Columban College Finals Fundamentals of Nursing

COLUMBAN COLLEGE
FINALS
FUNDAMENTALS OF NURSING
FUNDAMENTALS OF NURSING
Situation: The nursing process is a problem – solving activity that the nurse utilizes in the care of the clients.
1. Assessment data must be descriptive, concise, and complete. An assessment should NOT include:
A. subjective data from the client
B. a detailed physical examination
C. the use of interpersonal and cognitive skills
D. inferences or interpretative statements not supported with data
Rationale: D. The nurse should not generalize or form judgment not supported by the collected data. Inferences and
interpretative statement must be supported by data. Assessment do include options A, B and C.
Reference: Fundamentals of Nursing 7th Edition by: Potter and Perry © 2009 Chapter 16 item no. 2 pg. 245
2. A nurse assesses a client who comes to the clinic, “Tell me what medications you are on for your breathing problem. I
see from your last visit that your physician recommended routine exercise. Can you also tell me how successful you have
been following his plan?” The nurse’s assessment covers which Gordon’s functional health patterns?
A. value-belief pattern C. coping-stress tolerance pattern
B. cognitive-perceptual pattern D. health perception-health management pattern
Rationale: D. Health perception health management pattern describes the clients self-report and well-being, how client manage
value-belief pattern describes patterns or values, beliefs cognitive-perceptual pattern describes language adequacy, memory,
and decision-making ability. Coping - stress tolerance pattern describes client’s ability to manage stress.
3. The nursing diagnosis readiness for enhanced communication is an example of a (n):

A. risk nursing diagnosis C. potential nursing diagnosis
B. actual nursing diagnosis D. wellness nursing diagnosis
Rationale: D. The term readiness indicates wellness nursing diagnosis. An actual nursing diagnosis describes a human responds
to help conditions or life processes in an individual, family, or community. A potential nursing diagnosis is a risk for diagnosis.
4. A client signals with her call light. The nurse enters the room and finds the drainage tube disconnected, the IV has 100 ml
of fluid remaining, and the client has asked to be turned. Which of the following should the nurse perform first?
A. reconnect the drainage tubing
B. inspect the condition of the IV dressing
C. improve the client’s comfort, and turn to her side
D. go to the medication room, and obtain the next IV fluid bag
Rationale: A The nurse should reconnect the drainage tube first to ensure that wound is properly draining. The client should then
be turned (with care taken to ensure that the tubing remains connected), followed replacing the IV fluid bag, checking the IV site,
and restarting the IV fluid. With 100 mL left, the nurse has a bit of time to replace the IV bag before it runs dry, so caring for the
client’s wound and comfort should come first.
5. In which of the following examples is a nurse applying critical thinking attitudes when performing a dressing change?
A. following the procedural guideline for a dressing change
B. seeking necessary knowledge on the steps of the procedure
C. showing confidence in knowing which dressing materials to use
D. being sure that the dressing covers the entire wound completely
Rationale: C. In Critical thinking nurses have to exercise good judgment and decision making before actually delivering each
intervention.
6. A client is recovering from surgery for removal of an ovarian tumor. It is one day after having surgery. Because she has
an abdominal incision and dressing, the nurse has selected a nursing diagnosis of risk for infection. Which of the
following is an appropriate goal statement for the diagnosis?
A. client will remain afebrile by discharge
B. client’s wound will remain free of infection by discharge
C. client will receive ordered antibiotic on time over next 3 days
D. client’s abdominal incision will remain covered with a sterile dressing for 2 days
Answer: B. The specific, measurable goal is keeping the wound free of infection.
Situation: A routine nursing responsibility is to monitor the client’s vital signs.
7. A 52-year-old woman is admitted with dyspnea and discomfort in her left chest with deep breaths. She has smoked for 35
years and recently lost over 10 pounds. Which vital sign should not be delegated to a nursing assistant?
A. temperature C. Respiratory rate
B. radial pulse D. oxygen saturation
Rationale: C. Although measurement of respiration can be delegated, the situation presents a chief complaint of dyspnea and
discomfort on breathing. Monitoring of respiratory rate in this case should be done by the nurse. Since the client may have
decreased ventilation and will benefit from learning.
8. The client requests to get out of bed to go to the bathroom. He has orders for “up ad lib.” What action do you take?
A. Obtain orthostatic BP measurement
B. Tell him it is not a good idea, and provide a urinal
C. ask the nursing assistant to assist him to the bathroom
D. give him some slippers, and tell him where the bathroom is located
Rationale: A. Since the ‘’up ad lib’’ orders are new and the client has been on bed rest, checking orthostatic blood pressure
before allowing the client to ambulate is the correct answer. If no sign of orthostatic hypotension is present, then a nursing
assistant could assist him to the bathroom. Giving the client a urinal is not a good choice if the client is asymptomatic when
orthostatic blood pressure is checked.
Situation: In data collection, the nurse conducts a thorough physical examination to validate data gathered during her history
taking.
9. The nurse conducts a general survey on an adult client, which includes:

A. appearance and behavior C. observing specific body systems
B. measurement of vital signs D. conducting a detailed health history
Answer: A. The general survey focuses on general appearance and behavior including gender and race, age, signs of distress,
body type, posture, gait, hygiene and grooming, dress, affect, mood, and speech. The other actions are carried out in different
part of the assessment.
10. To correctly palpate the client’s skin for temperature, the nurse uses the:
A. base of the hands C. dorsal surface of the hands
B. fingertips of the hands D. palmar surface of the hands
Answer: C. The nurse accurately assesses temperature by palpating the skin with the dorsum or back of the hand, because this
area of the hand is more sensitive to temperature than is the base of the hands, the fingertips, or the palmar surface.
11. To auscultate the client’s lung fields, the nurse uses a systematic pattern comparing:
A. top to bottom C. side to side
B. anterior to posterior D. interspace to interspace
Answer: C. The sounds of lung fields on one side of the body are compare with the sounds of the same fields on the opposite
sides of the body. The other answers would provide incorrect comparison.
12. While auscultating heart sounds, the nurse documents that S 2 is best heard at the base. This sound (S 2) correlates with
closure of the:
A. aortic and mitral valves C. aortic and pulmonic valves
B. mitral and tricuspid valves D. tricuspid and pulmonic valves
Answer: C. The S2 (dub) sound is the second heart sound and indicates closure of the aortic and pulmonic valves. The closing of
the aortic and tricuspid valves is the S1 sound. The mitral and tricuspid valves do not close together, nor do the aortic and mitral
valves.
13. To spread breast tissue evenly over the chest wall during an examination, the nurse asks the client to lie supine with:
A. both arms overhead with palms upward
B. hands clasped just above the umbilicus
C. the dominant arm straight along side the body
D. the ipsilateral arm behind the head.
Answer: D. Lying in the supine position with the ipsilateral arm behind the head helps the breast tissue to flattened evenly
against the chest wall. The other options do not allow the tissue to spread on the chest wall.
14. The nurse is teaching a client how to perform a testicular self-examination. The nurse informs the client:
A. “The testes are normally round, movable, and have lumpy consistency.”
B. “Contact your health care provider if you feel a painless pea-size nodule.”
C. “The best time to do a testicular self-examination is before your bath or shower.”
D. “Perform a testicular self-examination weekly to detect signs of testicular cancer.”
Answer: B. Painless, pea-size nodules should be checked by a healthcare provider, testicular self-examination should be
performed monthly and should be done after a bath or shower. The testes feel smooth, rubbery, and free of nodules.
15. The client is being assessed for range of joint movement. You ask the client to move the arm toward the body evaluating
the movement of:
A. Flexion C. Abduction
B. Extension D. Adduction
Answer: D. Adduction is movement toward the body. Abduction is movement away from the body flexion is movement that
decreases the angle of the joint, whereas extension is movement that increase the angle of the joint.
Situation: Administering medication is a dependent nursing intervention where nurses continuously and consistently apply the
principles of safe drug administration.
16. When identifying a new client before administering medications, the nurse asks the client to state his name. The client
does not state the correct name. The nurse asks again, and the client states still another name. What is the nurse’s next
action?
A. laugh at the client and tell him to quit “kidding”
B. give the medications without any further questioning
C. look at the client’s armband to identify the client, and disregard what the client said
D. investigate the client’s mental status before administering any further medications
Answer: C. Even if the client gives the appropriate name, the nurse should always check the client’s armband to ensure that this
is the correct client for the given medications. This one of the “five rights” that must be followed prior to medication
administration.
17. A nursing student takes a client’s antibiotic to his room. The client asks the nursing student what it is and why he should
take it. The nursing student’s reply includes the following information:
A. only the client’s physician can give this information
B. the name of the medication and a description of its desired effect
C. information about medications is confidential and cannot be shared
D. due to limits placed on nursing students, the client will have to speak with his assigned nurse about this
Rationale: B. The nursing student should know the name, dose, and purpose of all medications that he or she is responsible for
administering. Part of client teaching is sharing this information with the client, so the student should be able to verbalize this
information to the client. This information is not confidential and the student nurse should be present this information without
waiting for a physician or the client’s assigned nurse.
18. The nurse is administering a sustained-release capsule to a new client. The client insists that he cannot swallow pills. The
best course of action for the nurse is to:
A. ask the physician to change the order
B. crush the pill with a mortar and pestle
C. hide the capsule in a piece of solid food
D. open the capsule and sprinkle it over pudding
Rationale: A. Sustained-release medication should never be crushed or sprinkled on food. Hiding the capsule in a piece of solid
food is not an appropriate nursing step. The nurse should contact the physician for an order change.
19. The nurse takes the medication to a client, and the client tells the nurse to take it away because she is not going to take
it. The nurse’s first action should be to:
A. ask the client’s reason for refusal
B. explain that she must take the medication
C. take the medication away and chart the client’s refusal
D. tell the client that her physician knows what is best for her
Rationale: C. Nurses should not become defensive if a client refuses medication therapy, recognizing that every person of
consenting age has a right to refuse medication.
20. A client is receiving an IV push medication. If this type of drug infiltrates into the outer tissues, the nurse will:
A. continue to let the IV run
B. apply a warm compress to infiltrated site
C. follow facility policy or drug manufacturer’s directions
D. not worry about this because vesicant filtration is not a problem
Rationale: C. The infusion of the medication should be halted and the facility policy or drug manufacturer’s directions follow.
Infiltration of some medications will create no harm. For others, harm can be averted by the application of warm compresses. Still
others may require other treatments if infiltration occurs.
Situation: Communication is vital and inevitable, thus nurses must relate therapeutically.
21. When working with an older adult, the nurse should remember to avoid:
A. touching the client C. shifting from subject to subject
B. allowing the client to reminisce D. asking the client how her or she feels
Rationale: C. The nurse should avoid shifting from subject to subject, because if can create confusion. All individuals require
touch. Allowing older adults to reminisce can be helpful and therapeutic. Asking the client how he or she feels is a method of
opening communication.
22. A nurse should consider zones of personal space and touch when caring for clients. If the nurse is taking the client’s
nursing history, she should:
A. sit next to the client C. be 18 inches to 4 feet from the client
B. be 4 to 12 feet from the client D. be 12 inches to 3 feet from the client
Rationale: C. The personal zone is 18 inches to 4 feet and is best when the nurse is taking a client history. The intimate zone is 0
to 18 inches, and the nurse is in this zone when performing assessment. The social zone is 9 to 12 feet and is use when making
rounds with a physician. The public zone is 12 feet or more.
Situation: Client education is an essential component of safe quality care.
23. A nurse is going to teach a client how to perform a breast self-examination. The behavioral objective that best measures
the client’s ability to perform the examination is:
A. the client will verbalize the steps involved in breast self-examination within 1 week
B. the nurse will explain the importance of performing breast self-examination once a month
C. the client will perform breast self-examination correctly on herself before the end of the teaching session
D. the nurse will demonstrate breast self-examination on a breast model provided by American Cancer Society
Rationale: C. In psychomotor learning it involves acquiring skills that require the integration of mental and muscular activity. In
option C, the client is able to demonstrate BSE correctly.
24. An older adult is being started on a new antihypertensive medication. In teaching the client about the medication, the
nurse:
A. speaks loudly
B. presents the information once
C. expects the client to understand the information quickly
D. allows the client time to express himself or herself and ask questions
Rationale: D. The nurse should allows the client time to express himself and ask questions. Speaking loudly is typically not
effective, and information may have to be presented several times. The client will learn the information at his own speed.
Situation: Essential skills are necessary when taking care of dying clients and eventually caring of the person after his/her death.
25. A self-care goal for the nurse who cares for dying and grieving clients might be:
A. learn not to take the loss so seriously
B. limit involvement with clients who are grieving
C. maintain life balance, and reflect on the meaning of one’s work
D. admit that you are not well suited to care for grieving clients and families
Rationale: C. For nurses who work with dying and grieving clients, the maintenance of life balance and reflection on the purpose
for the work is the key to longevity in the career. Loss is serious, and nurses do take loss seriously. Involvement with grieving
client can be healthy for the nurse. Nurses need to determine what discipline in nursing works for them.
26. During post-mortem care the nurse should give priority to:
A. locating the client’s clothing
B. providing culturally and religiously sensitive care in body preparation
C. transporting the body to the morgue as soon as possible to prevent body decomposition
D. providing all post-mortem care to protect the deceased’s family from having to see the body
Rationale: B. Providing the integrity of rituals and mourning practice gives families a sense of fulfilled obligations and promotes
acceptance of death. If the family wants to provide post mortem care, then the nurse should be sensitive to their needs. The
body should be transported to the morgue when the family is ready. Locating the client’s clothing is not a priority; it can be done
after the other tasks are completed.
Situation: Nurses are everyday challenged in the provision of the client’s physiological needs.
27. The most effective way to break the chain of infection is by:
A. hand hygiene C. placing clients in isolation
B. wearing gloves D. providing private rooms for clients
Rationale: A. Good hand hygiene is the most effective way to break the chain of infection. Wearing gloves can help in decreasing
disease transmission, but clean hands are required for it to be truly effective. Placing clients in isolation is costly and often
unnecessary, and clients can be psychologically harmed by isolation. Even providing private rooms for clients will not be effective
if health care workers do not follow good hand hygiene practices.
28. After coming in contact with infected clients, and after handling contaminated equipment or organic material, visitors are
encouraged to:
A. wear gloves before eating or handling food
B. use a private room to talk with family members
C. leave the facility to prevent contamination of others
D. perform hand hygiene before eating or handling food
Rationale: D.
29. The nurse has redressed a client’s wound and now plans to administer a medication to the client. It is important to:
A. leave the gloves on to administer the medication
B. remove gloves and perform hand hygiene before leaving the room
C. remove gloves and perform hand hygiene before administering the medications
D. leave the medication on the bedside table to avoid having to remove gloves before leaving the client’s room
30. When a nurse is performing surgical hand asepsis, the nurse must keep hands:
A. below elbows C. at a 45-degree angle
B. above elbows D. in a comfortable position
Rationale: B. When surgical hand hygiene is performed, the hands should always be kept above the elbows so that the water
runs from the hands to the elbows.
31. To sterilize surgical instruments, parenteral solutions and surgical dressings:

A. an autoclave is used C. ethylene oxide gas is used
B. soap and water is used D. chemicals are used for disinfection
Rationale: A. Autoclave sterilizes heat – tolerant surgical instruments and semicritical client care items. Semicritical are items
that come in content with mucus membranes or nonintact skin also present a risk. Chemical disinfect heat – sensitive
instruments and equipment such as endoscope, respiratory therapy equipment. Ethylene oxide (ETO) gas sterilizes most
medical materials.
32. A principle of good body mechanics includes which of the following concepts?
A. keeping the knees in a locked position
B. bending at the waist to maintain a center of gravity
C. maintaining a wide base of support and bending at the knees
D. holding objects away from the body to improve leverage
33. A client begins to fall during ambulation. How would the nurse prevent injury to the client?
A. call for assistance
B. instruct the client to sit in the nearest chair
C. allow the client to fall to prevent injury to the nurse
D. slide the client down the nurse’s body and leg to the floor
Rationale: D. The nurse should allow the client to slide to the floor while protecting the client’s head from injury. This prevents
injury to both the client and the nurse. After the client is seated on the floor, the nurse should call for assistance and transfer the
client appropriately. Instructing the client to sit in the nearest chair may not be practical. Propping the client is an incorrect
answer.
34. You discover an electrical fire in a client’s room. Your first action would be to:
A. activate the fire alarm
B. confine the fire by closing all doors and windows
C. evacuate any clients or visitors in immediate danger
D. extinguish the fire by using the nearest fire extinguisher
Rationale: C. The nurse’s first step when a fire is discovered is to evacuate any clients or visitors in immediate danger. Then the
nurse should activate the fire alarm, confine the fire, and then extinguish it.
35. The family of your confused, ambulatory client insists that all four side rails be up when the client is alone. The best way
to handle this situation would be to:
A. ask them to stay with the client at all times
B. inform them of the risks associated with side rail use
C. thank them for being conscientious and put the four rails up
D. provide the client a one-to-one sitter while the side rails are up
Rationale: B. The use of side rails when a client is disoriented will cause more confusion and further injury. A confused client who
is determined to get out of bed may attempt to climb over the side rail or climb out at the foot of the bed, and may fall or
experienced other injury. After the nurse has this discussion with the family then the nurse should perform a thorough nursing
assessment and develop a plan to ensure the client’s safety.
36. In addition to bathing, which intervention best promotes client comfort:

A. snacks C. books on tape
B. back rub D. postural drainage
Rationale: B. Back rub promotes relaxation, relieve muscular tension, and decrease the perception of pain. Audio books and
snacks may provide temporary comfort. Postural drainage is indicated for specific individuals.
37. The priority when providing oral hygiene to an unconscious client is to prevent:
A. aspiration C. dental caries
B. mouth odor D. mouth ulcerations
Rationale: A. When providing oral hygiene to an unconscious client, the nurse should position the client appropriately and use
suction to ensure that there is no risk of aspiration. Good oral hygiene is still necessary to prevent mouth odor, dental caries, and
ulcerations.
38. The following four clients are all at risk for fluid volume excess. Which of the clients do you see first?
A. an 88-year-old with a fractured femur scheduled for surgery
B. a 65-year-old recently diagnosed with congestive heart failure
C. a 50-year-old with second-degree burns on the ankles and feet
D. a 20-year-old with a 5-year history of type 1 diabetes mellitus
Rationale: B. The 65-year-old with congestive heart failure is at greatest risk for problems from fluid volume excess. Fluid
overload in this client could quickly cause light threatening problems. The 50-year-old with second-degree burns is at risk for fluid
volume deficit.
39. A client has the following gas levels: pH, 7.52; PaCO 2, 28 mm Hg; PaO2, 92 mm Hg; HCO3, 17 mEq/L. You would expect
the health care provider to order:
A. oxygen at 3 L/min via nasal cannula
B. sodium bicarbonate 1 amp every 12 hours
C. potassium chloride 20 mEq in ½ normal saline
D. deep breathing exercises to ease respiratory effort
Rationale: D.
40. You are teaching a client about healthy nutrition. You recognize that the client understands the teaching when he states:
A. I need to stop eating red meat
B. I will increase the servings of fruit juice to four a day
C. I will make sure that I eat a balanced diet and exercise regularly
D. I will not eat so many dark green vegetables and eat more yellow vegetables
Rationale: C. The client should adopt a balance eating pattern that include a variety of nutrient – dense foods and beverages
among the basic food groups. The nurse should encourage the client to consume fruits, vegetables, whole grain products, and
fat – free or low – fat milk while staying within energy needs. Total fat intake should be kept between 20% and 35% of total
calories with most fats coming from polyunsaturated or monounsaturated fatty acids. The client should choose and prepare foods
and beverages with little added sugars or sweeteners and foods with little salt while at the same time eating potassium - rich
foods.
41. Which action is initially taken by the nurse to verify correct position of a newly placed small-bore feeding tube?
A. place an order for X-ray examination to check position
B. confirm the distal mark on the feeding tube after taping
C. test the pH of the gastric contents, and observe the color
D. auscultate over the gastric area as air is injected into the tube
Rationale: A. Radiography will confirm placement more reliably than other methods of checking placement.
42. To minimize nocturia, clients should avoid fluids:

A. after lunch C. 2 hours before bedtime
B. in the late afternoon D. 4 hours before bedtime
Rationale: C. Clients should avoid fluids for 2 hours before bedtime to prevent nocturia. The other options will not prevent
nocturia.
43. When applying a condom catheter, it is important to secure the catheter on the penile shaft in such a manner that the
catheter is:
A. tight and drainage well
B. dependent and drainage well
C. secured with adhesive tape applied in a circular pattern
D. snug and secure, but does not cause constriction to blood flow
Rationale: D. A condom catheter should fit snugly and securely but should not cause constriction that impedes blood flow it
should not be tight or placed in a dependent position, and should never be secured with tape in a circular pattern, which should
can impede blood flow.
44. Diarrhea that occurs with a fecal impaction in the result of:
A. a clear liquid diet
B. irritation of the intestinal mucosa
C. inability of the client to form a stool
D. seepage of stool around the impaction
Rationale: D. Although a mask of solid matter may obstruct the large intestine, liquid stool may leak around the obstruction
(impaction). A clear liquid diet is not the cause of the diarrhea, nor is irritation of the intestinal mucosa. This type of diarrhea is
not cause by the inability of the client to form stool.
45. A cleaning enema is ordered for a 55-year-old client before intestinal surgery. The maximum amount of fluid given is:
A. 150 to 200 mL C. 400 to 750 mL
B. 200 to 400 mL D. 750 to 1000 mL
Rationale: D. The maximum volume of enema to be administered to an adult is 750 to 1000 mL. An infant is given 150 to 200
mL; a toddler, 250 to 350 mL; and a school-aged child, 300 to 500 mL. an adolescent is given 550 to 750 mL.
46. The client at greatest risk for developing adverse effects of immobility is a:
A. 3-year-old child with a fractured femur
B. 78-year-old man in traction for a broken hip
C. 48-year-old woman following a thyroidectomy
D. 38-year-old woman undergoing a hysterectomy
Answer: B. A client in traction is at the greatest risks for adverse effects of immobility. The other clients described are individual
who are still able to move around to some degree and have less immobility than the individual in traction.
47. The nurse is caring for a client who has right-sided weakness. The nurse needs to help the client walk. What should the
nurse do while walking with the client?
A. hold the client’s left hand while walking
B. hold the client’s right hand while walking
C. put a gait on the client and provide support on the left side
D. put a gait belt on the client and provide support on the right side
Answer: D. A gait belt helps stabilize the client and helps the client maintain the center of balance. The nurse should always
stand on the client’s affected side and support the client when using a gait belt. Providing support by holding the client’s are is
incorrect, because the nurse cannot easily support the client’s weight to lower the client to the floor if the client faints or falls. In
addition, if the client falls with the nurse holding on arm, the shoulder joint maybe dislocated.
48. When obtaining a wound culture to determine the presence of a wound infection, the specimen should be taken from the:
A. necrotic tissue
B. wound drainage
C. drainage on the dressing
D. wound after it has first been cleansed with normal saline
Answer: D. The wound should be cleaned with saline, then a culture specimen should be obtained from the wound. Necrotic
tissue, drainage on the dressing, and old wound drainage can harbor old bacteria that may not necessarily be infecting the
wound.
49. Postoperatively the client with a closed abdominal wound reports a sudden “pop” after coughing. When the nurse
examines the surgical wound site, the sutures are open and pieces of small bowel are noted at the bottom of the now
opened wound. The correct intervention would be to:
A. allow the area to be exposed to air until all drainage has stopped
B. place several cold packs over the areas, protecting the skin around the wound
C. cover the areas with sterile saline-soaked towels and immediately notify the surgical team; this is likely to indicate a
wound evisceration
D. cover the area with sterile gauze, place a tight binder over the areas, and ask the client to remain in bed for 30
minutes because this is a minor opening in the surgical wound and should reseal quickly
Answer: C. In wound evisceration, the bowel extrudes from the body. The nurse should cover the visible bowel with sterile saline-
soaked towels and notify the surgical team. The area should not be allowed to be exposed or to dry out. Cold packs and binders
are not acceptable options.
50. For a client who has a muscle sprain, localized hemorrhage, or hematoma, what wound care product helps prevented
edema formation, control bleeding, and anesthetize the body part?
A. binder C. elastic bandage
B. ice bag D. Absorptive diaper
Answer: B. The application of cold will help constrict blood vessels, which will reduce swelling that occurs with bleeding and
edema formation in a muscle sprain. It also provides a numbing effect. Binders and elastic bandages are not initial treatments for
a sprain. A diaper would not be used for a muscle sprain.
Situation: The Nurse’s ability to relate to others is a very important aspect of interpersonal communication and helps
to maintain an effective relationship. Nurse Tia is a Medical Nurse preparing to conduct her morning rounds to
different age group of clients in the ward.
51. Which of the following would Nurse Tia use to communicate with a very young child?
A. Role playing
B. Explaining procedures
C. Showing him pictures
D. Showing him a movie
Role playing is an excellent way to communicate with a very young child
Reference: FUNDAMENTALS OF NURSING, MADE INCREDIBLY EASY! LIPPINCOTT WILLIAMS &
WILKINS CHAPTER5, QUICK QUIZ ITEM NO. 2, PAGE 94.
52. What type of behavior provides encouragement during communication with clients without indicating
agreement or disagreement?
A. Clapping C. Looking away
B. Sighing D. Nodding
Nonverbal behaviors, such as nodding and making momentary eye contact, provide encouragement
without indicating agreement or disagreement.
53. What’s the main source of information and communication among nurses, doctors, physical therapists, social
workers, and other caregivers?
A. Computer
B. Medical record
C. Telephone
D. Word of mouth
The medical record is the main source of information and communication among nurses, doctors, physical
therapists, social workers, and other caregivers.
54. When developing a therapeutic nurse- patient relationship, during what phase would Nurse Tia review
the patient’s surgical history?
A. Orientation
B. Working
C. Pre-interaction
D. Termination
During the Pre-interaction phase, you can review the patient data that you might already have, such as the
medical or surgical history.
WILKINS CHAPTER5, QUICK QUIZ ITEM NO.1, PAGE 93.
55. One of Nurse Tia’s clients is discharged. The Community nurse visits an older adult female client who asks the
community nurse to buy some groceries for her because she is not feeling well today. Which statement should
the community nurse use in response?
A. “I am not allowed to buy groceries for clients.”
B. “Let’s discuss how we can solve this problem.”
C. “Do you have any support systems for shopping?”
D. “Nurses are professionals and do not run errands.”
The nurse’s duty is to help the client; but, in helping the client, the nurse’s first action is to finish the
assessment and then find immediate and long-term solutions to the problem. In option 1, the nurse uses a
passive approach and hides behind policies and rules, even though this can be true. In option 3, the nurse
asks a closed-ended question, which is unlikely to further nurse-client communication. Option 4 is
inappropriate and indicates that the nurse thinks more of status than of helping the client.
Reference: SAUNDERS: Q & A Review for the NCLEX-RN® EXAMINATION, Linda Anne Silvestri, 4 th
Edition, © 2009, Unit IV, pg. 741, Item no. 1550.
Situation: Taking the vital signs is a quick and efficient way of monitoring varied client’s conditions or identifying
problems and evaluating the client’s response to interventions.
56. Which method of assessing temperature is the least accurate?

A. Oral C. Tympanic
B. Rectal D. Axillary
Axillary temperature, the least accurate reading is usually 1 0 to 20 F (0.60 to 1.10 C) lower.
57. A nurse in the newborn nursery is performing vital signs on the newborn infant. Which finding would indicate a
normal respiratory rate?
A. 28 breaths per minute
B. 50 breaths per minute
C. 70 breaths per minute
D. 80 breaths per minute
The normal respiratory rate for a newborn infant is 30 to 60 breaths per minute. Therefore options A, C, and
D are incorrect.
58. Which heart rate in a neonate would be considered normal?

A. 60 to 80 beats/minute.
B. 100 to 120 beats/minute
C. 120 to 140 beats/minute
D. 160 to 200 beats/minute
A heart rate of 120 to 140beats/minute in a neonate is considered normal.
59. Which breath sound is referred to as snoring sound that results from secretions in the trachea?
A. Stertor
B. Stridor
C. Wheezing
D. Expiratory grunting
Stertor is a snoring sound that results from secretions in the trachea and large bronchi.
60. The highest temperature reading would be expected to occur during what time of day.
A. 4 and 5 a.m.
B. 8 and 9 a.m.
C. 4 and 8 p.m
D. 9 and 11 a. m.
Temperature normally fluctuates with rest and activity. Lowest readings typically occur between 4 and 5
a.m.; the highest readings, between 4 and 8 p.m.
Situation: Fluids and electrolytes constantly shift from compartment to compartment to facilitate body processes such
as oxygenation and acid base balance. Clinical Coordinator Kim is evaluating the extent of knowledge of Novice
Nurses on the composition of fluid compartments and electrolytes necessary to develop an appropriate care plan.
61. Nurse Kim asked one of the Nurses on which of the following fluids is located inside the cell?
A. Interstitial. C. Extracellular.
B. Intracellular. D. Internal.
The fluid inside the cells-about 55% of total body fluid-is called intracellular fluid. The rest is called
extracellular fluid.
62. Nurses know that the major extracellular electrolytes are:

A. Sodium and chloride.
B. Potassium and phosphorus.
C. Potassium and sodium.
D. Phosphorus and chloride
The major extracellular electrolytes are sodium and chloride.
63. Which of the following is an example of a hypertonic solution?

A. Half/normal saline.
B. 0.33% sodium chloride.
C. Dextrose 2.5% in water.
D. Dextrose 5%in half-normal saline
Some examples of hypertonic solution are dextrose 5% in half normal saline (405 m0sm/L), dextrose 5% in
normal saline (560 m0sm/L), and dextrose 5% in lactated Ringer’s solution (527 m0sm/L).
64. Nurse Kim further asks Novice Nurses that when capillary blood pressure exceeds colloid osmotic pressure,
which of the following situations occurs?
A. water and diffusible solutes leave the capillaries and circulate into the interstitial fluid.
B. water and diffusible solutes return to the capillaries.
C. No change occurs
D. Intake and output are affected
When capillary blood pressure exceeds colloids osmotic pressure, water and diffusible solutes leave the
capillaries and circulate into the interstitial fluid. When capillary blood pressure falls below colloids osmotic
pressure, water and diffusible solutes return to the capillaries.
65. Nurse Kim gave a case situation to the Novice Nurses that a Physician prescribed intralipids intravenously for
a client. Before initiating the intralipids, which should the nurse assess that is related to the infusion?
A. Allergies
B. Vital signs
C. History of seizures
D. Serum glucose level
Before administering any medication, the nurse assesses for allergies to all of the agent’s components. Fat
emulsions such as intralipids contain an emulsifying agent made from egg yolks, so client who are
hypertensive to eggs are at risk for developing hypersensitivity reactions. Options B, C, and D are unrelated
to administering fat emulsion.
Situation: Medication administration is an essential part of nursing practice which requires a sound knowledge based
on order for the medication to be administered safely. Rita, a Medication Nurse assigned in a private station is
reviewing the medications in the Patient’s chart.
66. A Physician prescribes Digoxin 0.15 mg intravenous slow push (IVSP) for one of the patients. Nurse Rita has
a Digoxin 0.5 mg/ 2 mL in stock. Calculate the number of milliliters per dose that the patient should have.
A. 6 mL/ dose C. 600 mL/ dose
B. 0.6 mL/ dose D. 15 mL/ dose
0.5 mg *  = 2 mL * 0.15, so  = 0.6. If you go 6 mL, you forgot the decimal point. 15 mL is too much, and 600 mL is
a lethal dose.
Reference: Saunders Nursing Survival Guide Drug Calculations & Drug Administration 2 nd Edition: Dr.
Cynthia Chernecky: Chapter 2: pg.47; Item no.1
67. Calcium Gluconate comes in a vial of 1 g/10 mL. The prescription indicates that Nurse Rita should give the
patient 320 mg of Calcium Gluconate IVSP. Calculate the number of milliliters per dose the patient should
have.
A. 3.2 mL/ dose
B. 0.032 mL/ dose
C. 320 mL/ dose
D. 3200 mL/ dose
1000:10 = 320:, or 3200/1000 = 3.2. If you got 0.032,320, or 3200, you converted grams to milligrams
incorrectly.
68. Adriamycin (Doxorubicin HCL) 20 mg/m² is the prescribed chemotherapy for Mrs. Cortez, who is 57 inches tall
and weighs 142 pounds. Nurse Rita is double checking the dosage the pharmacy sent (Adriamycin 34 mg in
50 cc of D 5 W). The nomogram indicates that a female client’s body surface area (BSA) is 1.7 m². Did you
receive the correct dosage from the pharmacy?
A. Yes
B. No
C. It is not possible to determine dosage from the information given.
D. Chemotherapy is not prescribed by BSA.
Yes. 1.7 * 20 = 34. You need BSA and prescription to calculate the answer and chemotherapy is prescribed
by BSA.
69. If female client, still 57 inches tall, returns at a later time weighing 200 pounds, will her dose be the same?
A. Yes
B. No
C. It is not possible to determine dosage from the information given.
D. Chemotherapy is not prescribed by BSA.
No. dosage is based on BSA, which is based on weight. Chemotherapy is prescribed by BSA, and changes
in weight do affect the dosage of chemotherapy.
70. Maritzah is 9 years old and weighs 67.5 lb. The prescribed dose for Erythromycin Stearate is 20 mg/kg QID.
You have Erythromycin Stearate 200 mg/5 mL in stock. Calculate the number of teaspoons of Erythromycin
per dose for Maritzah.
A. 3 tsp/dose C. 3/4 tsp/dose
B. 1 tsp/dose D. 4 tsp/dose
67.5 ÷ 2.2 = 30.68 * 20 = 614 mg rounded = 15 mL ÷ 5 mL = 3 tsp/dose.
Situation: Personal hygiene affects an individual’s comfort, safety and well being. Honey, a Charge Nurse for 4 years
still take time to provide comfort for her clients through bed bath.
71. When performing personal hygiene on a female patient, it’s important to wash the genital area in what
direction?
A. Back to front
B. Side to side
C. In a circular motion
D. Front to back
It’s best to wash the female genital area from the front to back to avoid contaminating the urethal orifice
with fecal material from the anal area.
72. Which recommendation by the nurse to an adolescent patient with acne would be most appropriate?
A. Wash the skin frequently.
B. Use cosmetics liberally to cover blackheads.
C. Use emollients on the area.
D. Squeeze blackhead as they appear.
Washing the skin frequently remove oil and debris, whereas liberal use of cosmetics and emollients can
clog the pores. Squeezing blackheads is always discouraged because it may lead to infection.
Reference: Fundamentals of NURSING The Art and Science of Nursing Care Volume 2 Sixth Edition by:
Carol Taylor CHAPTER 37 Item no.4 Page no. 1177
73. Which of the following is the correct position to perform mouth care on a comatose patient?
A. Semi-Fowler’s C. Prone
B. Side Lying D. Supine
The side lying position with the head of the bed lowered will help water and debris drain from the patient’s
mouth and prevent aspiration.
Reference: FUNDAMENTALS OF NURSING, MADE INCREDIBLY EASY! LIPPINCOTT
WILLIAMS & WILKINS CHAPTER13, QUICK QUIZ ITEM NO.3, PAGE 364.
74. When giving a back massage, which stroke uses alternating kneading and stroking of the patient’s back and
upper arms?
A. Petrissage C. Effleurage
B. Message D. Tapotement
Petrissage involves using alternating kneading and stroking maneuvers on the patient’s back and upper
arms.
WILKINS CHAPTER 13, QUICK QUIZ ITEM NO.1, PAGE 363.
75. When providing morning care to a patient, which of the following is the correct direction for washing the
patient’s eye?
A. Outer canthus to inner canthus
B. Lower canthus to upper canthus
C. Inner canthus to outer canthus
D. Upper canthus to lower canthus
The eye should be cleared from the inner canthus to outer canthus.
Situation: Nursing has a similar diagnostic language, a clinical judgment to classify health problems within the domain
of nursing.
76. Identify all of the following that are purposes of diagnosing. The purpose of diagnosing is to identify:
1. how an individual, group or community responds to actual or potential health and life processes
2. factors that contribute to or cause health problems (etiologies)
3. strengths the patient can draw on to prevent or resolve problems
4. nursing interventions to resolve health problems
A. 1 and 2
B. 3 and 4
C. 1, 2, and 3
D. All of the above
Identifying nursing interventions to resolve health problems is done during the planning step of the nursing
process.
Reference: Fundamentals of Nursing – The Art
and Science of Nursing Care Volume 1, Sixth
Edition
Unit III – The Nursing Process, Chapter 13 – Diagnosing
Page 281, Item No. 1
77. The terms diagnose and diagnosis have legal implications. They imply that there is a specific problem that
requires management by a qualified expert. Which of the following statements is false?
A. If you make a diagnosis, it means that you accept accountability for accurately naming and managing
problem.
B. If you treat a problem or allow a problem persist without ensuring that the correct diagnosis has been
made, you may cause harm and be accused of negligence.
C. You are accountable for detecting, identifying, or recognizing signs and symptoms that may indicate
problems beyond your expertise.
D. When a nurse diagnose a medical problem, they are just as accountable as physician for detecting,
identifying, and managing the signs and symptoms of disease.
While nurses are accountable to identify and document nursing diagnoses and the signs and symptoms
suggestive of medical and collaborative problem, their responsibility for medical problems is related only to
the scope of their practice and they do not share the same responsibility as their physician colleagues.
Reference: Fundamentals of Nursing – The Art and Science of Nursing Care Volume 1, Sixth Edition
78. To determine the significance of a blood – pressure reading of 148/100, it is first necessary to:
A. Compare this reading to standards.
B. Check the taxonomy of nursing diagnoses for a pertinent label.
C. Check a medical text for the signs and symptoms of high blood pressure.
D. Consult with colleagues.
A standard or a norm, is a generally accepted rule, measure, pattern, or model to which can be compared
data in the same class or category. For example, when determining the significance of a patient’s blood –
pressure reading, appropriate standards include normative values for the patient’s age group, race and
illness category. Deviation from an appropriate norm may be the basis for writing a diagnosis.
79. When the initial nursing assessment revealed that the patient had not had a bowel movement for 2 days, the
student wrote the diagnostic label “constipation.” Which of the following comments is she most likely to hear
from her instructor?
A. “Hold on a minute. . . Nursing diagnoses should always be derived from clusters of significant data rather
than from a single cue.”
B. “Job well done. . . You’ve identified this problem early and we can manage it before it becomes more
acute.”
C. “Is this an actual or a possible diagnosis?”
D. “This is a medical, not a nursing problem.”
A data cluster is a grouping of patient data or cues that point to the existence of a patient health problem.
Nursing diagnoses should always be derived from clusters of significant data rather than from a single cue.
There may be a reason for the lack of a bowel movement for 2 days, or it might be this individual’s normal
pattern.
80. Which of the following nursing diagnoses are correctly written as two-part nursing diagnoses?
(1) Ineffective Coping related to inability to maintain marriage
(2) Defensive Coping related to loss of job and economic security
(3) Altered Thought Processes related to panic state
(4) Decisional Conflict related to placement of parent in nursing hom
A. (1) and (2)
B. (3) and (4)
C. (1), (2), and (3)
D. All of the above
Each of the four diagnoses is a correctly written two-part diagnostic label and etiology or cause.
Situation: Mr. Price tells the nurse that he fears becoming “hooked on drugs” and consequently waits until his pain
becomes unbearable before requesting his PRN analgesic. The nurse plans to be more attentive to Mr. Price and to
assess his needs for pain management more closely.
81. Which of the following consequences of informal planning ought to be the major concern for this nurse?
A. The lack of coordinated plan known by everyone will result in uneven pain management
B. Faulty prioritization of patient needs
C. Inability to evaluate the patient’s responses to nursing care
D. Lack of a record for reimbursement purposes
If this nurse fails to incorporate this learning into the formal plan of care, other professional caregiver’s will
not be aware of the need to monitor the patient’s pain needs more closely, (b), (c), and (d) may all be
correct responses, but they should not be the major concern of the nurse.
Unit III – The Nursing Process, Chapter 14 – Outcome Identification and Planning
82. When helping Mr. Price turn in bed, the nurse notices that his heels are reddened and plans to place him on
precautions for skin breakdown. This is an example of:
A. Initial planning
B. Standardized planning
C. Ongoing Planning
D. Discharge planning
Ongoing planning problem oriented and has as its purpose keeping the plan up to date as new actual or
potential problems are identified.
83. During the outcome identification and planning step of nursing process, the nurse works in partnership with the
patient and family to do which of the following?
(1) Formulate and validate prioritized nursing diagnoses
(2) Identify expected patient outcomes
(3) Select evidence-based nursing interventions
(4) Communicate the plan of nursing care
A. 1 and 3
B. 2 and 4
C. 2, 3, and 4
D. All of the above
Formulating and validating nursing diagnoses occur during the diagnosing step of the nursing process.
84. Use Maslow’s hierarchy of human needs to prioritize the following patient problems from highest priority (#1)
to lowest priority (#4):
(1) Disturbed Body Image
(2) Ineffective Airway Clearance
(3) Spiritual Distress
(4) Impaired Social Interaction
A. 2, 4, 1, 3 C. 1, 4, 3, 2
B. 3, 1, 4, 2 D. 3, 2, 4, 1
Maslow’s hierarchy is (1) physiologic needs; (2) safety needs; and (3) love and belonging needs; (4) self-
esteem needs; and (5) self-actualization needs. (2) is an example of love and belonging need, (1) is an
example of self-esteem need, and (3) is an example of a self-actualization need.
85. From which of the following are outcomes derived?

A. The problem statement of the nursing diagnosis
B. The etiology of the problem of the nursing diagnosis
C. The defining characteristics of the problem
D. The evaluative statement
Outcomes are derived from the problem statement of the nursing diagnosis. For each nursing diagnosis in
the plan of care, at least one outcome should be written that, if achieved, demonstrates a direct resolution
of the problem statement.
Situation: A woman who is firmly committed to natural childbirth and who has attended each natural childbirth class in
preparation for labor and delivery undergoes a cesarean delivery when her fetus displays signs of distress.
Inconsolable, she cries and calls herself a failure as a mother.
86. Her loss may best be described as:

A. Actual
B. Perceived
C. Psychological
D. Combination of the above
Each of the above is only partially correct because there are elements of the loss of the type of delivery she
values, which are actual, perceived, and psychological.
Carol Taylor CHAPTER 33 Item no. 1 Page no. 1012
87. The period of acceptance of loss and grief during which the person learns to deal with experienced loss is best
termed:
A. Anticipatory grieving
B. Bereavement
C. Mourning
D. Stages of death and dying
Mourning is defined as the period of acceptance of loss and grief during which the person learns to deal
with experienced loss. The text offers other definitions for anticipatory grieving, bereavement, and the
stages of death and dying.
88. A patient with AIDS whom you have been visiting at home tells you, “I’m no longer afraid of dying. I think I’ve
made my peace with everyone, and I’m actually ready to move on.” This reflects his progress to which stage of
death and dying?
A. Acceptance C. Bargaining
B. Anger D. Denial
The patient’s statement does not reflect anger, bargaining, or denial; thus, by a process of elimination,
acceptance is the correct choice.
89. When you next visit this dying patient with AIDS, he breaks down and cries and tells you that it is unfair that he
should have to die now when he’s finally made peace with his family and wants to live. You are shocked by
this change in his mood. Your best reply would be:
A. ”You can’t be feeling this way. You have to proceed through the stages of dying in an orderly progression,
and you’ve just moved backward.”
B. “It does seem unfair. Tell me more about how you are feeling.”
C. “You’ll be all right; who knows how much time any of us has to enjoy relationships with those we love?
You’re lucky to have had the opportunity to make your peace.”
D. “Tell me about your pain. Did it keep you awake last night?”
You want to validate that you have heard what the patient is saying and invite him to share more of his
feelings, concerns, and fears,. You do not want to offer false reassurance C or use diversion (D): both of
these strategies would communicate your lack of interest in what he is really feeling. It is simply not true
that people have to move through these stages in an orderly fashion A.
90. Which definition of death is gaining in popularity, as more people believe that critical human functions are
personality, conscious life, and the capacity for remembering, judging, reasoning, acting, enjoying, and
worrying?
A. Heart-lung death
B. Higher-brain death
C. Personhood death
D. Whole-brain death
Because the functions described are controlled by the cortex, or higher brain. There is no such thing as
personhood death.
Situation: You are caring for a comatose patient whose primary diagnosis is breast cancer but who has suffered
multiple complications and who is now in the end stages of her illness. She has been in the medical intensive care
unit for 3 weeks. Her husband tells you that his wife often talked about the end of her life and that she was very clear
about not wanting aggressive treatment that would merely prolong her dying. You both agree that this seems to be all
that therapy is now doing for her.
91. Which of the following orders would you recommend the husband speak to her physician about?
A. Comfort-measures-only
B. Do-not-hospitalize
C. Do-not-resuscitate
D. Slow-code-only
Comfort-measures-only order, because she would want all aggressive treatment to be stopped at this point
and all care to be directed to a comfortable, dignified death. Because she is already in the hospital, there is
no need for B at this point, and a do-not-resuscitate order is not sufficiently comprehensive. One should
never recommend performing a slow-code-only order because it violates good practice.
92. If you are involved in the terminal weaning of a patient, you will want to do all of the following except:
A. Participate in the decision-making process by offering the family information about the advantages and
disadvantages of continued ventilator support
B. Explain to the family what will happen at each phase of the weaning and offer support
C. Check the orders for sedation and analgesia and make sure that the anticipated death is comfortable and
dignified
D. Tell the family that death will occur almost immediately after the patient is removed from the ventilator
A, B, are all nursing interventions that should be carried out by that should be carried out by the nurse
involved in terminal weaning. Because there are no guarantees how any patient will respond once removed
from a ventilator, and because it is possible for the patient to breathe on his or her own and live for hours,
days, and, rarely, even weeks, the family should definitely not be told that death will occur immediately.
93. If your patient tells you that he has no one he trusts to make healthcare decisions for him should he become
incapacitated, you should help him to prepare:
A. Combination advance medical directive
B. Durable power of attorney for healthcare
C. Living will
D. None of the above
The living will is a document whose precise purpose is to allow individuals to record specific instructions
about the type of healthcare they would like to receive in particular end-of-life situations. Both the
combination directive and the durable power of attorney involve appointing someone to make decisions,
which is something this patient is reluctant to do.
94. The patient is competent, understands the consequences of her actions, is not depressed, and persists in
refusing treatment. Her doctor is adamant that she cannot be allowed to die this way, and her daughter
agrees. An ethics consult has been placed. Who is the appropriate decision maker?
A. Patient
B. Daughter
C. Doctor
D. Ethics consult team
Because this patient is competent, she has the right to refuse therapy that she finds to be
disproportionately burdensome, even if this hastens her death. Neither her daughter nor her doctor has the
authority to assume her decision-making responsibilities unless she asks them to do this. The ethics
consult team is not a decision-making body; it can make recommendations but has no authority to order
anything.
95. The family of a patient who has just died asks to be alone with the body and asks for supplies to wash the
body. You know that the mortician usually washes the body. Your best response is:
A. Inform the family that there is no need for them to wash the body since the mortician does this
B. Explain that hospital policy forbids their being alone with the deceased patient and that d a hospital
supplies are to be used only by hospital personnel
C. Give the supplies but watch the family so that nothing unusual happens
D. Provide the requested supplies and ask if this request is linked to their religious or cultural customs and if
there is anything else you can do to be of assistance
Answer A ignores the needs of the family and reflects an ignorance of or insensitivity to cultural and
religious practices; B is simply not true; and C presumes that the family is up to no good purpose and,
unless you have reason to suspect something out of the ordinary, is simply uncalled-for.
Situation: Nurse Dinky notice that Mr. Wong, who has cataracts, is sitting closer to the television than usual.
96. Nurse Dinky interprets that the etiologic basis of his sensory problem is an alteration in which of the following?
A. Environmental stimuli
B. Sensory reception
C. Nerve impulse conduction
D. Impulse translation
Cataracts are inferring with the patient’s ability to receive visual stimuli──altered sensory reception. The
nature of incoming stimuli (A), the conduction of nerve impulses (C), and the translation of incoming
impulses (D) in the brain are not a problem here.
97. Which of the following would be most important to include in the plan of care for a patient who is 85 years old
and has Presbycusis?
A. Obtaining large-print written material
B. Speaking distinctly using lower frequencies
C. Decreasing tactile stimulation
D. Initiating a safety program t prevent falls
Presbycusis is a normal loss of hearing as a result of the aging process. Speaking distinctly in lower
frequencies is indicated. The other choices refer to interventions for other sensory problems.
98. When planning the care for a patient related to disturbed sensory perception, Nurse Dinky would integrate
knowledge of which system as responsible for monitoring and regulating incoming sensory stimuli to maintain,
enhance, or inhibit cortical arousal?
A. General adaptation system
B. Kinesthetic/visceral system
C. Reticular activating system
D. Sensory/perceptual system
The reticular activating system, enhances, or inhibits cortical arousal by monitoring and regulating incoming
sensory stimuli. The general adaptation system (A) is the system responsible for responding to stress.
Kinesthetic and visceral (B) are senses that arise internally from muscles and hollow organs and are the
body’s basic orienting systems. Sensory and perceptual systems (D) are the two components of the
sensory experience.
99. When evaluating a patient’s sensory experience, which four conditions would be essential for a person to
receive data and experience the world?
A. A stimulus, a receptor, an intact nerve pathway, and a functioning brain
B. The visual, auditory, olfactory-gustatory, and tactile senses
C. The basic orienting systems arising from muscles, joints, hollow organs, and movement
D. The reticular activating system, variable stimuli, memory, and motivation
A stimulus, a receptor, an intact nerve pathway, and a functioning brain are the four conditions necessary
for a person to receive data and experience the world.
100. When assessing a patient’s sensory experience, which of the following would Nurse Dinky identify as the
major components?
A. The kinesthetic and visceral sense
B Reception and perception
C. The intensity, size, change, or representation of stimuli
D. Vision, hearing, smell, taste, and touch
Reception and perception are the major components of any sensory experience. All other choices are
merely part of the sensory experience.

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3. The nursing diagnosis readiness for enhanced communication is an example of a (n):

Situation: A routine nursing responsibility is to monitor the client’s vital signs.

9. The nurse conducts a general survey on an adult client, which includes:

Situation: Client education is an essential component of safe quality care.

31. To sterilize surgical instruments, parenteral solutions and surgical dressings:

36. In addition to bathing, which intervention best promotes client comfort:

42. To minimize nocturia, clients should avoid fluids:

56. Which method of assessing temperature is the least accurate?

58. Which heart rate in a neonate would be considered normal?

62. Nurses know that the major extracellular electrolytes are:

63. Which of the following is an example of a hypertonic solution?

85. From which of the following are outcomes derived?

86. Her loss may best be described as:

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