NUR 110: Nursing Fundamentals 1
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Free NUR 110: Nursing Fundamentals 1 Questions
A nurse in a long-term care facility is caring for a client with dementia who is upset over not being able to find their spouse, who passed away years ago. Which of the following clients should the nurse plan to visit first after addressing this situation?
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79-year-old post-operative patient
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62-year-old congestive heart failure patient
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56-year-old alcoholic patien
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32-year-old paraplegic patient
Explanation
The Correct Answer is:
A. 79-year-old post-operative patient
Detailed Explanation:
After attending to the emotional needs of the client with dementia, the nurse should next prioritize the 79-year-old post-operative patient. This client is at greatest risk for immediate complications such as hemorrhage, infection, or respiratory distress due to age-related physiological decline and surgical recovery. Early assessment helps detect complications promptly, ensuring patient safety. The other clients, though requiring care, are not at the same acute risk as a recent post-operative patient.
A client has an order for 4 mg morphine sulfate IM every 4 hours PRN for pain greater than 8 out of 10 on the numeric pain scale. Available is morphine sulfate 10 mg/5 mL. How many milliliters should the nurse administer per dose?
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1.5 mL
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2.0 mL
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2.5 mL
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3.0 mL
Explanation
The Correct Answer is:
B. 2.0 mL
Detailed Explanation:
To find the correct dose:
Available concentration = 10 mg / 5 mL
Ordered dose = 4 mg
Set up the proportion:
10 mg : 5 mL = 4 mg : x mL
(10x = 20)
x = 2 mL
The nurse should administer 2.0 mL per dose. Always use a leading zero for doses less than 1 and avoid trailing zeros to prevent medication errors.
The nurse looking for behaviors that reflect sleep deprivation in patients unaware of their sleep problems should note:
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Hyperactivity
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Nocturnal enuresis (bed-wetting)
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Slurred speech
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Impaired judgment
Explanation
The Correct Answer is:
D. Impaired judgment
Detailed Explanation:
Sleep deprivation affects cognitive functioning, decision-making, and concentration. Impaired judgment is one of the most common behavioral indicators, even when individuals are unaware of their sleep deficit. Clients may make poor decisions, display mood swings, decreased alertness, and reduced problem-solving ability. Unlike physical signs, cognitive and behavioral changes often go unnoticed but can significantly impair safety, learning, and social interactions. The nurse should assess sleep patterns and provide education on healthy sleep habits and rest promotion.
A nurse is preparing to teach a couple about care for their newborn. Which of the following actions indicate the nurse is addressing the affective domain of learning?
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The nurse shows the best positions to hold the newborn while feeding.
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The nurse explains the steps of warming a bottle.
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The nurse has both parents demonstrate changing a diaper.
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The nurse asks the clients their views on breastfeeding
Explanation
The Correct Answer is:
D. The nurse asks the clients their views on breastfeeding.
Detailed Explanation:
The affective domain of learning involves attitudes, emotions, values, and feelings. By asking the couple about their views on breastfeeding, the nurse is exploring their beliefs and emotional readiness related to newborn care. This approach encourages open discussion, respects cultural and personal values, and builds trust. In contrast, demonstrating or explaining procedures addresses the cognitive or psychomotor domains, which focus on knowledge and physical skill acquisition rather than emotional or value-based learning.
A 14-year-old female student is brought to the clinic by her mother who says that the client has been trying to lose weight. The client complains of feeling tired and weak and admits that she has been using laxatives to help lose weight. The nurse recognizes that the client is probably experiencing what electrolyte imbalance?
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Hypocalcemia
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Hyperkalemia
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Hypokalemia
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Hypernatremia
Explanation
The Correct Answer is:
C. Hypokalemia
Detailed Explanation:
Laxative abuse leads to excessive loss of water and electrolytes, particularly potassium, through the gastrointestinal tract. Low serum potassium (hypokalemia) can cause muscle weakness, fatigue, cardiac dysrhythmias, and general lethargy. In this case, the client’s symptoms of weakness and fatigue are classic indicators of hypokalemia. Chronic laxative use is common in eating disorders like bulimia or anorexia nervosa, and monitoring electrolyte levels is essential to prevent serious complications such as cardiac arrest.
The nurse maintains a journal in which to reflect on the nurse's clinical practice. Which entry is an example of reflection for action?
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"It has been over 4 hours since I have medicated the client for pain."
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"The client's son reported to me that the client needed medication for postoperative pain."
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"I obtained the medication. When I got to the room, the client was sleeping. I refused to give the medication."
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"Next time I will assess the client before obtaining the medication."
Explanation
The Correct Answer is:
D. "Next time I will assess the client before obtaining the medication."
Detailed Explanation:
Reflection for action involves using past experiences to guide and improve future nursing practice. In this example, the nurse analyzes a prior event and identifies how to act differently next time—assessing the client before obtaining medication. The other statements describe reflection-in-action (thinking during an event) or reflection-on-action (thinking after an event). Reflection for action demonstrates growth, learning, and proactive adjustment to improve patient care outcomes.
A nurse is preparing for a teaching session with a patient who has recently been diagnosed with narcolepsy. Which activity indicates the assessment phase of teaching?
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Determining the patient's health literacy level
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Selecting an appropriate video about narcolepsy for the patient
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Recommending the patient attend a support group
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Discussing the option of behavioral therapy to control symptoms
Explanation
The Correct Answer is:
A. Determining the patient's health literacy level.
Detailed Explanation:
The assessment phase of the teaching process involves gathering information about the patient’s learning needs, abilities, readiness, and preferences. By determining the patient’s health literacy level, the nurse assesses how well the patient can understand and apply health information—crucial for planning effective education. Selecting teaching materials, recommending support groups, and discussing therapies occur during the planning or implementation phases, after assessment data have been collected.
A report on a group of clients is being given to a nurse. The nurse should see which of the following clients first, according to the ABCDE priority framework?
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A client who is scheduled for discharge and has become febrile this morning.
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A client who has early dementia and awoke confused to their location this morning.
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A client who has pneumonia and has developed wheezing.
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A client who is postoperative and has a urine output of 50 mL for the past 4 hours.
Explanation
The Correct Answer is:
C. A client who has pneumonia and has developed wheezing.
Detailed Explanation:
The ABCDE (Airway, Breathing, Circulation, Disability, Exposure) framework prioritizes airway and breathing issues first. Wheezing in a client with pneumonia indicates narrowing of the airways and potential respiratory compromise, which can rapidly lead to hypoxia or respiratory failure. This client requires immediate assessment and possible interventions such as oxygen therapy, bronchodilators, or airway support. The other clients are stable or have non-life-threatening conditions that can be safely addressed afterward.
Working on a medical-surgical unit is a nurse. Four calls with requests for the nurse arrive at the nurses' station simultaneously. The certified nursing assistant can be assigned which requests?
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Insert the tip of the syringe with lubricant into the urethra and instill 10 mL of lubricant.
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Use thumb and finger to spread labia with the dominant hand.
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Cleanse the labia folds and meatus with circular strokes beginning at the meatus and working outward.
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Cleanse the labia folds and meatus with strokes from top to bottom using a new cotton swab each time.
Explanation
The Correct Answer is:
D. Cleanse the labia folds and meatus with strokes from top to bottom using a new cotton swab each time.
Detailed Explanation:
A certified nursing assistant (CNA) can perform perineal care, which includes cleansing the labia and meatus using clean technique. The correct method is to clean from front to back (top to bottom) using a new cotton swab for each stroke to prevent infection. In contrast, inserting lubricant into the urethra or manipulating the labia for sterile catheter insertion requires sterile technique and nursing judgment, which are outside the CNA’s scope of practice.
A nurse is evaluating a nursing assistive personnel's (NAP) care for a client with an indwelling catheter. Which action by the NAP will cause the nurse to intervene?
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Placing the drainage bag in the bed
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Kinking the catheter tubing to obtain a urine specimen
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Securing the catheter tubing to the patient’s thigh
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Emptying the drainage bag when half full
Explanation
The Correct Answer is:
A. Placing the drainage bag in the bed.
Detailed Explanation:
The drainage bag should always be kept below the level of the bladder to prevent the backflow of urine, which can introduce bacteria and cause a urinary tract infection. Placing the bag in the bed increases the risk of contamination and infection. The other actions—securing the catheter tubing, preventing kinks, and emptying the bag when half full—are correct practices that promote comfort, safety, and infection control for clients with indwelling catheters.
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