REVIEW TEST - FUNDAMENTALS OF NURSING

1. The nurse is assessing a patients bladder by percussion. The nurse elicits dullness after
voiding. What does the finding indicate?
A.
B.
C.
D.

Incomplete bladder emptying

Kidney enlargement
Ureteral obstruction
Dehydration

ANSWER: A. Incomplete bladder emptying

DULLNESS OF THE BLADDER AFTER VOIDING PROVIDES A ROUGH ESTIMATE OF
AT LEAST 500ML OF URINE but may vary as much as 1000ml with dullness extending above
the umbilicus.
(B) Kidney enlargement is assessed through palpation of the kidney both right and left side/
ballottement method
(C)Uteral obstruction
(D) Dehydration - There is no connection between the relation of percussing the bladder
that elicit dullness after voiding to dehydration
**additional info: Urinary bladder has a capacity of 400-600ml
First urge to urinate is felt at a bladder volume of 150ml
Tension receptors in the bladder wall will activate of approx.. 300ml
2. A 28 year old client is admitted with severe bleeding from fractured femur. Which
intravenous fluid does the nurse anticipate using as the most appropriate to replace
potential fluid loss?
A. Normal Saline
B. 3% Saline
C. 5% Dextrose in water
D. 5% Dextrose in 0.225 Saline
ANSWER: C. 5% Dextrose in Water
Hypotonic solutions are used to patients with dehydration circulatory volume typically has a free
water deficit
HYPOTONIC SOLUTION (promote osmosis of extracellular fluid INTO the cells) replaces
potential fluid loss and treats dehydration
HYPERTONIC SOLUTION (promote osmosis of extracellular fluid OUT of the cells)
EDEMA (fluid retention)
ISOTONIC SOLUTION (do not promote osmosis but increases the extracellular fluid volume)
(A) Normal Saline (isotonic solution)
(B) 3% Saline (hypertonic solution)
(D) 5% Dextrose in 0.225 Saline (hypertonic solution)

REVIEW TEST - FUNDAMENTALS OF NURSING

3. The nurse instructor is teaching the students assessment skills in the lab. Where would
the instructor teach the students to assess for pain at the costovertebral angle?
A. At the umbilicus and the right lower quadrant of the abdomen
B. At the suprapubic region and the umbilicus
C. At the lower of the 12th rib and spine
D. At the 7th rib and the xyphoid process
ANSWER: C At the lower border of the 12th rib and the spine. The kidney lies directly below
this area, with percussion, pain is elicited when the person has kidney inflammation. The
presence of pain is marked as a positive Murphys punch sign as costoverterbral tenderness.
(A) At the umbilicus and the right lower quadrant of the abdomen, mc burney point of
specialized tenderness in acute appendicitis
(B) At the suprapubic region and the umbilicus assess for a large distended bladder
(C) At the 7th rib and xyphoid process, associated at the thoracic veterbra with tenderness of
the xiphoid process and the mobility of the 7th rib
4. During a clients urinary bladder catheterization, the bladder is emptied gradually. The
best rationale for the nurses action is that completely emptying an overdistended bladder
at one time tends to cause
A. Renal Failure
B. Abdominal Cramping
C. Possible shock
D. Atrophy of bladder musculature
ANSWER: C Possible shock. Rapid emptying of an over distended bladder may cause
hypotension and shock due to the sudden change of pressure within the abdominal viscera.
Previously, removing no more than 1,000mL at one time was the standard of practice, but is no
longer thought to be necessary as long as the overdistented bladder is emptied slowly.
(A)Renal Failure-kidney fails to adequate filter waste product from the blood in which
inability to empty the bladder empty completely.
(B) Abdominal Cramping- acute retention of the urine feels pain is lower abdomen along
with inability to urinate.
(D)Atrophy of bladder musculature- atrophy means a wasting away of muscle acute
mass as well urinary tract which weakens the bladder holds the urine out of the body in
which compromising ability to control urinary functions
5. The nurse administers Packed Red Blood Cells (PRBCs) to a client with anemia. Which
of the following nursing actions is appropriate?
A. Discontinue intravenous catheter if a blood transfusion reaction occur.
B. Administer PRBC through a percutaneous inserted central catheter line with a 20-gauge
needle.
C. Flush PRBC with a 5% dextrose and 0.45% normal saline.
D. Stay with the client during the first 15 minutes of infusion.

REVIEW TEST - FUNDAMENTALS OF NURSING

ANSWER: D. Stay with the client during the first 15 minutes of infusion
The first 15 minutes of the transfusion are the most critical time so the nurse must stay with the
client and monitor for signs and symptoms of transfusion reaction. In addition to, the most likely
time or a blood transfusion reaction to occur the during the first 15 minutes or the first 50 ml of
the infusion (Other books says Severe blood transfusion reactions occur within 15-20 minutes of
transfusion or within the transfusion of the first 100 ml of blood).
(A) is incorrect because if a blood transfusion does occur, it is imperative to keep an
established IV line so that medication can be administered to prevent or treat
cardiovascular collapse in case of anaphylaxis or transfusion reaction.
(B) is incorrect because an 18-19 G needle will be needed to achieve a
maximum flow rate of blood products. If a smaller G needle must be used, RBC may be
diluted with normal saline.
(C) is incorrect because RBCs will hemolyze in dextrose or LR
solution and should be infused only with normal saline solution since it is the only solution
compatible with blood transfusion.
6. The nursing instructor is teaching her clinical group about the care of an adult patient
requiring mechanical ventilation. What would the instructor teach the students?
A.
B.
C.
D.

Keep the patient in a Low Fowlers position.

Perform tracheostomy care at least every 12 hours.
Keep the patient on bed rest continually.
Monitor cuff pressure every 8 hours.

ANSWER: D. Monitor cuff pressure every 8 hours.

Cuff pressure is monitored every 6-8 hours to maintain the pressure at less than 25 mmHg
(optimal cuff pressure is 15-20 mmHg) and at the same time the nurse should assess the presence
of a cuff leak. High cuff pressure can cause tracheal bleeding, ischemia and pressure necrosis
whereas low cuff pressure can increase the risk of aspiration pneumonia
(A) is incorrect because the patient should be placed in a semi-fowlers position to facilitate
ventilation and promote drainage.
(B) is incorrect because it is important to perform tracheostomy care at least every 8 hours and
more frequently if needed to minimize the risk of infection
(C) is incorrect because the patient should be encouraged to ambulate. Mobility and muscle
activity are beneficial because they stimulate respirations and improve morale. If the patient has
become stable, he is encouraged to get out of bed and move to a chair as soon as possible. If the
patient is unable to get out of bed, the nurse encourages performance of active range of motion
exercises every 6-8 hours and if the patient cannot perform these exercises, the nurse performs
passive range of motion exercises every 8 hours to prevent contractures and venous statis.

REVIEW TEST - FUNDAMENTALS OF NURSING

7. While assessing the patient, the nurse observes constant bubbling in the water-seal
chamber of a closed chest-drainage system. What should the nurse conclude?
A.
B.
C.
D.

The system is functioning normally

The patient has a pneumothorax
The system has an air leak
The chest tube is obstructed.

ANSWER: C. The system has an air leak

Chest tubes were inserted to patients to remove air, blood, or excess fluid from the pleural space
and re-expand the involved lung.
(A) Read explanation below on how the sytem function normally. This is not the correct
answer because there is a constant bubbling in the water-seal chamber.
(B) The patient might have pneumothorax for it is also one of the indications of having the
chest tube be inserted in the first place. BUT this is not the best answer because the
problem lies with the drainage system and not on lungs perse.
Normal functioning & management: Water-seal chamber needs to manage the system. In
managing this, check the fluid level regularly because water can evaporate. If necessary,
add sterile fluid until the level reaches the 2-cm mark or the level the water-seal chamber
gradations indicate. Check for tidaling in the water-seal chamber as the patient breathes.
Expect to see 5 to 10 cm (2 to 4 inches) of fluctuation, reflecting pressure changes in the
pleural space during respiration.
Fluctuation stops when the lung has re-expanded, but it can also stop when the tubing is
obstructed or a dependent loop hangs below the rest of the tubing. It can also stop when
the suction source is not functioning (which is why letter D. is not the answer because the
question said it is constant bubbling and not the stopping of fluctuation). Expect
continuous bubbling in the water-seal chamber initially and occasional bubbling after
that. Look for constant or intermittent bubbling in the water-seal chamber, which
indicates leaks in the drainage system.
8. The student nurses are studying the conduction system of the heart. The instructor
explains that the electrical conduction of the heart usually originates in the SA node. Which
sequence completes the conduction?
A. SA node to Bundle of HIS to AV node to Purkinje fibers
B. SA node to AV node to Purkinje fibers to Bundle of HIS
C. SA node to bundle of HIS to Purkinje fibers to AV node
D. SA node to AV node to bundle of HIS to Purkinje fiber
ANSWER: D. The normal sequence of the electrical conduction of the heart starts with SA node
(which is the natural pacemaker of the heart that releases electrical stimuli at a regular rate, the
rate is dictated by the needs of the body) The electrical stimulus from the SA node eventually
reaches the AV node and is delayed briefly so that the contracting atria have enough time to
pump all the blood into the ventricles. Once the atria are empty of blood the valves between the

REVIEW TEST - FUNDAMENTALS OF NURSING

atria and ventricles close. At this point the atria begin to refill and the electrical stimulus passes
through the AV node and Bundle of His into the Bundle branches and Purkinje fibres
9. The management of the patients gastrostomy is an assessment priority for the home care
nurse. What statement would indicate that the patient is managing the tube correctly?
A. I clean my stoma twice a day with alcohol
B. I am placing sterile dressings on my stoma site
C. I am flushing my tube with 30-50 mL of water after my feeds
D. I have been giving my medications all at the same time to avoid hassle
ANSWER: C. I am flushing my tube with 30-50 mL of water after my feeds
Frequent flushing is needed to prevent occlusions Flushing the tube with water will avoid tube
occlusions. The tube should be flushed with at least 30 to 50 mL of water or normal saline after
each feed.
(A)Routine site care should include cleansing the site daily with mild soap and water, as
alcohol will irritate and dry the skin surrounding the insertion site.
(B)Clean dressing changes are acceptable, but flushing the tube with water
is the assessment priority for the nurse.
(C)Medications should be given separately, flushing in between.
10. The family of one of your patients who is comatose asks you why the physician is
recommending removal of the patients NG tube and the insertion of a gastrostomy tube.
What would be your best answer?
A. It is more comfortable for the patient.
B. It is less permanent.
C. Regurgitation and aspiration are less likely
D. It is easier to feed the patient
ANSWER: C. Regurgitation and aspiration are less likely
Gastrostomy is also preferred over NG feedings in the patient who is comatose because the
gastroesophageal sphincter remains intact, making regurgitation and aspiration less likely than
with NG feedings.
(A, D)This change in care is not motivated by the possibility of faster infusion or easier
personal care. Comfort is a subjective assessment.
(B)A gastrostomy tube is more permanent than an NG tube.
(D)A gastrostomy tube is not easier to feed a patient through than an NG tube;
Ngtube feeding is almost the same as Gastrostomy tube feeding.

REVIEW TEST - FUNDAMENTALS OF NURSING

11. A nurse is caring for a patient with impaired renal function. A creatinine clearance
measurement has been ordered. The nurse is aware that the specimens needed for the
calculation of the patients creatinine clearance will include what?
A. A fasting serum potassium level and a random urine sample
B. A 24-hour urine specimen collection and a serum creatinine level midway through the
urine collection process
C. A blood, urea, nitrogen level, and serum creatinine level on three consecutive
mornings
D. A sterile urine specimen and an electrolyte panel, including sodium, potassium,
calcium, and phosphorus values.
ANSWER: B. A 24-hour urine specimen collection and a serum creatinine level midway
through the urine collection process.
To calculate creatinine clearance, a 24-hour urine specimen is collected. Midway through the
collection, the serum creatinine level is measured. The following formula is then used to
calculate the creatinine clearance: (Volume of urine [mL/min] urine creatinine [mL/min])
serum creatinine (mg/dL)
A, C, D Not needed to compute creatinine clearance
>ADDITIONAL: The combination of blood and urine samples can be used to evaluate
a creatine clearancehow effectively your kidneys filter small molecules, such as
creatinine, from your blood. In addition, since creatinine is usually removed from the
blood at a constant rate, blood creatinine levels can be used as a standard by which
doctors can compare other urine or blood tests. Your serum (blood) creatinine level can
also be combined with your age, weight, and gender to evaluate your estimated
glomerular filtration rate (eGFR). Glomeruli are tiny ball-shaped structures in your
kidneys that help filter blood and prevent the loss of valuable substances, such as blood
cells and proteins. The eGFR is an educated estimate of the amount of blood that is
filtered per minute by your glomeruli and is often used to detect kidney damage.
12. The nurse is to administer several medications to the client via the N/G tube. The
nurses first action is to:
A. Add the medication to the tube feeding being given
B. Crush all the tablets and capsule before administration
C. Administer all of the medication mixed together
D. Check for placement of the nasogastric tube
ANSWER: D. Check for placement of the nasogastric tube
Check for placement of the nasogastric tube. The nasogastric tube should be verified for
placement before administering any medication through it.

REVIEW TEST - FUNDAMENTALS OF NURSING

(A)Medications should never be added to the tube feeding.
(B)Not all tablets can be crushed, such as sustained release tablets, nor all capsules
should be opened. Medications should be reviewed carefully before crushing a tablet or
opening a capsule. (C)Medications should be dissolved and administered separately,
flushing between 1 and 30 mL of water between each medication.
13. The physician has ordered parenteral fluids, 1,000 mL of D5LR in eight hours. The IV
tubing box states the drip factor is 20 drops/mL. How many drops should infuse?
A. 30
B. 40
C. 50
D. 60
ANSWER: B. 40
Order is 1000 mL to run for 8 hours with drip factor of 20gtts/mL
The basic formula in IVF computation is
gtts/min = [volume (mL) / time(mins)] x gtts/mL
1000 mL/480 mins = 2.0833 mL/min
2.0833 mL/min x 20 gtts/mL = 41.67 (Answer ranges from 40-42gtts/min.)
8 hrs ------------------------> convert to minutes 8hrs x 60mins/1hr = 480 mins.
1000mL/480mins x 20gtts/mL = 41. 67 (Answer ranges from 40-42gtts/min.)
NOT B, C, or D because the computation would never result to any of the three.
14. When preparing to insert a straight catheter, as in catheterization for residual, you will
need:
A. a syringe (prefilled with water)
B. nonallergenic tape
C. a urinary drainage bag
D. lubricant
ANSWER: D. Lubricant
Upon insertion, the tip of the catheter should always be lubricated first.
(A) A syringe prefilled with water is not used in straight catheter. We use syringe prefilled
with water to inflate the balloon in indwelling catheter to remain it in place for a longer
period of time. Straight catheter is a one-time use catheter designed to be used long
enough to drain the bladder or for urine specimen collection and is immediately removed
upon completion.
(B) Nonallergenic tape is not used in preparing or inserting catheter. Used in indwelling
catheter
(C) Drainage bag will be used after the insertion of straight catheter.

REVIEW TEST - FUNDAMENTALS OF NURSING

15. Which of the following is a correct part of the procedure for changing of bowel
diversion ostomy appliance? ANSWER: D
A. Schedule the ostomy change for 30-45 minutes before meal time.
B. Don sterile gloves before removing the ostomy pouch
C. Peel the bag off quickly to decrease the amount of pain
D. Empty each pouch into a bed pan before removing the ostomy appliance
ANSWER: D. Empty each pouch into a bed pan before removing the ostomy appliance
Assessing the fullness of bag (need to be emptied when one third to one half full).When the fluid level in
the bag becomes too high, the weight of it may loosen the face plate and separate it from the skin, causing
the effluent to leak and may irritate the peristomal skin.

(A) Avoid time close to meals because stoma odor and stool may reduce appetite of the
person.
(B) Why not B? In changing ostomy appliance we only need is clean gloves or disposable
gloves to protect the staff from contact with body secretion.
(C) Peel the bag off quickly doesnt decrease the pain we need to remove it gradually so the
pain may be decrease.
16. Placement of a Nasogastric tube can be verified by?
A. Shining a light on the clients oropharynx
B. Asking the client to swallow to see if the gag reflex is stimulated.
C. Using a syringe to aspirate stomach contents and checking their acidity
D. Injecting 50cc of water into the tube and listening over the stomach with a stethoscope
ANSWER: C. Using a syringe to aspirate stomach contents and checking their acidity
Aside from the injection of air and auscultating the epigastric area, another way to check the
placement of the tube is to pull back the plunger of the syringe, and if stomach contents is aspirated,
then the placement is correct. When aspirating air into tube we may also check the content and the
residue of it.

(A) Shining a light is a part of assessing when inserting a nasogastic tube its not a procedure to
assess the placement of it.
(B) Swallowing facilitates NGT insertion.
(D)The ideal level of flushing water is 20-30 ml. And it is used when giving meal to prevent the tube
from becoming clogged. Usually, this is done at the end of a cycled feeding or after giving medicine
through the tube.

17. Ms. Ramos is unable to void. Percussion over the symphysis pubis in a client with a
distended bladder would reveal a change in the percussion note from
a.
b.
c.
d.

Resonant to hyperresonant (normal lung tissue)

Tympanic to dull (tympanic sound is heard in a full bladder)
Hollow to dull
Dull to resonant

REVIEW TEST - FUNDAMENTALS OF NURSING

ANSWER: C.
When the bladder is empty or contains small amount of urine, a hollow note is heard
when the bladder is percussed. Percussion over a full bladder produces a duller sound.
Dull sounds are normally heard over dense areas.
Tympanic sounds are hollow, high, drumlike sounds.
Tympanic sounds over the bladder indicates a full bladder.
Resonant sounds are low pitched, hollow sounds heard over normal lung tissue.
Hyperresonant sounds that are louder and lower pitched than resonant sounds are
normally heard when percussing the chests of children and very thin adults.
18. The nurse explains to the client with ileostomy that some form of skin barrier must be
used around the stoma at all times. The primary function of the skin barrier is to:
a. Help prevent formation of odor
b. Help maintain an accurate output of record
c. Protect against irritation from ileostomy effluent
d. Allow the client to keep the ostomy pouch on longer
ANSWER: C. Protect against irritation from ilesotomy effluent
Because of the high digestive enzymes, ileostomy effluent is irritating to skin and can cause
excoriation and ulceration. Some form of protection must be used to keep the effluent from
contacting the skin.
(A) A skin barrier does not decrease odor formation, odor is controlled by diet.
(B) The barrier does not affect the accuracy of output records.
(D)Pouches are usually worn for 4 to 7 days before being changed.
19. Which of the following findings is indicative of a fecal impaction?
A. Loss of desire to defecate
B. Alternating patterns of normal stool and diarrhea
C. Constipation with liquid fecal seepage
D. Absence of stool upon digital rectal exam
ANSWER: C. Constipation with liquid fecal seepage
Fecal impaction is a large lump of dry, hard stool that stays stuck in the rectum. It is most often
seen in people who re constipated for a long time. While this stool may be too large to pass,
loose, watery stool may be able to get by, leading to leakage of fecal material and sometimes
mistaken as diarrhea.
20. At 3:00PM, Mr. Brady had 150 cc remaining in his IV bag. Maria Ramirez,RN, hung a
new 1000 cc bottle of IV fluid at 4:30pm and at 10:15pm there is 700 cc left. In addition,
during Marias shift Mr.Brady drank two cartons of milk, each 240 cc and 250 cc of water.
He had liquid stool measuring 350 cc and he voided three times: 260 cc, 310 cc, 175 cc.
Which of the following should Maria record on her I and O sheet?

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A. intake = 940 cc; output = 745 cc
B. intake = 1340 cc; output = 745 cc
C. intake = 1180cc; output = 1095 cc
D. intake = 1640 cc; output 1095 cc
Answer: C. intake = 1180 cc; output = 1095 cc. The answer is letter C because when you
compute the actual intake of Mr.Brady during Marias shift, the total intake of his IV fluid is
450cc and the total intake P.O is 730 which is equals to an intake of 1,180 cc. For the total output
of Mr.Brady during Marias shift, add the total urine output of 745 cc to the liquid stool output of
350. The total output is 1,095 cc.