Liberty University - NURS 325 Fundamentals Final Exam, Questions and Answers (spring 2020) All answers correct.

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Fundamentals Final Exam, Questions and Answers • Question 1 The nurse is teaching a new mother about the sleep requirements of a neonate. Which comment by the patient indicates a correct under... standing of the teaching? a. “I can’t wait to get the baby home to play with the brothers and sisters.” b. “I will ask my mom to come after the first week, when the baby is more alert.” c. “I won’t be able to nap during the day because the baby will be awake.” d. “I can get the baby on a sleeping schedule the first week while my mom is here.” • Question 2 A nurse is a preceptor for a nurse who just graduated from nursing school. When caring for a patient, the new graduate nurse begins to explain to the patient the purpose of completing a physical assessment. Which statement made by the new graduate nurse requires the preceptor to intervene? a. “Nurses use data from their patient’s physical assessment to determine a patient’s educational needs.” b. “I will use the information from my assessment to figure out if your antihypertensive medication is working effectively.” c. “Nursing assessment data are used only to provide information about the effectiveness of your medical care.” d. “Information gained from physical assessment helps nurses better understand their patients’ emotional needs.” • Question 3 The nurse is caring for a patient who has been diagnosed with a terminal illness. The patient states, “I just don’t feel like going to work. I have no energy, and I can’t eat or sleep.” The patient shows no interest in taking part in the care by saying, “What’s the use?” Which response by the nurse is best? a. It sounds like you have lost the ability to sleep. b. It sounds like you have lost hope. c. It sounds like you have lost your appetite. d. It sounds like you have lost energy. • Question 4 The nurse is suctioning a patient with a tracheostomy tube. Which action will the nurse take? a. Liberally lubricate the end of the suction catheter with a water-soluble solution. b. Limit the length of suctioning to 10 seconds. c. Set suction regulator at 150 to 200 mm Hg. d. Apply suction while gently rotating and inserting the catheter. • Question 5 A woman is in labor and refuses to receive any sort of anesthesia medication. Which alternative treatment is best for this patient? a. Pudendal block (regional anesthesia) b. Relaxation and guided imagery c. Transcutaneous electrical nerve stimulation (TENS) d. Herbal supplements with analgesic effects • Question 6 A nurse teaches a patient about atelectasis. Which statement by the patient indicates an understanding of atelectasis? a. “Atelectasis affects only those with chronic conditions such as emphysema.” b. “If I develop atelectasis, I will need a chest tube to drain excess fluid.” c. “Hyperventilation will open up my alveoli, preventing atelectasis.” d. “It is important to do breathing exercises every hour to prevent atelectasis.” • Question 7 Which patient is most in need of a nurse’s referral to adoption services? a. An infertile couple religiously opposed to artificial insemination b. A woman considering abortion for an unwanted pregnancy c. A woman who suffered miscarriage during her first pregnancy d. An infertile couple who has been attempting conception for 3 months • Question 8 Having misplaced a stethoscope, a nurse borrows a colleague’s stethoscope. The nurse next enters the patient’s room and identifies self, washes hands with soap, and states the purpose of the visit. The nurse performs proper identification of the patient before auscultating the patient’s lungs. Which critical health assessment step should the nurse have performed? a. Draping stethoscope around the neck b. Running warm water over stethoscope c. Cleaning stethoscope with alcohol d. Rubbing stethoscope with betadine • Question 9 A patient with a hip fracture is having difficulty defecating into a bedpan while lying in bed. Which action by the nurse will assist the patient in having a successful bowel movement? a. Withholding narcotic pain medication b. Administering laxatives to the patient c. Preparing to administer a barium enema d. Raising the head of the bed • Question 10 A nurse is inserting an indwelling urinary catheter for a male patient. Which action will the nurse take? a. Hold the shaft of the penis with the dominant hand. b. Cleanse the meatus with circular strokes beginning at the meatus and working outward. c. Cleanse the meatus 3 times with the same cotton ball from clean to dirty. d. Hold the shaft of the penis at a 60-degree angle. • Question 11 A nurse is caring for a patient with sleep apnea. Which types of ventilator support should the nurse be prepared to administer for this patient? (Select all that apply.) d. Bilevel positive airway pressure (BiPAP) a. Continuous positive airway pressure (CPAP) b. Assist-control (AC) c. Pressure support ventilation (PSV) d. Bilevel positive airway pressure (BiPAP) e. Synchronized intermittent mandatory ventilation (SIMV) • Question 12 The nurse is caring for a postpartum patient. The patient’s labor has lasted over 28 hours within the hospital; the patient has not slept and is disoriented to date and time. Which nursing diagnosis will the nurse document in the patient’s care plan? a. Sleep deprivation b. Insomnia c. Impaired parenting d. Ineffective coping • Question 13 A nurse is caring for a patient with continuous cardiac monitoring for heart dysrhythmias. Which rhythm will cause the nurse to intervene immediately? a. Sinus rhythm b. Paroxysmal supraventricular tachycardia c. Ventricular tachycardia d. Atrial fibrillation • Question 14 A nurse is teaching a patient about patient-controlled analgesia (PCA). Which statement made by the patient indicates to the nurse that teaching is effective? a. “I can receive the pain medication as frequently as I need to.” b. “I need the nurse to notify me when it is time for another dose.” c. “I feel less anxiety about the possibility of overdosing.” d. “I will only need to be on this pain medication.” • Question 15 A male patient in stable condition is in the intensive care unit (ICU) and is asking to see his spouse and two daughters. What should the nurse do? a. Allow the two daughters to visit, and let the wife visit when they leave. b. Allow the wife and one daughter to enter the ICU but not the other daughter. c. Allow only 5 to 10 minutes with the family. d. Allow the wife and daughters to visit at the patient’s request. • Question 16 The nurse is assessing how a patient’s pain is affecting mobility. Which assessment question is most appropriate? a. “Would you please rate your pain on a scale from 0 to 10 for me?” b. “When does your pain medication typically take effect on your pain?” c. “What activities, if any, has your pain prevented you from doing?” d. “Have you considered working with a physical therapist?” • Question 17 A nurse hears the following comments from different patients. Which patient comment does the nurse identify as faith? a. I go to church every Sunday. b. I get a feeling of awe when looking at the sunset. c. I have something to look forward to each day. d. I believe there is life after death. • Question 18 A patient expresses concerns over having black stool. The fecal occult test is negative. Which response by the nurse is most appropriate? a. “Are you under a lot of stress?” b. “This is probably a false negative; we should rerun the test.” c. “You should schedule a colonoscopy as soon as possible.” d. “Do you take iron supplements?” • Question 19 The patient is having a difficult time dealing with an AIDS diagnosis. The patient states, “It’s not fair. I’m totally isolated from God and my family because of this. Even my father hates me for this. He won’t even speak to me.” What should the nurse do? a. Use therapeutic communication to establish trust and caring. b. Assure the patient that the father will accept this situation soon. c. Point out that the patient has no control and that he or she must face the consequences. d. Tell the patient to move on and focus on getting better. • Question 20 A nurse is caring for a 15-year-old who in the past 6 months has had multiple male and female sexual partners. Which response by the nurse will be most effective? a. “Your current friends are leading you to make poor choices. You should find new friends to hang out with.” b. “I think it’s best to notify your parents. They know what’s best for you and can help make sure you practice safe sex.” c. “Having sexual interaction with both males and females places you at higher risk for STIs. To protect yourself, you need to decide which orientation you are.” d. “Sexually transmitted infections and unwanted pregnancy are a real risk. Let’s discuss what you think is the best method for protecting yourself.” • Question 21 Which clinical manifestation will the nurse expect to observe in a patient with excessive white blood cells present in the urine? a. Reduced urine specific gravity b. Fever with chills c. Increased blood pressure d. Abnormal blood sugar • Question 22 The nurse is administering pain medication for several patients. Which patient does the nurse administer medication to first? a. The patient who needs to be premedicated before walking b. The patient who needs to take a scheduled dose of maintenance pain medication c. The patient who is experiencing 8/10 pain and has an immediate order for pain medication d. The patient who has a PCA running that needs the syringe replaced • Question 23 Which sociocultural finding in the history of a patient will alert the nurse to a possible developmental problem? a. Childhood obesity b. Loss of stamina c. Prolonged poverty d. Family relocation • Question 24 Order: zidovudine (Retrovir) 100 mg by nasogastric tube, q6h Drug available: How many milliliters would you give per dose? 30 mL • Question 25 Which nursing observation of the patient in intensive care indicates the patient is sleeping comfortably during NREM sleep? a. Eyes closed, tossing in bed, respirations 18, heart rate 80 b. Eyes closed, lying quietly, respirations 12, heart rate 60 c. Eyes closed, lying supine in bed, respirations 22, heart rate 66 d. Eyes closed, mumbling to self, respirations 16, heart rate 68 • Question 26 The nurse is assessing a patient with emphysema. Which assessment finding requires further follow-up with the health care provider? a. Increased anterior-posterior diameter of the chest b. Accessory muscle used for breathing c. Clubbing of the fingers d. Hemoptysis • Question 27 The patient has a risk for skin impairment and has a 15 on the Braden Scale upon admission. The nurse has implemented interventions. Upon reassessment, which Braden score will be the best sign that the risk for skin breakdown is removed? a. 23 b. 20 c. 12 d. 13 • Question 28 The nurse is caring for a group of patients. Which patient will the nurse see first? a. A patient praying to Allah. b. A patient having a folk healer in the room. c. A patient saying that God has left and there is no reason for living. d. A patient refusing treatment on the Sabbath. • Question 29 A patient in a motor vehicle accident states, “I did not run the red light,” despite very clear evidence on the street surveillance tape. Which defense mechanism is the patient using? a. Dissociation b. Compensation c. Conversion • Question 30 Order: lamivudine (Epivir) 0.15 g, PO, bid Drug available: How many milligrams should the patient receive per day? • Question 31 Which nursing intervention is most effective in preventing hospital-acquired pneumonia in an older-adult patient? a. Discontinue the humidification delivery device to keep excess fluid from lungs. b. Monitor oxygen saturation, and frequently auscultate lung bases. c. Decrease fluid intake to 300 mL a shift. d. Assist the patient to cough, turn, and deep breathe every 2 hours. • Question 32 The nurse is updating the plan of care for a patient with impaired skin integrity. Which findings indicate achievement of goals and outcomes? (Select all that apply.) Selected a. Granulation tissue is present. b. Nonblanchable erythema is absent. c. Skin is intact with no redness or swelling. e. No injuries to the skin and tissues are evident. a. Granulation tissue is present. b. Nonblanchable erythema is absent. c. Skin is intact with no redness or swelling. d. The patient’s expectations are not being met. e. No injuries to the skin and tissues are evident. • Question 33 An order is written for phenytoin 500 mg IM q3-4h prn for pain. The nurse recognizes that treatment of pain is not a standard therapeutic indication for this drug. The nurse believes that the health care provider meant to write hydromorphone. What should the nurse do? a. Give the patient hydromorphone, as it was meant to be written. b. Administer the medication and monitor the patient frequently. c. Refuse to give the medication and notify the nurse supervisor. d. Call the health care provider to clarify the order. • Question 34 The nurse is caring for a young-adult patient on the medical-surgical unit. When doing midnight checks, the nurse observes the patient awake, putting a puzzle together. Which information will the nurse consider to best explain this finding? a. The patient has been kept up with the noise on the unit. b. The patient misses family and is lonely. c. The patient was waiting to talk with the nurse. d. The patient’s sleep-wake cycle preference is late evening. • Question 35 A nurse has withdrawn a narcotic from the medication dispenser and must waste a portion of the medication. What should the nurse do? a. Place the wasted portion of the medication in the sharps container. b. Have another nurse witness the wasted medication. c. Return the wasted medication to the medication dispenser. d. Exit the medication room to call the health care provider to request an order that matches the dosages. • Question 36 A nurse is providing care to a group of patients. Which patient will the nurse see first? a. A patient with an indwelling catheter that has stool on the catheter tubing b. A patient who is dribbling small amounts on the way to the bathroom and has a diagnosis of urge incontinence c. A patient who has just voided and needs a postvoid residual test d. A patient with reflex incontinence with elevated blood pressure and pulse rate • Question 37 The nurse is providing an educational session on sleep regulation for new nurses in the Sleep Disorder Treatment Center. Which statement by the nurses will best indicate that the teaching is effective? a. “If the patient has an interruption in the spinal reflexes, it can influence the functions of sleep.” b. “If the patient has an interruption in the urinary pathways, it can influence the functions of sleep.” c. “If the patient has a disease process in the cranial nerves, it can influence the functions of sleep.” d. “If the patient has a disease process in the central nervous system, it can influence the functions of sleep.” • Question 38 The nurse is caring for a patient with fluid volume overload. Which physiological effect does the nurse most likely expect? a. Decreased tissue perfusion b. Increased preload c. Increased heart rate d. Decreased afterload • Question 39 A trauma survivor is requesting sleep medication because of “bad dreams.” The nurse is concerned that the patient may be experiencing post-traumatic stress disorder (PTSD). Which question is a priority for the nurse to ask the patient? a. “Can you describe your phobias?” b. “Are you reliving your trauma?” c. “Are you having chest pain?” d. “Can you tell me when you wake up?” • Question 40 A nurse is evaluating a nursing assistive personnel’s (NAP) care for a patient with an indwelling catheter. Which action by the NAP will cause the nurse to intervene? a. Securing the catheter tubing to the patient’s thigh b. Placing the drainage bag on the side rail of the patient’s bed c. Kinking the catheter tubing to obtain a urine specimen d. Emptying the drainage bag when half full • Question 41 During a routine physical examination of a 70-year-old patient, a blowing sound is auscultated over the carotid artery. Which assessment finding will the nurse report to the health care provider? a. Phlebitis b. Thrill c. Bruit d. Right-sided heart failure • Question 42 A nurse is preparing to perform a complete physical examination on a weak, older-adult patient with bilateral basilar pneumonia. Which position will the nurse use? a. Lateral recumbent b. Prone c. Supine d. Sims’ • Question 43 A woman who was sexually assaulted a month ago presents to the emergency department with reports of recurrent nightmares, fear of going to sleep, repeated vivid memories of the sexual assault, and inability to feel much emotion. Which medical problem will the nurse expect to see documented in the chart? a. Acute stress disorder b. Post-traumatic stress disorder c. General adaptation syndrome d. Alarm reaction • Question 44 A nursing student is providing education to a group of older adults who are in an independent living retirement village. Which statement made by the nursing student requires the nurse to intervene? a. “Using pillows and taking pain medication if needed before having sexual intercourse often help alleviate pain and improve sexual functioning.” b. “You do not need to worry about getting a sexually transmitted infection at this point in your life.” c. “Avoiding alcohol use will enhance your sexual functioning.” d. “You need to tell your partner how you feel about sex and any fears you may have.” • Question 45 A nurse is caring for a patient who expresses a desire to have an elective abortion. The nurse’s religious and ethical values are strongly opposed. How should the nurse best handle the situation? a. Inform the patient that, because of immoral issues, another nurse will have to care for her. b. Attempt to educate the patient about the consequences of abortion. c. Continue to care for the patient, and limit conversation as much as possible. d. Refer the patient to a family planning center or another health professional. • Question 46 A nurse is assessing a patient with prolonged stress. Which conditions will the nurse monitor for in this patient? (Select all that apply.) Selected a. Cancer b. Infections e. Diabetes a. Cancer b. Infections c. Low blood pressure d. Allostasis e. Diabetes • Question 47 A nurse is teaching a patient about medications. Which statement from the patient indicates teaching is effective? a. “If I am 30 minutes late taking my medication, I should skip that dose.” b. “My parenteral medication must be taken with food.” c. “Once I start feeling better, I will stop taking my antibiotic.” d. “I will rotate the sites in my left leg when I give my insulin.” • Question 48 A female teen with celiac disease continues to eat food she knows will make her ill several hours after ingestion. While planning care, the nurse considers maturational and tertiary-level interventions. Which intervention will the nurse add to the care plan? a. Assist the teen in meeting dietary restrictions while eating foods similar to those eaten by her friends. b. Teach the teen about the food pyramid. c. Gently admonish the teen and her parents regarding the consistently poor diet choices. d. Administer antidiarrheal medications with meals. • Question 49 Order: nystatin (Mycostatin) 0.5 million units, qid, swish and swallow Drug available: How many milliliters of Mycostatin per dose would you pour? 5 mL • Question 50 The nurse is emptying an ileostomy pouch for a patient. Which assessment finding will the nurse report immediately? a. Malodorous stool b. Liquid consistency of stool c. Presence of blood in the stool d. Continuous output from the stoma • Question 51 The nurse is caring for a patient with a Stage II pressure ulcer and has assigned a nursing diagnosis of Risk for infection. The patient is unconscious and bedridden. The nurse is completing the plan of care and is writing goals for the patient. Which is the best goal for this patient? a. The patient will state what to look for with regard to an infection. b. The patient will remain free of odorous or purulent drainage from the wound. c. The patient’s family members will wash their hands when visiting the patient. d. The patient’s family will demonstrate specific care of the wound site. • Question 52 A nurse is caring for a patient with left-sided hemiparesis who has developed bronchitis and has a heart rate of 105 beats/min, blood pressure of 156/90 mm Hg, and respiration rate of 30 breaths/min. Which nursing diagnosis is a priority? a. Impaired gas exchange b. Activity intolerance c. Risk for skin breakdown d. Risk for infection • Question 53 A nurse is assessing a patient’s cranial nerve IX. Which items does the nurse gather before conducting the assessment? (Select all that apply.) c. Tongue blade e. Lemon applicator a. Vial of sugar b. Snellen chart c. Tongue blade d. Ophthalmoscope e. Lemon applicator • Question 54 A patient is receiving vancomycin. Which function is the priority for the nurses to assess? a. Hearing b. Vision c. Heart tones d. Bowel sounds • Question 55 A patient refuses medication. Which is the nurse’s first action? a. Educate the patient about the importance of the medication. b. Agree with the patient’s decision and document it in the chart. c. Discreetly hide the medication in the patient’s favorite gelatin. d. Explore with the patient reasons for not wanting to take the medication. • Question 56 A nurse is assessing several patients. Which assessment findings will cause the nurse to follow up? (Select all that apply.) Selected a. Crackles in lower lung lobes d. Pleural friction rub present e. Orthopnea a. Crackles in lower lung lobes b. A 160-degree angle between nail plate and nail c. Grade 5 muscle function level d. Pleural friction rub present e. Orthopnea f. Nonpalpable lymph nodes • Question 57 A nurse is assisting a patient in making dietary choices that promote healthy bowel elimination. Which menu option should the nurse recommend? a. Dinner salad topped with hard-boiled eggs, cheese, and fat-free dressing b. Broccoli and cheese soup with potato bread c. Grape and walnut chicken salad sandwich on whole wheat bread d. Turkey and mashed potatoes with brown gravy • Question 58 The nurse is caring for two patients with the same last name. In this situation which right of medication administration is the priority to reduce the chance of an error? a. Right patient b. Right route c. Right dose d. Right medication • Question 59 The patient has right-sided heart failure. Which finding will the nurse expect when performing an assessment? a. Basilar crackles b. Cyanosis c. Chest pain d. Peripheral edema • Question 60 The patient is admitted with chronic anxiety. Which action is most appropriate for the nurse to take? a. Look at how anxiety influences the patient’s ability to function. b. Help the patient realize that there is little hope of relief from anxiety. c. Realize that the patient’s only goal is relief of the anxiety. d. Focus on finding quick remedies for the anxiety. • Question 61 The nurse is caring for an adolescent with an appendectomy who is reporting difficulty falling asleep. Which intervention will be most appropriate? a. Adjust temperature in the patient’s room to 21° C (70° F). b. Encourage the discontinuation of a soda and chocolate nightly snack. c. Close the door to decrease noise from unit activities. d. Ensure that the night-light in the patient’s room is working. • Question 62 The nurse is creating a plan of care for an obese patient who is suffering from fatigue related to ineffective breathing. Which intervention best addresses a short-term goal the patient could achieve? a. Limiting the diet to 1500 calories a day b. Running 30 minutes every morning c. Stopping smoking immediately d. Sleeping on two to three pillows at night • Question 63 A nurse is caring for a patient with rheumatoid arthritis who is now going to be taking 2 acetaminophen (Tylenol) tablets every 6 hours to control pain. Which part of the patient’s social history is the nurse most concerned about? a. Patient smokes 2 packs of cigarettes a day. b. Patient takes antianxiety medications. c. Patient occasionally uses marijuana. d. Patient drinks 1 to 2 glasses of wine every night. • Question 64 A 15-year-old patient is concerned because her mother wants her to receive the human papillomavirus (HPV) vaccination, but the patient is unsure if she wants it. Which response by the nurse is most therapeutic? a. Promote the importance of the vaccine, and recommend that the patient get the vaccine as soon as possible. b. Ask the patient what concerns she may have about the vaccination. c. Remind her that her mother knows best and that she should respect her parents’ wishes. d. Inquire about how many sexual partners she has had in the past year. • Question 65 A nurse is assessing a patient who started to have severe pain 3 days ago. When the nurse asks the patient to describe the pain, the patient states, “The pain feels like it is in my stomach. It is a burning pain, and it spreads out in a circle around the spot where it hurts the most.” Which type of pain does the nurse document the patient is having at this time? a. Chronic pain b. Superficial pain c. Idiopathic pain d. Visceral pain • Question 66 An older couple expresses concern because they are easily fatigued during sexual intercourse and cannot reach climax. Which strategies to increase sexual stamina will the nurse offer? (Select all that apply.) Selected a. Avoid alcohol and tobacco. e. Eat well-balanced meals. f. Plan sexual activity around a time when the couple feels rested. a. Avoid alcohol and tobacco. b. Use extra lubrication to decrease discomfort. c. Take pain medication before intercourse. d. Encourage intimate touching, such as hugging and kissing. e. Eat well-balanced meals. f. Plan sexual activity around a time when the couple feels rested. • Question 67 The nurse is caring for a group of patients. Which task can the nurse delegate to the nursing assistive personnel? a. Implementing negative-pressure wound therapy on a stable patient b. Assessing a surgical patient for risk of pressure ulcers c. Applying an elastic bandage to a medical-surgical patient d. Treating a pressure ulcer on the buttocks of a medical patient • Question 68 A school nurse recognizes a belt buckle–shaped ecchymosis on a 7-year-old student. When privately asked about how the injury occurred, the student described falling on the playground. Which action will the nurse take next? a. Contact social services and report suspected abuse. b. Talk to the principal about how to proceed. c. Interview the patient in the presence of the teacher. d. Disregard the finding based upon child’s response. • Question 69 Order: zidovudine (Retrovir) 100 mg by nasogastric tube, q6h Drug available: How many milligrams should the patient receive per day? • Question 70 Order: lamivudine (Epivir) 0.15 g, PO, bid Drug available: How many milliliters should the patient receive per dose? [Show More]

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