Fundamentals of Nursing
"no good and don't care." The nurse
1. A mother complains that her 13-year-old has
started to grow rapidly, and asks the nurse if this is
normal and how long it will last. The best nursing
response is:
A "This is unusual at this age, and a physician
should be contacted."
B "This is normal, but will only last a few
months."
C "This is normal and can last until about age
20."
D "This is normal, but growth should be
completed by about age 15 or 16."
2 A 21-year-old who has just graduated from
college has had a serious automobile
accident and faces many months of
hospitalization and rehabilitation. The nurse,
in planning care, recognizes that according to
Havighurst, this client may delay or have
difficulty with successful accomplishment of
which developmental task?
A Selecting a mate and getting started in an
occupation
B Exhibiting socially responsible behavior
and developing an ethical system of
behavior
C Developing a conscience and developing
appropriate masculine or feminine role
D Selecting an occupation and developing
intellectual skills necessary for civic
competence
3 A mother is frustrated because her 2 1/2-
year-old is not toilet trained and will not use
the potty when placed on it. What suggestion
by the nurse is most appropriate?
A Do not let the child off the potty until
stool or urine is evacuated.
B Do not try to toilet-train the child, as it is
too early.
C Give the child a laxative and place on the
potty in 30 minutes.
D Make up a game to encourage the child
to want to use the potty.
4 An 82-year-old client complains that he is
"sick, old, and useless," and that people are
recognizes that these statements at this age
indicate negative resolution of which task,
according to Erikson?
A Integrity versus despair
B Identity versus role confusion
C Generativity versus stagnation
D Intimacy versus isolation
5 The nurse is developing a teaching plan for a
9-year-old female client who is diabetic.
Which actions would be appropriate,
according to Piaget?
A Teaching size of food portions and
importance of timing snacks and meals
B Discussing future hazards of pregnancy
for diabetic mothers
C Using hand puppets to teach proper
nutrition
D Using hypothetical problem situations to
teach potential problem solving
6 A client is hesitant to have needed surgery
because of multiple family, social, and church
obligations, saying, "I hate to let everybody
down." The nurse recognizes that this client's
moral dilemma is a result of the client
operating at which level of Kohlberg's stages
of moral development?
A Preconventional
B Conventional
C Postconventional
D Universal
7 A 68-year-old female client of a spouse with
Alzheimer's disease has been taking
caregiver classes. The nurse determines that
caregiver education has been effective and
that the client has progressed to Stage 3 in
Gilligan's moral development levels when the
client exhibits which behavior(s)?
A States that she will never place her
husband in a nursing home
B Has complex locks put on all outside
doors so that the husband cannot wander
outside
C Has the backyard fenced in so that the
husband can go outside safely
D Arranges for a "sitter" weekly so that she
can take a yoga class
Fundamentals of Nursing
11. A young woman who is contemplating pregnancy and has a
8 A client expresses fear over a complex,
"junk food" tells the nurse, "I will begin eating right and taking m
painful, sterile procedure, and asks that the
become pregnant." The best nursing response is:
minister be allowed to stay in the room and
close by while it is being performed. The best
nursing action would be to:
A "You must begin eating well and taking multiple vitamins a
suspect that you are pregnant."
A Explain that the procedure is sterile, and
B "You must eat well and take multiple vitamins both before
that the minister cannot stay, but can
pregnancy."
return as soon as it is completed
C "As long as you consume enough calories, there will not be
B Place the minister by a window where
become pregnant."
the client can see him during the
D "Eating well and taking multiple vitamins are not importan
procedure
trimester of pregnancy."
C Let the minister stand way back in a far
corner of the room during the procedure
D Place the minister in sterile apparel and
allow him to be close to the client during
the procedure

1 The nurse is seeing several pregnant women

2 at a community health clinic. Which woman
9 A mother expresses concern to the nurse
is at highest risk for having a low--birth
regarding her 5-year-old child's development.
weight infant or one with birth defects, and is
She says,: "I read Erikson and Piaget, and my
in need of prenatal education?
child does not seem to be on target. Also, my
neighbor's child seems more advanced. My
A A 25-year-old woman who smokes and
doctor says not to worry, but I do." The best
drinks two beers a day
nursing response is:
B An 18-year-old woman who is in her
eighth month and has gained 22 pounds
A "You are right to be concerned. Your
C A 30-year-old woman who was 10 pounds
child should meet all the guidelines for
overweight before becoming pregnant
the age."
D A 32-year-old, unmarried middle class
B "Tell me exactly what your child is or is
executive secretary.
not doing that causes you concern."
C "I wouldn't worry. All children progress at
their own rate."
D "Your child will probably catch up with
more age." 1 A new mother call the clinic crying because
3 her 2-day-old infant now weighs 7 pounds, 2
ounces, when he weighed 7 pounds, 8
ounces at birth. She says, "I must be doing
something wrong." The best nursing
1 A nurse who works in a long-term care
response would be:
0 facility notices that the elderly clients seem
depressed, and that they have little interest
A "You are right to be concerned. I will
in life. They spend their days watching
schedule an appointment for tomorrow."
television. When they attend crafts, they are
B "The baby is obviously not eating
disinterested in drawing pictures or coloring.
enough. Try feeding every two hours."
Based on these observations, and guided by
C "This is normal weight loss. The baby
Peck's theory on older adult development,
should be back to birth weight in 3-5
the nurse determines that:
days".
D "The baby should be taken to the nearest
A Activities such as gardening and baking
emergency room immediately."
may be indicated for these clients
B Humorous movies need to be shown
more frequently
C The activity director needs to bring in
musical groups more often 14 A 6-month-old infant is brought to the clinic
D Stringing glass beads and making seed by an aunt who says the baby's parents are
pictures may be more interesting to out of the country on business. The nurse
elderly clients notes that the infant seems healthy but
withdrawn, and is below the fifth percentile
for weight and height on the standard
growth chart. The aunt states the baby has
had a succession of undependable baby-
Fundamentals of Nursing
sitters since she was born, and that the
parents are always working. Based on the
assessment data, the nurse forms a
preliminary diagnosis of:
A Weight loss related to infant colic
B Child abuse: shaken-baby syndrome
C Failure to thrive related to organic
causes
D Failure to thrive related to inorganic
causes
15 Parents of a 2 1/2-year-old child report that
the child has began to have temper
tantrums, and ask the nurse what they
should do. Strategies that the nurse could
suggest include:
A Determining the child's safety and then
leaving the room when the child has a
tantrum
B Attempting to reason with the child
during the tantrum
C Giving the child what is wanted to avoid
the tantrums
D Throwing cold water on the child during
the tantrum to help the child "snap out
of it"
16 Using Snellen's E chart, the nurse assesses
the visual acuity of a 5-year-old as
approximately 20/60. The nurse determines
that the findings at this age indicate:
A Normal vision
B Hyperopic vision
C Myopic vision
D Emmetropic vision
17 A nurse needs to complete diet and exercise
health assessments on preschool children.
Based on the nurse's knowledge of
preschool cognitive and social development,
the nurse determines that the best way to
obtain complete and accurate information is
to:
A Interview each child alone
B Interview a group of children together
C Interview each child's parents
D Interview each child together with the
parents
18 The nurse is developing a nutrition program
for 7- and 8-year-old children. Based on the
nurse's knowledge of health problems for
this age group, an important component of
the program should be:
A Identifying foods that contribute to
obesity
B Distinguishing between saturated and
unsaturated fats
C Realizing the importance of taking
vitamins every day
D Getting the best food buy for the money
19 Parents of a 15-year-old who walks with a
very noticeable limp following recovery from
a recent automobile accident ask the nurse
what to do, because the teen refuses to
return to school, and says, "I'm a cripple."
The best nursing response would to suggest
that the parents:
A Insist that the teen return to school as
soon as possible and learn to "deal with"
reactions of others
B Encourage their teen to attend a support
group of peers with similar handicaps
before returning to school
C Arrange for homeschooling for their teen
to avoid the rejection he experienced at
the previous school
D Ask the physician to prescribe an
antidepressant for their teen prior to
returning to school.
20 The nurse determines that a sex education
program regarding risk behaviors for teens
in a local school has been effective when:
A Teens report a reduction in masturbation
episodes
B Teens report more use of vaginal
douches
C Teens report fewer sexual encounters
D The rate of STDs and teen pregnancy
decreases
21. A 25-year-old comes to the clinic with complaints
of difficulty sleeping, weight loss, stomach
discomfort, and vague aches and pain. The history
reveals that the client was laid off from work two
months previously, is not seeking employment, has
no friends or family within 200 miles, and has almost
no social contact with anyone. The priority action of
the nurse should be to:
Fundamentals of Nursing
A Suggest that the client take over-the-
counter sleeping medications
B Schedule the client for stomach x-rays and
further tests
C Refer the client to a local employment
service
D Refer the client to a mental health
professional
2 The nurse is providing a community
2 education program on hypertension to a
predominately African-American group of
young adults. The nurse should plan the
program to address which controllable
contributing factors for hypertension?
A Vigorous physical activity and weight loss
B Obesity and stress
C Biologic inheritance and socioeconomic
status
D Alcohol and substance abuse
2 A 22-year-old woman reports the following
3 health history: sexual activity beginning age
14, multiple sex partners, and previous
Trichomonas vaginitis. Based on this history,
the nurse knows that an essential screening
exam to prepare the client for will be:
A Papanicolaou (Pap) test
B Breast exam and mammography
C Chest x-ray
D Drug screen
2 A 43-year-old woman reports symptoms of
4 hot flashes, weight gain, and insomnia. She
says: "I can't be going through menopause,
something else must be wrong! My mother
didn't go through menopause until she was
54 years old!" What is an appropriate
response by the nurse?
A "You definitely are going through
menopause, even though it is unusual to
do so at such a young age."
B "These are not menopausal symptoms,
and you need tests to determine what is
happening."
C "This is menopause, and you will have to
learn to live with it."
D "Menopause usually happens anytime
between ages 40 and 55. It sounds like
you are upset about this."
2 A 45-year-old male client who has attended
5 classes on coronary heart disease prevention
reports that he quit smoking, doesn't have
hypertension, and doesn't eat much red
meat. What other important behavior would
indicate that the nurse's teaching has been
effective?
A Seeing a physician yearly for an EKG
B Swimming for an hour, four times weekly
C Drinking a glass of wine every day
D Avoiding strenuous activity
2 A 50-year-old client complains about getting
6 older, saying: "Everything is starting to sag
and wrinkle! I don't want to go anywhere
looking like this." The nurse determines that,
according to Erickson, this client is
experiencing:
A Generativity
B Stagnation
C Disengagement
D Continuity
2 An 86-year-old client sitting up in a chair
7 complains of being cold even though the
room thermometer measures 78 degrees.
The most appropriate nursing action would
be to:
A Get the client a sweater, blanket, and
stockings
B Check the client's temperature
C Ignore the complaint, since the room is
sufficiently warm
D Put a space heater next to the client
2 A nurse is planning a community education
8 program on osteoporosis. Which group of
high-risk individuals needs to be included in
the mailing list of invitations to attend the
program?
A Premenopausal women
B Physically active men and women ages
40-55
C Men and women who consume large
amounts of dairy products
D Inactive elderly men
Fundamentals of Nursing
2 The daughter of an 88-year-old female client D Give very complete and comprehensive
9 newly admitted to a nursing home states that explanations of all information
her mother does not socialize much at all,
and asks the nurse to "be sure to plan
activities to get her out more." Keeping
continuity theory in mind, what assessment
information does the nurse need to obtain 3 The nurse observes the following client behaviors: fidgeti
before planning any intervention? 3 tenseness, and wrinkled brow. How should the nurse best
nonverbal cues?
A The amount of social activity the client
was involved in when younger A Determine and document that the client is anxious
B The mobility ability of the client B Ask the client specific questions about possible cau
C The visual and hearing abilities of the as, "Are you afraid of something?"
client C Ask the client, "Why are you so nervous and jumpy
S The ability of the client to understand D Say to the client, "You look worried. Is something b
and engage in meaningful conversation

3 The nurse learns from a report that a client has suffered s

3 The nurse is preparing to discharge several 4 an accident. What is the best way for the nurse to prepar
0 clients from the hospital. All the clients this client?
require medications and special diets at
home. The nurse will assess financial status A Having all supplies and equipment ready to be abl
of which client in particular, who may be B Learning about the client's support systems (famil
most in need of financial assistance to obtain C Learning more about the specifics of the disfigurem
medications and proper food? reactions by the nurse
D Reviewing all medications and treatment procedur
A A 60-year-old Caucasian male
B A 90-year-old Caucasian female
C A 75-year-old African-American male
D A 87-year-old African-American female

31. The nurse notes that a client appears very worried and upset about an upcoming
procedure. After acknowledging the client's discomfort and providing
3 information
The nurseand
comes into a client's room to
support, the nurse evaluates that comfort care provided has been successful
5 by:
obtain an admission history, moves the
chair next to the top bed rail by the
client's head, and sits down to better hear
the client. The client draws back and
A Taking the client's blood pressure moves to the opposite side of the bed. The
B Asking the client to relate the information back to the nurse to confirm
best nursing response would be to:
understanding
C Asking if the client understands the information A Lean over and touch the client to
D Asking if the client is now more comfortable about having the procedureconvey reassurance
performed than previously B Move the chair a foot or two away
from the bed and observe the client's
response
C Say, "I will come back later when you
are ready to talk to me."
D Ignore the behavior and continue with
the interview, observing the client for
3 The nurse is preparing to communicate depression
2 educational information to an 83-year-old,
English-speaking client of Hispanic descent.
The nurse determines that the best way to
verbally communicate with this client is to: 3 A client is crying. The nurse is very busy,
6 but recognizes the client's need for
A Speak quickly and avoid facing the client interaction. The best way for the nurse to
directly, which could be perceived as convey a willingness to be with the client
threatening for support is to:
B Speak slowly and provide brief and
simple explanations A Ask the client, "Would you like to
C Get an interpreter or family member to talk?" from the doorway, and come
interpret for the nurse
Fundamentals of Nursing
back in if the client says, "Yes." the client
B State, "I'll be back later and we can C Using a paper and pencil to write
talk about your problems." questions and information
C State: "We can talk while I do your D Using pictures and gestures to
dressing change", accomplishing both communicate
getting work done and listening to the
client
D Pull up a chair, sit down, and state: "I
41. The nurse has offered a diabetic education program. What is
see that something is bothering you.
client compliance with a diabetic treatment plan?
Do you want to talk?"

3 The nurse is assessing a new client for possible impairment of verbal

7 communication. What components need to be in the assessment?
A The client expresses a desire to learn about diabetes trea
B The client can list foods that are not allowed on a diabetic
C The client willingly learns about diabetes treatment and fo
A Educational background and socioeconomic status plan.
B Level of education and past personal experiences D The client is able to discuss diabetes treatment and passe
C Hearing, vision, and cognitive functioning content with a score of 90%.
D Ability to read and write

3 A client asks about a procedure with which the nurse is unfamiliar. What is the
8 best nursing response? 4 The nurse is developing a teaching plan on
2 self-injection of insulin for a group of diabetic
clients. The plan includes information about
A "I don't know much about that procedure, but I will find out injections
and bring and
youtypes of insulin, and
information about it." demonstrations of injection technique. What
B affective
"I don't have time to explain that now, but I'll get back to you later."component is important for the
C "It is your doctor's responsibility to explain that procedurenurse to plan to include in educating these
to you."
D "The technicians in special care will explain the procedureclients?
to you when
you go for the test."
A Helping clients accept the need for daily
injections
B Having clients demonstrate injection
procedures on themselves
A client presents with the following: C Asking clients to describe the injection
3 history of cancer of the esophagus, procedure
9 treatment with surgery and radiation, D Giving a test on the types of insulin and
speech garbled and thick, able to read duration of action
and write English. The most appropriate
nursing diagnosis for the nurse to
determine, based upon this information,
is:
4 A nurse who is applying behaviorist learning theory offers
A Impaired communication 3 risk factors for heart disease in a straightforward, non-dis
B Impaired verbal communication strategies are appropriate for the nurse applying this lear
C Self-esteem disturbance
D Social isolation A Encourage positive teacher--learner relationships,
delivery methods
B Give a short test, and provide positive feedback
C Assess clients' developmental and individual learni
teaching strategies accordingly
40 A client is able to understand only D Encourage clients to establish goals, and promote
minimal English, and no interpreter is
available. What alternative measures
can the nurse to use to enhance
communication?
4 Prior to beginning a teaching session on self-care of a col
A Speaking loudly to the client 4 assess the client's readiness to learn by assessing:
B Speaking more slowly and facing
Fundamentals of Nursing
A Client's recognition of a need to learn, and belief that learning
besides,
will lead
I know
to self-
all that stuff." Based on
care ability these behaviors, the nurse may suspect
B Client's knowledge and previous experience with colostomies that:
C Client's pain and comfort levels, and willingness to learn
D Client's cognitive and sensory abilities A The client may be unable to read the
instructions
B The client is noncompliant
C The client doesn't understand the
instructions
4 A client who is doing a return demonstration D The client is confused
5 of how to change a wound dressing to the leg
contaminates the dressing after
appropriately cleansing the wound. The best
nursing response is to:
4 A client presents with the following: recent medical diagn
A Say, "You have done this all wrong! Let 9 failure, four new medications, and reduced activity levels
me show you again." breath. The most appropriate nursing diagnosis based up
B Remove the dressing, cleanse the wound
again, and apply a new dressing A Health-Seeking Behavior (exercise and activity) rel
C Say and do nothing to avoid upsetting health status
the client B Noncompliance with medical treatment plan relate
D Say, "You did a good job of cleansing the activity
wound. Let's look at ways to best put the C Risk for ineffective coping related to deficient know
dressing on." D Deficient Knowledge (medication) related to inexpe
ordered therapy

4 The nurse is assessing a client's psychomotor ability to learn how to care for a
6 colostomy. Aspects to include in the assessment are:
A Muscle strength and motor coordination
B Memory and reading ability
C Cultural values and beliefs
D Emotional state and possible conflicts
The nurse is planning an educational
4 program on cancer detection for a
7 community group. What should be
included in the plan to assure that the
program will address various learning
styles of clients?
5 The nurse is teaching a client about reducing blood chole
0 dietary management. The most appropriate learning outc
would be:
A The client will understand benefits of a low-fat diet
reduction
B The client will accurately select low-fat foods from
C The nurse will teach the client about low-fat foods
reduction
D The client will list some common low-fat foods
51. When considering delegation of responsibility, the
registered nurse should first consider which "right" of
delegation?

A Multicolored posters with bright colors A Right task

B Lecture to the group, using many B Right circumstance
examples C Right person
C Audiovisuals, examples, group C Right supervision
discussions, and activities
D A game board, with clients matching
terms

4 A client from a homeless shelter who has 52 Which of the following describes the primary
8 had minor surgery and has been given an difference between a nurse leader and a
instruction sheet in preparation for nurse manager?
discharge is noted to be noncompliant
with instructions when dressing for A The manager plans and organizes work.
discharge. When asked by the nurse if the B The leader is an excellent listener.
instructions were clear, the client said, "I'll C The manager initiates change.
read them later, when I have my glasses; D The leader mentors others.
Fundamentals of Nursing

53 What leadership style does the nurse who 58 Which characteristic of a manager could
leads a discussion, then asks the undermine the manager's authority?
participants to vote on a topic for the next
meeting, represent? A Has confidence in directing the work of
others
A Autocratic B Is unsure of the authority given
B Bureaucratic C Changes management style based on
C Democratic the situation
D Laissez-faire D Accepts responsibility and
accountability for actions

5 Which type of leader would be best suited for

4 a group of individuals who will follow the 59 What can a nurse manager do to best help
leader's directions in spite of any hardships a new nurse learn his job?
they entail because they have faith in the
leader?
A Ask other nurses to keep an eye on the
A Charismatic new nurse
B Transactional B Assign a preceptor to the new nurse
C Transformational C Point out the nurse's weak areas at a
D Situational staff meeting
D Let the new nurse learn without
interference

5 Which person would be best suited for a

5 leadership position? 60 During which stage of change would
implementation take place?

A A person who has shown an ability to A Covert

gain cooperation from others B Moving
B A person who is quiet but persuasive C Unfreezing
through coercive tactics D Refreezing
C A person who has been a positive role
model in clinical practice
D A person with great vision for the future 61. Body heat that is lost when the nurse turns on the
of nursing air conditioning at the client's request is what type of
loss?

A Radiation
5 Which job would be the responsibility of a
B Conduction
6 first-level manager?
C Convection
D Vaporization

A A nurse case manager

B A head nurse
C A Director of Nursing
D A Nursing Supervisor

6 When should the nurse take a client's

2 temperature if the nurse wants to assess at
5 What management function is represented the point of highest body temperature?
7 when a nurse manager sets goals and
develops a budget for the nursing unit?
A 0400 and 0600 (4 a.m. & 6 a.m.)
B 1000 and 1400 (10 a.m. & 2 p.m.)
A Controlling C 1500 and 1800 (3 p.m. & 6 p.m.)
B Directing D 2000 and 2400 (8 p.m. & midnight)
C Planning
D Organizing
Fundamentals of Nursing
C Subtract the apical heart rate from the
systolic blood pressure.
6 What type of fever would the nurse D Subtract the radial pulse from the
3 document if the client had a wide range of diastolic blood pressure.
temperature fluctuations over normal for a
period of 24 hours?

A Intermittent
B Remittent
C Relapsing 68 A nurse checks the forehead temperature of
D Constant a 12-week-old infant. The temperature is
37.8°C (100°F). What immediate action
should the nurse take?

A Record the temperature and recheck in

64 What intervention would be most
appropriate for a client with mild
hypothermia?
A Applying blankets
B Applying an electronic hypothermia
blanket
C Administering warmed intravenous fluids
D Providing a warm air temperature
one hour.
B Record the temperature, as this is
normal range.
C Recheck the forehead temperature.
D Recheck an axillary temperature with an
electronic device.
69 The blood pressure of a 50-year-old client is
168/100. Which nursing action is most
appropriate?

A Referring the client to a physician

65 When assessing the pulse of a client on B Rechecking the blood pressure in one
digitalis, what rate would the nurse expect week
as compared with the pulse prior to starting C Advising the client to go to the
digitalis? emergency room
D Rechecking the blood pressure annually
A It would be doubled.
B It would be slightly higher .
C It would not change.
D It would decrease.
7 Which technique is best for assessing the
0 respirations of a 3-year-old?

66 A nurse documents deep respirations on the

client record. Which criteria were most likely A Use a stethoscope and auscultate the
assessed? lungs.
B Place one hand against the chest when
A A large amount of air inhaled and a counting.
small amount exhaled C Observe the rise and fall of the
B A large amount of air inhaled and a large abdomen.
amount exhaled D Tell the child you will check his
C A small amount of air inhaled and a breathing.
small amount exhaled
D A small amount of air inhaled and a
large amount exhaled
71. Which exam technique is being used when the
nurse touches the client's abdomen to examine the
size of the liver?
67 A nurse needs to assess a client's pulse
pressure. What is the correct procedure?
A Inspection
B Palpation
A Subtract the diastolic from the systolic C Percussion
blood pressure. D Auscultation
B Subtract the systolic from the diastolic
blood pressure.
Fundamentals of Nursing
A Fully alert and oriented
B Sleepy or drowsy
C Stuporous
D Comatose

7 In a client with long-term emphysema, the 7 A nurse has a client close her eyes, and
2 nurse might expect to see which condition 7 the nurse places a paper clip in the client's
when inspecting the nails? palm. The client correctly identifies the
object. What test did the nurse perform?
A A rapid blanch test
B Clubbing A Paresthesia
C Koilonychia B Extinction
D Paronychia C Stereognosis
D One- and two-point discrimination

73 A client is diagnosed with a conduction

hearing loss. What might the nurse indicate 78 What evidence most likely told the nurse a
to the client could be a reason for this loss? client had a negative Romberg test?

A There has been damage to the inner A Maintains an upright posture and foot
ear. stance
B Something has happened to the hearing B Unable to maintain foot stance
center of the brain. C Moves feet apart
C An ear infection has torn the tympanic D Increased swaying
membrane.
D The auditory nerve is not functioning.

79 An adolescent male has dark pubic hair that

is beginning to curl, elongation of the penis,
74 How would the nurse document a high- and continuing enlargement of the testes
pitched musical sound that was auscultated and scrotum. What stage of development
during expiration? would the nurse indicate in the client
record?
A Friction rub
B Rales A Stage 2
C Rhonchi B Stage 3
D Wheeze C Stage 4
D Stage 5

75 A client begins to tremor when he holds a

coffee cup. What is the correct term to use
when the nurse documents this event? 80 When assessing a client's skin, the nurse
notes a deep, irregular-shaped area of skin
A A fasciculation loss that extends below the dermis. What
B A tremor term would the nurse use when
C An intention tremor documenting this?
D A resting tremor
A An ulcer
B A fissure
C A keloid
D An erosion

76 A client has a 5 on the Glasgow Coma Scale. 881.A client has a yeast infection. What category of
When assessing this client, the nurse would microorganism is yeast?
expect what level of consciousness?
Fundamentals of Nursing
A Bacteria
8 A mother is planning on weaning her 5-
B Fungi
6 month-old infant from breastfeeding. She
C Parasites
says that the infant may get my
D Viruses
infections, since the baby will not be
getting immunity through her breast milk.
What response by the nurse would be
most appropriate?

A "Infections are a major cause of death

8 A client has a disease. The nurse knows that
2 an infection becomes a disease when what
occurs?
A When the signs and symptoms are
unique
B When the pathogen can be identified
C When microorganisms invade a part of
the body
D When bacteremia are present
in newborns, so you may want to
reconsider."
B "You baby will be fine; the natural
immunity will continue until the baby
produces its own antibodies."
C "Infants begin to make their own
immunity between 1 and 3 months of
age."
D "Just don't allow your infant to get the
DPT until 1 year of age if you stop
breastfeeding now."

8 A hospitalized client is in a private room.

8 A client is identified as having Rocky
7 When outside the room, the client must wear
3 Mountain Spotted Fever. This is an example
a surgical mask. What type of isolation
of what type of indirect transmission?
precaution is in use?

A Airborne transmission A Airborne

B Droplet transmission B Contact
C Vector-borne transmission C Droplet
D Vehicle-borne transmission D Standard

8 A home health nurse has just changed a

8 soiled dressing from an infected wound of
8 The nurse notes hyperemia when
4 evaluating the incision of a client. The
nurse knows that this indicates what stage
in the inflammatory response?
A Vascular and cellular response
B Exudate production
C Reparative phase
D Margination
a client's. After placing the soiled dressing
in a paper bag provided by the client, how
should the nurse dispose of it?
A Place the paper bag inside a plastic
bag for disposal.
B Throw the paper bag into a garbage
can.
C Take the bag home and dispose of it.
D Ask the client to dispose of the bag.

8 A client with tuberculosis is expecting visitors, and asks if

9 masks if they are healthy. What response by the nurse w
85 What type of immunity is lost when a client
develops human immunodeficiency virus
(HIV)?
A "Only the visitors who will have close contact with
mask."
A Active immunity
B "Visitors do not need to be concerned. Only the hea
B Passive immunity
a mask."
C Humoral immunity
C "Everyone who enters your room must wear a mas
D Cellular immunity
from tuberculosis."
D "Only visitors who might be at risk to get this disea
mask."
Fundamentals of Nursing
90 A client has been diagnosed with a urinary
tract infection. What is the most likely
cause of this infection?
A Staphylococcus aureus
B Escherichia coli enterococci
C Neisseria gonorrhoeae
D Streptococcus beta-hemolytic A or B
91. The nurse is preparing a presentation at a senior
citizens center on the leading cause of accidents in
older adults. What topic should the nurse concentrate
on presenting?
A Automobile accidents
B Accidental medication overdose
C Falls
D Home fires
9 An elderly client, hospitalized with a cerebral
2 vascular accident, is unable to ambulate
without help. This client becomes disoriented
and tries to get out of bed. What safety
measure is most appropriate for this client?
A Use a bed exit safety monitoring device
B Restrain the client in bed
C Check the client every 15 minutes
D Ask a family member to stay with the
client
9 Which statement by a father indicates
4 understanding of safety measures for his 3-
year-old child?
A "I shouldn't give him ice cream bars on a
stick."
B "He knows how to swim, so I usually read
a book by the pool."
C "I can leave him for a few minutes only
when he is asleep."
D "He can cross the street by himself to
play with his best friend."
9 Which adolescent would be at the highest
5 risk for committing suicide or homicide?
A An African-American male
B A Caucasian female
C A European-American female
D An male of French descent
96 When planning a safety seminar in the
workplace for a group of middle-aged
adults, what should be a primary focus?
A Motor vehicle accidents
B Occupational accidents
C Falls
D Fires
7 What test would be most appropriate to
7 perform on an elderly person on admission to
a care facility?
A The Get Up and Go test
B The sundowner's test
C The Denver Developmental Screening
test
D A vision screening exam
8 What statement by a nurse to a new nurse,
8 orienting to the unit, is correct regarding
seizure precautions?
A Any seizure can lead to status
epilepticus.
B Apply oxygen if the client turns cyanotic.
C Do not force a tongue depressor between
the teeth.
D Administering an anticonvulsant drug is
not beneficial.
9 When evaluating the decibel level at a
9 concert lasting one hour, the nurse would be
especially concerned with what level?
A 40 decibels
B 80 decibels
C 100 decibels
D 130 decibels
10 A nurse applies restraints to a client who is
0 combative. The nurse informs the physician
and knows that the physician must see the
client within what time frame for
evaluation?
Fundamentals of Nursing
A 1 hour
B 4 hours
C 12 hours
D 24 hours