NUR 110: Nursing Fundamentals 1
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Free NUR 110: Nursing Fundamentals 1 Questions
A patient has an order for a one-time dose of methylprednisolone 80 mg IM. The methylprednisolone is available in a 120 mg/2 mL concentration vial. How many milliliters should the nurse administer? (TYPE NUMBERS ONLY. Round to the nearest tenth. Use a leading zero if applicable. Do not use a trailing zero.)
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1.0
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1.2
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1.3
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1.5
Explanation
The Correct Answer is:
C. 1.3
Detailed Explanation:
Use the formula:
Volume to administer=Desired dose ÷ Available dose×Volume on hand
(80 mg ÷ 120 mg)×2 mL=1.33 mL
Rounded to the nearest tenth, the nurse should administer 1.3 mL of methylprednisolone. This ensures accurate dosing and prevents under- or overdosing while maintaining safe medication administration standards.
Which natural chemical does the body produce at night to decrease wakefulness and promote sleep?
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Dopamine
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Serotonin
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Endorphins
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Melatonin
Explanation
The Correct Answer is:
D. Melatonin.
Detailed Explanation:
Melatonin is a hormone produced by the pineal gland in response to darkness. It helps regulate the body’s circadian rhythm by signaling that it is time to sleep, thereby decreasing wakefulness and promoting rest. Melatonin levels rise in the evening, peak during the night, and decline in the morning. In contrast, dopamine and serotonin influence mood and alertness, while endorphins act as natural pain relievers and do not play a direct role in sleep regulation.
A nurse is caring for a client who is admitted to the hospital with a phosphorus level of 2.2 mg/dL. What intervention does the nurse need to take?
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Walk the patient down the hallway
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Administer IV fluids per MD order
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Administer phosphorus supplements per MD order
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Restrict phosphorus-containing foods
Explanation
The Correct Answer is:
C. Administer phosphorus supplements per MD order.
Detailed Explanation:
A phosphorus level of 2.2 mg/dL indicates hypophosphatemia, which can lead to muscle weakness, respiratory failure, decreased cardiac output, and impaired oxygen delivery to tissues. The nurse should administer oral or IV phosphorus supplements as prescribed to restore normal levels. Monitoring for improvement in muscle strength and serum phosphate levels is essential. Walking the patient or restricting phosphorus intake would worsen symptoms, while IV fluids alone do not correct the deficiency.
A nurse is working with an older adult and educating the client on how to ambulate with the aid of a walker. The nurse notes that the client appears disengaged and the client states, "I'm just too old to learn." What would be most appropriate for the nurse to do to motivate this client?
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Tell the client how to move the walker as the client ambulates.
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Describe how the walker can improve the client's quality of life.
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Explain how the walker supports the client's lower extremities.
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Fully discuss the rationale for using the walker.
Explanation
The Correct Answer is:
B. Describe how the walker can improve the client's quality of life.
Detailed Explanation:
Linking the skill to meaningful outcomes activates motivation in adult learners. By emphasizing how the walker supports independence, reduces fall risk, enables participation in valued activities, and may decrease pain, fatigue, and caregiver burden, the nurse addresses the client’s belief of being “too old” with hopeful, relevant benefits. This approach builds self-efficacy, counters internalized ageism, and invites goal setting (“walk safely to the garden daily”). Once the client sees personal value, readiness to learn improves, after which step-by-step instruction, demonstration, practice, and teach-back will be more effective.
As the nurse assesses a client's blood pressure, the patient's wrist severely flexes inward. The nurse questions the client's response because this finding may indicate:
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Hypomagnesemia
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Hypophosphatemia
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Hyperchloremia
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Hypercalcemia
Explanation
The Correct Answer is:
A. Hypomagnesemia
Detailed Explanation:
Severe wrist flexion during blood pressure assessment is known as a positive Trousseau’s sign, which indicates neuromuscular irritability caused by low magnesium or calcium levels. Hypomagnesemia increases nerve excitability and muscle contraction, leading to carpopedal spasms when blood flow is temporarily occluded. This electrolyte imbalance can result from malnutrition, alcoholism, or diuretic use. The nurse should promptly report this finding, assess for concurrent hypocalcemia, and anticipate intravenous magnesium replacement.
A nurse follows surgical asepsis techniques for inserting an indwelling urinary catheter in a client. What is an accurate guideline for using this technique?
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Consider the outer 3 in. (8 cm) edge of a sterile field to be contaminated.
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Consider the outside of the sterile package to be sterile.
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Hold sterile objects above waist level to prevent inadvertent contamination.
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Open sterile packages so that the first edge of the wrapper is directed toward the nurse
Explanation
The Correct Answer is:
A. Consider the outer 3 in. (8 cm) edge of a sterile field to be contaminated.
Detailed Explanation:
In surgical asepsis, the outer 1-inch (2.5 cm) to 3-inch (8 cm) margin of a sterile field is considered contaminated because it can easily come into contact with nonsterile surfaces. Maintaining a sterile field prevents the introduction of microorganisms during invasive procedures such as catheter insertion. The nurse must avoid touching this edge and keep sterile items within the inner sterile area to ensure aseptic technique integrity.
A nurse is working on a medical-surgical unit. Four calls come to the nurses' station with requests for the nurse at the same time. The nurse enters the room and finds the patient unresponsive. Which priority-setting framework is most appropriate to use in this situation?
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Acute vs. Chronic
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Head-to-toe
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ABCDE
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Least restrictive/least invasive
Explanation
The Correct Answer is:
C. ABCDE
Detailed Explanation:
The ABCDE priority framework—Airway, Breathing, Circulation, Disability, Exposure—is used in emergency and life-threatening situations. When a patient is found unresponsive, the nurse must immediately assess airway patency, then breathing, circulation (pulse), level of consciousness, and exposure for injuries or causes. This systematic approach ensures that life-threatening conditions are addressed first. The other frameworks are helpful in stable or non-emergent situations but are not appropriate when immediate survival assessment is required.
The client is admitted to the nurse's unit with a diagnosis of heart failure. His heart is not pumping effectively, which is resulting in edema and coarse crackles in his lungs. The term for this condition is:
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Fluid volume deficit
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Fluid volume excess
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Myocardial infarction
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Atelectasis
Explanation
The Correct Answer is:
B. Fluid volume excess
Detailed Explanation:
In heart failure, the heart’s decreased pumping efficiency leads to poor circulation and fluid accumulation in the lungs and peripheral tissues. This results in pulmonary congestion, manifested as coarse crackles, and peripheral edema. The condition is known as fluid volume excess or hypervolemia. Excess fluid overloads the vascular system, causing increased venous pressure and leakage into interstitial spaces. Management includes diuretics, fluid restriction, and monitoring of daily weights to prevent complications such as pulmonary edema.
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.
The nurse in a community health clinic is assessing a 10-year-old client accompanied by his parents. They are discussing their concerns about the child's somnambulism. Which of the following would be the highest priority nursing diagnosis for this patient?
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Risk for caregiver role strain
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Risk for injury
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Risk for delayed development
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Sleep deprivation
Explanation
The Correct Answer is:
B. Risk for injury
Detailed Explanation:
Somnambulism, or sleepwalking, places the child at significant risk for injury due to movement during sleep without awareness of surroundings. Safety is always the nurse’s highest priority. The child may fall, walk into objects, or attempt unsafe activities such as leaving the house. Interventions should include ensuring a safe environment, locking doors and windows, and educating parents on supervision and injury prevention. Addressing safety first helps prevent harm before addressing other related concerns.
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