of Nursing (7th ed.) St. Louis: Mosby Elsevier, 1029-
1084

Core Competency Standard: Research

Nursing Process: Evaluation
Cognitive Domain: Knowledge

12. According to her, Nursing is a helping or assistive profession to persons who are wholly or partly dependent or
when those who are supposedly caring for them are no longer able to give care.

A. Henderson
B. Orem
C. Swanson
D. Neuman

Rationale: B In self-care deficit theory, Nursing is defined as A helping or assistive profession to person who are
wholly or partly dependent or when people who are to give care to them are no longer availabla. Self-care, are the
activities that a person do for himself to maintain health, life and well-being.

13. The unique function of the nurse is to assist the individual, sick or well, in the performance of those activities
contributing to health that he would perform unaided if he has the necessary strength, will and knowledge, and do
this in such a way as to help him gain independence as rapidly as possible
A. Henderson
B. Abdellah
C. Levin
D. Peplau

Rationale: A This was an actual board question. Remember this definition and associate it with Virginia Henderson.
Henderson also describes the NATURE OF NURSING theory. She identified 14 basic needs of the client. She describes
nursing roles as SUBSTITUTIVE: Doing everything for the client, SUPPLEMENTARY: Helping the client and
COMPLEMENTARY: Working with the client. Breathing normally, eliminating waste, Eating and drinking adequately,
Worship and Play are some of the basic needs according to her.

14. The act of utilizing the environment of the patient to assist him in his recovery is theorized by
A. Nightingale
B. Benner
C. Swanson
D. King

Rationale: A, Florence nightingale do not believe in the germ theory, and perhaps this was her biggest mistaka. Yet,
her theory was the first in nursinc. She believed that manipulation of environment that includes appropriate noise,
nutrition, hygiene, light, comfort, sanitation etc. could provide the client’s body the nurturance it needs for repair and
recovery.

14. Benner’s “Proficient” nurse level is different from the other levels in nursing expertise in the context of having:
A. the ability to organize and plan activities

B. having attained an advanced level of education

C. a holistic understanding and perception of the client
D. intuitive and analytic ability in new situations

15. The nurse uses a stethoscope to auscultate a male patient’s chest. Which statement about a stethoscope with a
bell and diaphragm is true?
a. The bell detects high-pitched sounds best
b. The diaphragm detects high-pitched sounds best
c. The bell detects thrills best
d. The diaphragm detects low-pitched sounds best
Answer: B
Rationale:
The diaphragm of a stethoscope detects high-pitched sound best; the bell detects low pitched sounds best. Palpation
detects thrills best.
Reference:
Murray, S., Mckinney, E., and Gorrie, T.(2002). Fundamentals of nursing care plans 8th edition; Philadelphia: W.
B. Saunders.
Nursing Process: Assessing

16. The nurse in charge measures a patient’s temperature at 102 degrees B. what is the equivalent Centigrade
temperature?
a. 39 degrees C
b. 47 degrees C
c. 38.9 degrees C
d. 40.1 degrees C
Answer: C
Rationale:
To convert Fahrenheit degrees to centigrade, use this formula: C degrees = (F degrees – 32) x 5/9 C degrees = (102
– 32) 5/9 + 70 x 5/9
38.9 degrees C

Reference:
Murray, S., Mckinney, E., and Gorrie, T.(2002). Fundamentals of nursing care plans 8th edition; Philadelphia: W.
B. Saunders.

17. A male patient undergoes a total abdominal hysterectomy. When assessing the patient 10 hours later, the nurse
identifies which finding as an early sign of shock?
a. Restlessness
b. Pale, warm, dry skin
c. Heart rate of 110 beats/minute
d. Urine output of 30 ml/hour
Answer: A
Rationale:
Early in shock, hyperactivity of the sympathetic nervous system causes increased epinephrine secretion, which
typically makes the patient restless, anxious, nervous, and irritable. It also decreases tissue perfusion to the skin,
 causing pale, cool clammy skin. An above-normal heart rate is a late sign of shock. A urine output of 30 ml/hour
is within normal limits.
Reference:
Murray, S., Mckinney, E., and Gorrie, T.(2002). Fundamentals of nursing care plans 8th edition; Philadelphia: W.
B. Saunders.

18. 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
A. Once, to establish a baseline
B. Once per year
C. Every 2 years
D. Twice per year

Rationale: A client age 40 to 49 with no family history of breast cancer or other risk factors for this disease
should have a mammogram every 2 years. After age 50, the client should have a mammogram every year

Reference: Potter, P. & Perry, A. (2009). Fundamentals of Nursing (7th ed.) St. Louis: Mosby Elsevier, 500-
515

Core Competency Standard: Safe & quality nursing practice

Nursing Process: Implementation
Cognitive Domain: Application

19. When prioritizing a client's plan of care based on Maslow's hierarchy of needs, the nurse's first priority would be:
A. allowing the family to see a newly admitted client.
B. ambulating the client in the hallway.
C. administering pain medication
D. placing wrist restraints on the client.

Rationale: In Maslow's hierarchy of needs, pain relief is on the first layer. Activity (option B) is on the second
layer. Safety (option D) is on the third layer. Love and belonging (option A) are on the fourth layer.
Reference: Potter, P. & Perry, A. (2009). Fundamentals of Nursing (7th ed.) St. Louis: Mosby Elsevier, 956-960

20. For which of the following time periods would the nurse notify the physician that the client had no bowel
sounds?
a. 2 minutes
b. 3 minutes
c. 4 minutes
d. 5 minutes
Answer: d
Rationale:To completely determine that bowel sounds are absents, the nurse must auscultate each of the four
quadrants for at least 5 minutes; 2,3 or 4 minutes is too short a period to arrive at his conclusion.
Reference: Lippincott’s Review Series. 5rd edition copyright 2006 by Lippincott Williams & Wilkins.
Nursing Process; Implementation
Cognitive Domain: Knowledge
Core competency: Health education

21. When percussing a client’s chest, the nurse would expect to find which of the following as normal signs over the
client’s lungs?
a. Tympany
b. Resonance
c. Dullness
d. Hyper resonance
Answer: b
Rationale: Normally, when percussing a client’s chest, percussion over the lungs reveals resonance, a hollow or
loud, low-pitched sound of long duration.
Reference: Lippincott’s Review Series. 5rd edition copyright 2006 by Lippincott Williams & Wilkins.
Nursing Process: Assessment
Cognitive Domain: Knowledge
Core competency: health education

22. The nurse is evaluating a client’s auditory function. To compare air conduction to bone conduction, the nurse should
conduct which test?

a. Whispered voice test

b. Weber’s test
c. Watch tick test
d. Rinne test
Rationale: D The Rinne test compares air conduction to bone in both ears. The whispered voice test evaluates low
pitched sounds, and the watch tick test assess high-pitched sounds. Both tests assess gross hearinc. The weber test
evaluates bone conduction.
Reference: Monahan Mcgraw-hill, Review for the NCLEX-RN

23. Mr. Visarra is newly admitted to the ward and before administering IV medications you read in his chart that he
has a peripherally inserted catheter (PICC) that is now 4 weeks old. Upon examination, you observed that the site
is clean and free from manifestations of infiltration, irritation, and infection. Your most APPROPRIATE action would
be to:
A. Administer the medication as ordered
B. Give medication through oral or intramuscular route
C. Document observation in the nurses’ notes to inform the physician and other nurses
D. Discontinue the PICC line since it is 4 weeks old
Rationale:

24. While changing linen of Aling Lala, a comatose client, the nursing aide reports that she noticed a reddened area in
the left buttock of the client. Upon inspection, you noted that the area blanches and is the size of a peso coin. Your
MOST appropriate immediate nursing approach would be to:
A. Endorse a schedule for turning and positioning the client round the clock
B. Measure the size of the reddened area for proper documentation
C. Position the client on her right side

25. Mr. Medina, 49 years old, has a doctor’s order to receive 1 liter of normal Saline solution to run for 24 hours. the
nurse would set the intravenous fluid to infuse at how many milliliters (ml) per hour and how many drops per
minute if the drop rate of the IV tubing is 15 drops/ml
A. 36 ml/hr, 7 gtts/min C. 42 ml/hour, 10 gtts/min
B. 48 ml/hour. 15 gtts/min D. 50 ml/hr, 18 gtts/min

26. Mr. Agpalo, 48 years old, is attending a smoking cessation program to be held at the nearby high school conducted
by the school nurse. This program is classified as:
A. Health promotion C. Diagnosis and treatment
B. Health restoration D. Rehabilitation

27. Where would the nurse tape Eileen’s indwelling catheter in order to reduce urethral irritation?
A. To the patient’s inner thigh C. To the patient’s outer thigh
B. To the patient’s lower thigh D. To the patient’s lower abdomen
Rationale:

28. How will you prevent ascending infection to Eileen who has an indwelling catheter?
A. See to it that the drainage tubing touches the level of the urine
B. Change the catheter every eight hours
C. See to it that the drainage tubing does not touch the level of the urine
D. Clean catheter may be used since urethral meatus is not a sterile area
Rationale:

29. A student nurse is observed putting a standard size cuff on an obese client. The action would probably result in BP
reading that is
A. False high C. False low
B. Normal D. Undetectable
Rationale:

30. When preparing for a subcutaneous injection, the proper size of syringe and needle would be:
A. Syringe 3-5 mL and needle gauge 21 to 23
B. Tuberculin syringe 1 mL with needle gauge 26 or 27
C. Syringe 2 mL and needle gauge 22
D. Syringe 1-3 mL and needle gauge 25 to 27
Rationale:

31. Mario listens to Richard’s bilateral sounds and finds that congestion is in the upper lobes of the lungs. The
appropriate position to drain the anterior and posterior apical segments of the lungs when Mario does percussion
would be:
A. Client lying on his back then flat on his abdomen on Trendelenburg position
B. Client seated upright in bed or on a chair then leaning forward in sitting position then flat on his
back and on his abdomen
C. Client lying flat on his back and then flat on his abdomen
D. Client lying on his right then left side on Trendelenburg position
Rationale:

32. The purpose of chest percussion and vibration is to loosen secretions in the lungs. The difference between the
procedures is:
A. Percussion uses only one hand while vibration uses both hands
B. Percussion delivers cushioned blows to the chest with cupped palms while vibration gently shakes
secretion loose on the exhalation cycle
C. In both percussion and vibration, the hands are on top of each other and hand action is in tune with client’s
breath rhythm
D. Percussion slaps the chest to loosen secretions while vibration shakes the secretions along with the inhalation
of air
Rationale:

33. When caring for a dying client, you will perform which of the following activities?
A. Encourage the client to reach optimal health
B. Assist client perform activities of daily living
C. Assist the client towards a peaceful death
D. Motivate client to gain independence

34. To obtain specimen for sputum culture and sensitivity, which of the following instruction is best?
A. Upon waking up, cough deeply and expectorate into container
B. Cough after pursed lip breathing

C. Save sputum for two days in covered container

D. After respiratory treatment, expectorate into a container

35. Which of the following laboratory test result indicate presence of an infectious process?
A. Erythrocyte sedimentation rate (ESR) 12mm/hr
B. White blood cells(WBC) 18,000/mm3
C. Iron 90g/100ml
D. Neutrophils 67%

36. What do you think is an important responsibility related to pain that is subjective in nature?
A. Divert attention of client in pain

B. Leave the patient alone while in pain

C. Believe what the patient says about the pain

D. Assume responsibility to eliminate pain as described by the client 

Rationale:

37. The client fell from the stairs, and had twisted her ankle. The injury caused inflammation of the ankle. The
nursing interventions for the inflamed ankle would least likely include which of the following?
A.) Elevate the ankle with pillow support
B.) Apply warm compress over the ankle for the first seventy-two hours
C.) Apply compression bandage over the ankle
D.) Administer anti-inflammatory drug as ordered by the M.D.
ANS: B
> Application of warm compress over an inflamed body part for the first 72hours of injury is not included in the
nursing interventions for inflammation. Cold compress is preferably applied during the first 72hours to cause
vasoconstriction and prevent/reduce swelling.

38. A client who is unconscious needs frequent mouth care. When performing a mouth care, the best position of a
client is:

a. Fowler’s position
b. Side lying
c. Supine
d. Trendelenburg

39. A walk-in client enters into the clinic with a chief complaint of abdominal pain and diarrhea. The nurse takes the
client’s vital sign hereafter. What phrase of nursing process is being implemented here by the nurse?

A. Assessment
B. Diagnosis
C. Planning
D. Implementation

40. Five teaspoon is equivalent to how many milliliters (ml)?

a. 30 ml
b. 25 ml
c. 12 ml
d. 22 ml

41. The nurse prepares to administer buccal medication. The medicine should be placed…

A. On the client’s skin

B. Between the client’s cheeks and gums
C. Under the client’s tongue
D. On the client’s conjunctiva

42. A client complains of difficulty of swallowing, when the nurse try to administer capsule medication. Which of the
following measures the nurse should do?

A. Dissolve the capsule in a glass of water

B. Break the capsule and give the content with an applesauce
C. Check the availability of a liquid preparation
 D. Crash the capsule and place it under the tongue

43. Resonance is best describe as:

A. Sounds created by air filled lungs

B. Short, high pitch and thudding
C. Moderately loud with musical quality
D. Drum-like

44. The nurse asked the client to read the Snellen chart. Which of the following is tested?

A. Optic
B. Olfactory
C. Oculomotor
D. Troclear

45. The physician orders a maintenance dose of 5,000 units of subcutaneous heparin (an anticoagulant) daily.
Nursing responsibilities for Mrs. Mitchell now include:

a. Reviewing daily activated partial thromboplastin time (APTT) and prothrombin time.
b. Reporting an APTT above 45 seconds to the physician
c. Assessing the patient for signs and symptoms of frank and occult bleeding
d. All of the above

46. The correct sequence for assessing the abdomen is:

a. Tympanic percussion, measurement of abdominal girth, and inspection

b. Assessment for distention, tenderness, and discoloration around the umbilicus.
c. Percussions, palpation, and auscultation
d. Auscultation, percussion, and palpation

47. Which of the following patients is at greatest risk for developing pressure ulcers?

A. An alert, chronic arthritic patient treated with steroids and aspirin

B. An 88-year old incontinent patient with gastric cancer who is confined to his
bed at home
C. An apathetic 63-year old COPD patient receiving nasal oxygen via cannula
D. A confused 78-year old patient with congestive heart failure (CHF) who requires
assistance to get out of bed.

48. A patient has exacerbation of chronic obstructive pulmonary disease (COPD) manifested by shortness of breath;
orthopnea: thick, tenacious secretions; and a dry hacking cough. An appropriate nursing diagnosis would be:

A. Ineffective airway clearance related to thick, tenacious secretions.

B. Ineffective airway clearance related to dry, hacking cough.
C. Ineffective individual coping to COPD.
D. Pain related to immobilization of affected leg.

49. Before rigor mortis occurs, the nurse is responsible for:

A. Providing a complete bath and dressing change

B. Placing one pillow under the body’s head and shoulders
C. Removing the body’s clothing and wrapping the body in a shroud
D. Allowing the body to relax normally

50. Which of the following is a primary nursing intervention necessary for all patients with a Foley Catheter in
place?

a. Maintain the drainage tubing and collection bag level with the patient’s bladder
b. Irrigate the patient with 1% Neosporin solution three times a daily
c. Clamp the catheter for 1 hour every 4 hours to maintain the bladder’s elasticity
d. Maintain the drainage tubing and collection bag below bladder level to facilitate drainage by gravity