SUNRISE NURSING & AFFILIATES, LLC- NURSING FUNDAMENTALS: EXAM #1

STUDENTS NAME: _______________________________ MAY 10, 2016

1) Dorothea Orem identified a theory of nursing. Which statement is associated

with Orems theory?
A. Promote nursing care that increases a patients self-care abilities
B. Helps nurses provide culture specific care that assists patients to achieve
and maintain health
C. Assists nurses to identify behavior associated with various stages of
coping with death and dying
D. Facilitates identification of a childs stage of development so that
appropriate nursing care is planned

2) A patient is admitted to a home health care program for palliative care. When
completing the admission interview and nursing assessment the patient
emphatically states, I want no intervention to extend my life other than
keeping me comfortable. When talking with family members they want the
patient to continue chemotherapy. What should the nurse do?
A. Protect the patients right to self determination
B. Initiate a referral to a psychiatric nurse practitioner
C. Ask the patient to reconsider chemotherapy for the sake of the family
D. Refer family members to the primary health care provider to resolve this
issue

3) A nurse is planning patient care based on moral and ethical principles. Which
nursing statement demonstrates an effort to implement the principle of
fidelity?
A. Lets talk about foods that are healthy and that you should include in
your daily diet
B. I know that you are out of work, so I have arranged for you to get follow
up care at our outpatient clinic
C. You said that your son wants you to have this surgery. What is important
is what you believe is best for you
D. Its been half an hour and I am back as I promised to ensure that the pain
medication I gave you is providing relief

4) A nurse is caring for an adult patient who is scheduled for surgery. Which
action is not associated with the nurse ensuring a valid, legal consent?
A. Observe the patient signing the consent form
B. Ensure that the patient is signing the consent form voluntarily
C. Assess if the patient has the capacity to make an informed consent
D. Review with the patient the risks and benefits of the surgery before the
consent is signed

5) Which situation should the nursing staff refer to the hospital Ethics
committee?
A. The adult patient with renal insufficiency who refuses dialysis
B. The wife who wants her unconscious husband to have a drug that is
available in a phase three trial
C. The parents of a developmentally disabled adult who disagree with the
health care decisions of the court appointed guardian

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 SUNRISE NURSING & AFFILIATES, LLC- NURSING FUNDAMENTALS: EXAM #1

STUDENTS NAME: _______________________________ MAY 10, 2016

D. The adult patient recently diagnosed with metastatic cancer who wants
hospice care but whose family wants chemotherapy to be given
immediately

6) A nurse is making every effort to implement nursing care based on moral

concepts and principles of ethics. Which nursing statement demonstrates an
effort to implement the principle of veracity?
A. Lets review the in bed leg exercises that you need to perform after
surgery
B. Here is the pain medication that I promised I would get for you
immediately
C. After receiving this drug, you may feel bone pain, but it should subside in
about a week
D. I am going to move you to a room away from the nurses station so that
you sleep better at night

7) Which term best describes the situation when a nurse says to a pediatric
patient, If you dont be quiet, I will not let your parents visit you today?
A. Battery
B. Assault
C. Negligence
D. Abandonment

8) Which of the following is designed to protect the nurse?

A. Americans with Disabilities Act
B. Nurse Practice Acts
C. Reporting of Abuse
D. Incident reports

9) A nurse accidentally administers a medication to the wrong patient and the

patient experiences a serious untoward reaction. For which tort can the nurse
be legally charged?
A. Malpractice
B. Assault
C. Battery
D. Fraud

10) Which statement is accurate regarding a nurse practice act?

A. Educational criteria that must be met by schools of nursing are legislated
exclusively by a states nurse practice act
B. Rules and regulations regarding the practice of nursing are identified in
each states nurse practice act
C. Nursing titles for a licensed nurse are regulated by the National League for
Nursing
D. A nurse practice act provides federal oversight of what a nurse can and
cannot do

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 SUNRISE NURSING & AFFILIATES, LLC- NURSING FUNDAMENTALS: EXAM #1

STUDENTS NAME: _______________________________ MAY 10, 2016

11) A patient is recovering from a brain attack (Stroke) and experiencing

dysphasia and aspiration. For which professional should the nurse seek a
consultation referral from the primary health care provider?
A. Clinical nurse specialist
B. Respiratory therapist
C. Nurse practitioner
D. Speech therapist

12) An older adult who lives alone is recovering after surgery for a total hip
replacement. Which is the most appropriate setting for this patient after
discharge from the hospital?
A. Home
B. Hospice
C. Skilled nursing facility
D. Assistive living apartment

13) A registered nurse graduated from an associate degree nursing

program. The hospital in which the nurse works is requiring all registered
nurses to attain a Bachelor of Science in Nursing (BSN) degree within 5 years.
Which educational program should the college counselor suggest is the most
appropriate for this nurse to attend?
A. Masters in Science in Nursing Program
B. Continuing Education Program
C. In service education program
D. General nursing program

14) A nurse asks a patient, How are you feeling? The patient responds, I
am doing fine while looking toward the floor. The nurse identifies that the
verbal and nonverbal communication are incongruent (dont match). What is
the nurses most appropriate response?
A. What is bothering you?
B. Lets talk about your illness
C. I am glad you are doing fine
D. Are you sure nothing is bothering you?

15) A nurse is talking with a patient about the patients concerns. Which
nursing action reflects the most important component of verbal
communication in this situation?
A. Answering questions that the patient is asking
B. Taking the lead in the interaction
C. Using simple sentence structure
D. Speaking in a calm voice

16) A nurse answers a patients question while standing by the side of the
patients bed. The patient responds saying Oh well, I just know that I am
going to be fine and then begins to cry, using a head shaking gesture to
indicate no. What should the nurse do first?
A. Pat the patients hand

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 SUNRISE NURSING & AFFILIATES, LLC- NURSING FUNDAMENTALS: EXAM #1

STUDENTS NAME: _______________________________ MAY 10, 2016

B. Sit in a chair near the head of the patients bed

C. Get a tissue from the bedside drawer for the patient
D. Use an open ended question to explore the patients feelings

17) A patient in the emergency department says to a nurse, I have been

so sick for a while with pain in my stomach and nothing seems to work.
Which statement by the nurse demonstrates the use of an open ended
question?
A. Tell me what you have been doing to manage your illness
B. Would you like for me to sit down with you for a little while?
C. Can you tell me how long you have been experiencing this pain?
D. It must be frustrating when nothing works to make you feel better

18) A nurse is providing preoperative teaching for a patient who is

scheduled for a pacemaker insertion in 3 days. The patient tells the nurse, I
am so nervous. I never had surgery before. What is the nurses most
therapeutic response?
A. What is it that concerns you the most?
B. Has anyone in your family had surgery before?
C. Being anxious before surgery is a normal response.
D. Having a pacemaker inserted is a routine procedure

19) Which statement by a nurse are examples of non-therapeutic

communication? SELECT ALL THAT APPLY.
A. I cant believe that you didnt eat all of that beautiful dinner
B. We are going to start an IV with a piggyback in a few minutes
C. Lets review what we accomplished today learning about insulin
D. Take a deep breath. You are getting excited over very simple surgery
E. I know youre angry about the cold coffee, but occasionally these things
happen

20) A nurse is caring for a patient who is hearing impaired but refuses to
wear hearing aids. What are the most appropriate ways to have a verbal
interaction with this patient? SELECT ALL THAT APPLY.
A. Speak in a normal volume
B. Speak in a very loud volume
C. Use a soft, higher pitched voice
D. Use a deep, slightly louder voice
E. Stand directly in front of the patient
F. Ensure that the patient known that a conversation is to begin

21) A nurse is using the SBAR communication technique during a crisis.

Which nursing intervention reflects the R-step of this technique?
A. Recording the reaction of the patient to the crisis
B. Reassessing the patient after medical intervention
C. Recommending a potential action to manage the crisis
D. Reporting the situation to the primary health care provider

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 SUNRISE NURSING & AFFILIATES, LLC- NURSING FUNDAMENTALS: EXAM #1

STUDENTS NAME: _______________________________ MAY 10, 2016

22) A nurse is working with a severely visually impaired patient. Which

approaches will be most effective when communicating with this patient
during a bed bath? SELECT ALL THAT APPLY.
A. Speak in a louder volume
B. Enunciate (Pronounce) every word slowly
C. Stand directly in front of the patient
D. Tell the patient exactly what will happen
E. Use touch to emphasize what is being done

23) A nurse is caring for a patient who is blind. What should the nurse do
to facilitate communication? SELECT ALL THAT APPLY.
A. Over articulate (over pronounce) words when speaking
B. Speak slightly louder than usual
C. Indicate when you are going to leave the room
D. Announce your presence when entering the room
E. Explain your intentions before touching the patient

24) Which are examples of violations of the Health Insurance Portability

and Accountability Act?
SELECT ALL THAT APPLY.
A. Failure to fill out an Incident Report after a patient fall
B. Discussing a plan of care with other student nurses in a debriefing
conference
C. Discussing test results with a patient in a populated sitting area in the unit
lounge
D. Leaving a patients vital signs sheet visible on a computer screen in the
hallway while taking the patients vital signs
E. Temporarily misplacing a form with the names of the patients with their
scheduled surgeries that is returned by a visitor

25) Which statement accurately pertain to nursing licensure? SELECT ALL

THAT APPLY.
A. A state board of nursing can never revoke a nursing license
B. A nursing license can be refused as a result of an unlawful action
C. A nursing license is not necessary when practicing nursing in the home
setting
D. A nursing license allows a nurse to practice in the state in which the
license was issued
E. A state board of nursing is responsible for ensuring that graduates of
recognized schools of nursing take the NCLEX licensure examination

26) Which actions meet obligations regarding the Health Insurance

Portability and Accountability Act (HIPPA) of 1996? SELECT ALL THAT APPLY.
A. Allowing patients, the right to review and copy their clinical record
B. Providing access to a patients clinical record to all members of the
nursing team

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 SUNRISE NURSING & AFFILIATES, LLC- NURSING FUNDAMENTALS: EXAM #1

STUDENTS NAME: _______________________________ MAY 10, 2016

C. Holding patient rounds in a hallway out of the hearing range of the patient
being discussed
D. Explaining to a person inquiring about the condition of a patient that
information about the patient is confidential
E. Giving medical information about an unconscious patient to a patients
daughter who is the person indicated in the patients proxy directive

27) Which statements are associated with State Nurse Practice Acts?
SELECT ALL THAT APPLY.
A. Nurse practice acts identify what a nurse can and cannot do
B. A purpose of state nurse practice acts is to regulate the practice of
nursing
C. The federal government is the regulating agency responsible for state
nurse practice acts
D. Student nurses are not obligated to meet the same standards of care as
are licensed nurses
E. If a student is involved in a disciplinary action by the state board of
nursing, the student may be prohibited from taking the National Council
Licensure Examination

28) Advance Directives includes which of the following? SELECT ALL THAT
APPLY
A. Health care proxy or Durable Power of Attorney for healthcare
B. Living Will
C. Do not resuscitate orders
D. Organ donation designation on drivers license
E. Assisted suicide designation

29) A nurse is obtaining a radial pulse and identifies that its rhythm is
irregular. What should the nurse do next?
A. Notify the patients primary health care provider
B. Obtain the patients blood pressure
C. Take the pulse in the other arm
D. Assess the apical pulse

30) A nurse is obtaining a patients blood pressure. What is reflected by the

diastolic blood pressure?
A. Contraction of the left ventricle
B. Volume of cardiac output
C. Resting arterial pressure
D. Pulse pressure

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 SUNRISE NURSING & AFFILIATES, LLC- NURSING FUNDAMENTALS: EXAM #1

STUDENTS NAME: _______________________________ MAY 10, 2016

31) A patient is experiencing the onset of a fever. Which nursing action is

appropriate during this phase?
A. Applying cloth covered ice packs to the groin
B. Covering the patient with a blanket
C. Lowering the heat in the room
D. Ensuring that the bed linen is dry

32) A nurse is caring for a patient who is presenting with diarrhea,

abdominal cramps, diaphoresis, shortness of breath, and severe anxiety.
Which thermometer should the nurse use to obtain this patients
temperature?
A. Tympanic thermometer
B. Paper strip thermometer
C. Plastic rectal thermometer
D. Electronic oral thermometer

33) A 74-year-old client currently has a temperature reading of 36 degrees

Celsius. The client walks 1 mile every day and take naps during the day.
Which of the following is most likely the reason for the lowered body
temperature?
A. The lowered body temperature is a natural results of the aging process
B. Increased stress from exercise has probably reduced the temperature
C. The individual circadian rhythm requiring daytime naps lowers the
temperature
D. Hormone levels are the most probable cause of the hypothermic condition

34) The nurse is ready to take vital signs on a 6-year-old child. The child
just had grape iced popsicle. An appropriate action would be to:
A. Take the rectal temperature
B. Take the oral temperature as planned
C. Have the child rinse out the mouth with warm water?
D. Wait 30 minutes and take the oral temperature

35) Which is the appropriate site for taking the pulse of a 2year old
patient?
A. Radial
B. Apical
C. Femoral
D. Pedal

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 SUNRISE NURSING & AFFILIATES, LLC- NURSING FUNDAMENTALS: EXAM #1

STUDENTS NAME: _______________________________ MAY 10, 2016

MATCH WORD IN COLUMN A WITH THE CORRECT DEFINITION FOUND IN COLUMN

B. PLACE THE MATCHING LETTER IN THE MIDDLE ANSWER COLUMN

COLUMN A YOUR COLUMN B

ANSWER
36 Autonomy A) Truthfulness
.
37 Ethical dilemma B) Belief about the worth of
. something
38 Fidelity C)Refers to preventing or removing a
. patient from harm
39 Justice D) Refers to fairness and equality
.
40 Non maleficence E) Refers to making only promises or
. commitment that can be kept
41 Value F) A situation in which a decision must
. be made between two or more actions
and the best action is unclear
42 Veracity G) Right of people to have individual
. liberty
43 Florence Nightingale H) Theory of Self Care Deficit
.
44 Lilian Wald I)Caring Theory: The Ten Caritas
.
45 Jean Watson J) Referred to as the Mother of
. Nursing
46 Dorothy Orem K) Founded the Henry Settlement
.
47 Evaporation L)Loss of heat via transfer of heat
. from body surface to cooler surfaces
and objects not in direct contact with
the body
48 Conduction M)Loss of heat from body surface to
. cooler air results
49 Convection N) Loss of heat by direct contact with

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 SUNRISE NURSING & AFFILIATES, LLC- NURSING FUNDAMENTALS: EXAM #1

STUDENTS NAME: _______________________________ MAY 10, 2016

. cold fingers
50 Radiation O) Loss of heat when a wet surface is
. exposed to air

Please write in where you would the names of the pulse site used to palpate a pulse
a patient

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 SUNRISE NURSING & AFFILIATES, LLC- NURSING FUNDAMENTALS: EXAM #1

STUDENTS NAME: _______________________________ MAY 10, 2016

The following calculation is worth 2 points:

The patients body temperature is 37 degrees Celsius. This represents

what degree in Fahrenheit?
Answer: __________________________

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