Fundamental of Nursing Test: Questions with Rationale Set 1

This examination is a practice test that involves various concepts under one of the major topics in
nursing: Fundamentals in Nursing.

The coverage of this exam are the following:

1. Physical Assessment
2. Roles of Nurses
3. Prioritization of Needs (Critical Thinking)
4. Development Assessment
The test set is randomly designed in such a way that it includes easy questions as well as difficult questions.
Please choose the best answer

1. A 28-month-old child with severe diarrhea is admitted. Upon assessment, the child is feverish, has dry lips,
and irritable. What is your first nursing priority upon admission?

a. Asses the hydration status

b. Assess the skin turgor
c. Obtain the apical-radial cardiac rate
d. Weigh the child

2. You were assigned to a patient. Upon assessment, the patient elicited Homan’s sign. What is the
nursing priority using this assessment?a. Encourage fluid and electrolyte balance
b. Encourage good venous circulation
c. Secure patent airway
d. Promote skincare

3. You were assigned to a patient with a nasogastric tube attached for almost three days. It is time to irrigate
it, what is the protocol that you will follow?

a. A 30 mL sterile saline must be forcefully instilled and provide a basin to catch the return flow.
b. A 20 mL sterile saline must be gently instilled and provide a basin to catch the return flow.
c. Instill 30 mL sterile water and then withdraw solution.
d. Gently instill 20 mL normal saline and then withdraw solution.

4. A nurse therapeutically responds to a patient with AIDS when he expressed feelings of depression and
facing death with the following phrase: “Are you afraid of dying?” What type of therapeutic technique is she
using?

a. Using open-ended question

b. Using a close-ended question
c. Using a leading question
d. Mirroring

5. What role does a nurse exhibits if she stands to protect the needs and wishes of the patient?

a. Caregiver
b. Counselor
c. Teacher
d. Client advocate

6. A post appendectomy patient is assigned to you. You have assessed him that he needs more knowledge
about proper wound care. What role should you apply in this situation?

a. Role Model
b. Counselor
c. Caregiver
d. Teacher

7. While on your night rounds, you have noticed two nursing aides placing bed sheets that they have taken
from the floor. What is the proper nursing action?

a. Confront the two nursing aides about their and actions and call them for private counseling
b. Continue your night rounds, they have their own liabilities on their actions.
c. Remind them the principle of medical asepsis
d. Provide a clothes basket for them

8. In a burn patient, in order to promote adequate fluid within 24 hours, what intravenous fluid is appropriate?

a. D5 Water
b. Lactated Ringer’s Solution
c. 0.9% NaCl Solution
d. D5NSS

9. Being assigned in a pediatric ward, what is the characteristic sign of a normal psychosocial
development of a toddler?

a. Erikson’s stage of initiative vs. guilt

b. Imaginary playmates.
c. Negative behavior
d. Demonstrations of sexual curiosity.

10. Defining stress, all of the following describes its characteristics except:

a. Stress response is natural, productive and adaptive

b. Stress is not always a result of damage to the body
c. Stress always results in a feeling of distress
d. Stress involves the entire body as a whole

11. A one-year-old child is admitted. Looking into the physical development of the child, what will be affected
or may have a delay?

a. Walking
b. Sitting
c. Running
d. Crawling

12. A mother is concerned about the diet of her child that has noncomplicated acute glomerulonephritis.
What is the appropriate diet regimen you must teach as a nurse?

a. Low-protein, low-potassium diet.

b. Regular diet, no added salt.
c. Low-sodium, low-protein diet.
d. Low-sodium, high-protein diet.

13. A patient is on Respiratory Isolation for Tuberculosis (TB).  Which of the following would be an indicator
for the removal of Isolation Precautions?

Object 1

a. Sputum Culture is negative for AFB, following a course of INH and PAS
b. Patient has been on Anti-Tubercular Drug Therapy with INH for one month’s time
c. Patient has no infiltrates on chest x-ray
d. Absence of adventitious breath sounds

14.A client is diagnosed to have Congestive Heart Failure.  Upon auscultating the client’s lungs the nurse
hears crackling sounds bilaterally at the bases. What term should you use in documenting this finding?

a. Rhonchi
b. Wheezing
c. Rales
d. Atelectasis

15. Which of the following response of a 10-year-old patient with acute appendicitis is an alarming sign?

a. “My pain has gone away.”

b. “I am afraid to have surgery.”
c.  “I feel hot and thirsty.”
d. “I feel better with my legs up towards my chest

16. A nurse assigned to a child with Acute Glomerulonephritis is picking up doctor’s orders to put in the
Kardex. Which of the orders should the nurse question?

a. Bed rest
b. Daily weights
c. Daily blood pressure
d. Strict I & O

17. Which of the following is an INCORRECT statement regarding diet therapy for a patient in renal failure?

a. Limit dietary protein

b. Provide a diet high in carbohydrates
c. Limit Sodium (NA) intake
d. Provide a diet high in Potassium rich food

18. You are assigned to speak to a group of High School students about HIV and AIDS. In discussing
transmission the nurse knows that the highest concentration of the HIV virus in infected patients is in the:

a. Saliva
b. Cerebrospinal Fluid
c. Blood
d. Semen

19. In teaching HIV in high school students, what is the appropriate health practice that the nurse should
emphasize?

a. Wash with antibacterial soap immediately after intercourse.

b. Use a latex condom and water-soluble during intercourse
c. After oral sex, use anti-bacterial mouth wash to destroy the HIV virus
d. Abstain from intercourse if the female partner is having her menstrual period.

20. Which of the following is appropriate in a depressed patient?

a. Using silence
b. Passive Friendliness
c. Using open-ended questions
d. Giving information
21. In a geriatric unit, you have noticed that one patient seemed to change his behavior. Which of the
following symptoms DOES NOT indicate that the patient is going into depression?

a. Being talkative
b. Sleeplessness
c. Complains of getting tired easily
d. Change in appetite

22. In admitting an elderly patients, it is a nurse’s goal to orient the patient. What is the effective nursing
action in order to prevent disorientation?

a. Secure the side rails up all the time

b. Do routine rounds
c. Leave a night light
d. Orient the patient every night before he or she sleeps

23. What is the proper order in the physical assessment when it comes to the examination of the abdomen?

a. Auscultation, Inspection, Percussion, Palpation

b. Inspection, Auscultation, Percussion, Palpation
c. Palpation, Percussion, Inspection, Auscultation
d. Inspection, Percussion, Palpation, Auscultation

24. In assessing the cranial nerve function, a nurse finds out that a patient has a difficulty in determining the
different scents when the eyes is closed. Which of the following cranial nerve had a problem?

a. CN III
b. CN II
c. CN I
d. CN V

25. In examining a patient with asthma in exacerbation, what lung sound is predominant?

a. Crackles
b. Pleural rub
c. Gurgles
d. Wheezes
1. Answer: A
The most critical part upon admission is the hydration status of the patient. While all the answers were
correct and important, the first objective is the hydration status of the child.

2. Answer: B

Promoting venous return flow may prevent thrombophlebitis. A sign that a patient may suffer from
thrombophlebitis is called Homan’s sign. The other goals are not well indicated in the assessment.

3. Answer: D
The proper way to irrigate the nasogastric tube is to use gentle pressure during the instillation of the normal
saline solution. Withdrawing the solution afterward can end the procedure. Gentle pressure is needed in
order to preserve the integrity of the stomach walls.

4. Answer: A

Open-ended questions can help the patient verbalize his feelings. It helps the nurse explore the thoughts of
the patient in order to provide a means of nursing care in terms of psychological support and as an active
listener.

5. Answer: D

As a client advocate, the nurse protects the interests of the client. She represents the patient when the
patient is not able to voice out his or her needs. She may also relay information to the physician when the
patient is not able to represent himself.

6. Answer: D.

Being a teacher in this situation means that you must allow the patient to learn proper wound care on his
own. As a teacher, the nurse helps the client to learn about their health and health care procedures.

7. Answer: C

As a part of the healthcare team, nurses should be able to know that they have responsibility for the situation
above. In order to correct the behavior of the two nursing aides, they must understand the reason to change
the beddings. Giving them information about germ transmission is the appropriate approach.

8. Answer: B

Lactated Ringer’s Solution must be used within the first 24 hours. Colloids such as D5Water and D5 NSS
increase capillary permeability which may increase the risk of pulmonary edema.

9. Answer: C

Assertion of automony is seen in 2 to 21/2-year-old toddlers as they begin their language and social
development. The stage of initiative vs. guilt (2) is more common in the preschool-age child, 3 to 6 years. At
3 to 4 years of age, children have imaginary playmates (1).

10. Answer: C

Stress does not always result in feelings of distress such as harmful or unpleasant stress. The others options
definitely describe stress.
11. Answer: A

A 1-year-old child normally learns to walk. Any interruption on this development such as physical stress and
hospitalization can affect the normal development. The child should sit (4) by 6 months and should already
be crawling (1) by 1 year of age.

12. Answer: B

A regular diet with moderate sodium is suggested for children who are in acute glomerulonephritis. If the
client’s condition progresses to renal failure, sodium, potassium, and protein are restricted

13. Answer: A

Clients who have been on anti-TB drug regimes for at least 2-3 weeks and have absence of AFB in at least
two successive sputum cultures, no longer need to be on Respiratory Isolation.  Taking medication alone, or
the absence of adventitious breath sounds such as rhonchi, rales, etc, or the absence of infiltrates on chest
x-ray, usually seen with Pneumonia would not be a reason to D/C Isolation, making choices (b), (c), and (d)
incorrect.

14. Answer: C

Rales are defined as abnormal lung sounds which is crackling in nature. Rhonchi is characterized by dry
coarse sounds which is present when the patient coughs. Wheezes is common upon expiration and denotes
narrowed passages.

15. Answer: A

The classic finding when an appendix ruptures is a sudden cessation of pain. Options b, c and dare expected
findings for a child of this age who is diagnosed with acute appendicitis.

16. Answer: C.

Blood pressure elevation signals a frequent complication associated with Acute Glomerulonephritis. The
nurse should expect to assess blood pressure every 2 to 4 hours with vital signs.  Options a, b and d are
appropriate orders for a child with Acute Glomerulonephritis

17. Answer: D

Patients with renal failure should have a diet that provides (high biologic value) proteins rich foods such as
eggs, dairy products and meats.  These are necessary to maintain a positive nitrogen balance.  Foods high
in calories are also necessary, and sodium intake should be limited. Foods high in Potassium should be
AVOIDED due to decreased ability of the kidney(s) to filter and excrete Potassium

18. Answer: C

The HIV virus has been found and isolated in all of the above body fluids, as well as in the stool and urine.
However, the highest concentration is found in the blood of infected individuals.

19. Answer: B

Although abstinence is still the best protection against the spread of the HIV virus, the use of a latex condom
with an H20 soluble lubricant is the most effective means. Other choices do not give assurance of preventing
acquiring the HIV virus.
20. Answer: C.

Using open-ended questions can allow the patient with depression to voice out his or her problems or what is
bothering him or her. Using silence at this time is not appropriate as well as with the other options.

21. Answer: A

Being talkative indicates that the patient may be developing dementia.

22. Answer: D

Elderly patients are at a higher risk for sustaining injuries, especially in unfamiliar surroundings. While other
choices are potential interventions that the nurse could implement, choice (c.) would allow the patient to
better visualize the surroundings, delimiting possible accidents or falls.  Orienting the patient, as well as
checking the patient, and keeping side rails up are also important , each patient must be assessed
individually to determine which measure(s) should be employed

23. Answer: B

Percussion is first done in order to assess all the quadrants and the next is palpation which involves direct
pressure. This step can also elicit pain or dullness.

24. Answer: C

The cranial nerve I or olfactory nerve is responsible to take in the scents and send signals to the brain.

25. Answer: D

Wheezes is continuous, lengthy, musical heard during inspiration or expiration. It is common to those with
asthma since there is an active narrowing of the bronchioles.