Fundamentals of Nursing - 2

Question 1

An asymptomatic adult has a blood pressure reading of 152/94 mmHg. The nurse notices that the cuff is too small for the patient's arm. What should the nurse do next?

Accepted Answer

Repeat the measurement using an appropriately sized cuff

Answer

Document the reading as confirmation of hypertension

Answer

Raise the patient's arm above heart level and repeat

Answer

Repeat the measurement using the same cuff more tightly

Question 2

The nurse receives reports about four adult patients. Which patient should be assessed first?

Accepted Answer

A patient with new breathlessness, confusion and oxygen saturation of 88% on room air

Answer

A patient with chronic arthritis reporting their usual knee pain of 6/10

Answer

An alert patient with a urinary infection and a temperature of 38.2°C

Answer

A patient with constipation for two days who is passing flatus without abdominal pain

Question 3

While preparing a sterile dressing, the tips of sterile forceps touch the outer 2.5 cm (1-inch) border of the opened sterile wrapper. What should the nurse do?

Accepted Answer

Remove the forceps from use and obtain another sterile pair

Answer

Wipe the forceps with alcohol and continue the procedure

Answer

Rinse the forceps with sterile saline and continue

Answer

Continue using the forceps because the wrapper was initially sterile

Question 4

An immobile patient has intact skin over the heel with persistent redness that does not blanch when pressed. Which nursing action is most appropriate?

Accepted Answer

Relieve pressure on the heel and reassess the affected skin

Answer

Massage the reddened area to stimulate circulation

Answer

Place a ring-shaped cushion directly beneath the heel

Answer

Apply moisturizer while leaving pressure on the heel unchanged

Question 5

A urine culture is ordered for a patient whose indwelling urinary catheter was inserted yesterday. How should the nurse collect the specimen?

Accepted Answer

Disinfect the needleless sampling port and obtain urine using a sterile syringe

Answer

Pour urine from the drainage bag into a sterile container

Answer

Disconnect the catheter from the tubing and collect the urine

Answer

Empty the drainage bag and collect the next urine draining into it

Question 6

A patient recovering from a stroke begins coughing and develops a wet-sounding voice while eating. What should the nurse do first?

Accepted Answer

Stop oral feeding and assess airway and breathing

Answer

Offer water to help clear the food

Answer

Continue feeding with smaller spoonfuls

Answer

Recline the patient and allow the meal to continue

Question 7

During an 8-hour shift, a patient drinks 200 mL of water and 150 mL of juice and receives 800 mL of IV fluid. Urine output is 900 mL and wound-drain output is 100 mL. These are all recorded entries. What is the recorded fluid balance, calculated as intake minus output?

Accepted Answer

+150 mL

Answer

-150 mL

Answer

+250 mL

Answer

+1150 mL

Question 8

A patient cannot swallow a prescribed enteric-coated tablet and asks the nurse to crush it. What is the most appropriate response?

Accepted Answer

Consult the pharmacist or prescriber about a suitable alternative formulation

Answer

Crush the tablet and mix it with soft food

Answer

Ask the patient to chew the tablet before swallowing

Answer

Dissolve the tablet in hot water before administration

Question 9

A patient's blood pressure is 138/82 mmHg while lying down and 108/68 mmHg one minute after standing. The patient reports dizziness. Which finding do these observations support?

Accepted Answer

Orthostatic hypotension

Answer

A normal postural response requiring no further assessment

Answer

An increase in blood pressure caused by standing

Answer

Orthopnoea

Question 10

After teaching a patient how to use a newly prescribed inhaler, the nurse asks whether the instructions are clear. The patient nods. Which action best verifies that learning has occurred?

Accepted Answer

Ask the patient to demonstrate the technique using a training device

Answer

Ask the patient to repeat the written instructions word for word

Answer

Document understanding because the patient nodded

Answer

Give the patient another leaflet without checking technique

Fundamentals of Nursing - 2

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