NUR 110: Nursing Fundamentals 1
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Free NUR 110: Nursing Fundamentals 1 Questions
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 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.
A nurse is preparing a patient for discharge home and is teaching them how to change their wound dressing. What is the best way to evaluate the effectiveness of the teaching session?
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Have the patient demonstrate removing the dressing and applying a new one.
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Give the patient a multiple-choice quiz on the content taught.
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Ask the patient to repeat all the steps of the procedure and rationale for each.
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Ask the patient whether or not the instructions were clear.
Explanation
The Correct Answer is:
A. Have the patient demonstrate removing the dressing and applying a new one.
Detailed Explanation:
The most effective way to evaluate teaching, especially for psychomotor skills like wound care, is through return demonstration. By having the patient perform the dressing change, the nurse can directly observe their technique, identify any errors, and provide immediate correction. This ensures that the patient can safely perform the task at home and helps reinforce learning through practice.
A nurse is assessing the care that a nursing assistant (NAP) is providing for a patient who has an indwelling catheter. Which NAP action will prompt the nurse to step in and provide this client with discharge education?
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Contact a certified medical interpreter to be present for teaching.
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Ask the daughter if she is comfortable interpreting for the patient.
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Provide the client with printed material in her language and do not attempt oral teaching
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Ask a coworker who is from Iran to complete the teaching
Explanation
The Correct Answer is:
A. Contact a certified medical interpreter to be present for teaching.
Detailed Explanation:
For discharge education, the nurse must ensure clear, accurate communication. The correct and ethical approach is to use a certified medical interpreter rather than relying on family members or untrained staff. Certified interpreters are trained to translate medical information precisely, maintain confidentiality, and ensure patient understanding. Using family members or coworkers can lead to miscommunication and violates patient privacy. Providing printed materials alone without verbal teaching is also inadequate for comprehensive education.
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.
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. Which request can be delegated to the certified nursing assistant?
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A client who finished working with physical therapy and is requesting pain medication.
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A client with a new infection who reports feeling itchy and febrile after her antibiotic this morning.
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A client who is receiving normal saline and is agitated because her IV machine is beeping.
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A client who had abdominal surgery 2 days ago and requires a walker and assistance to get to the bathroom.
Explanation
The Correct Answer is:
D. A client who had abdominal surgery 2 days ago and requires a walker and assistance to get to the bathroom.
Detailed Explanation:
The certified nursing assistant (CNA) can safely assist a stable, postoperative client with ambulation, as this task falls within their role of providing basic care and support with activities of daily living. The nurse should first ensure that the client’s condition is stable and that ambulation has been previously approved. The other tasks involve assessment, clinical judgment, or medication administration—responsibilities that cannot be delegated to a CNA. Delegation decisions must always prioritize patient safety and scope of practice.
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 client has a prescription for progesterone 5 mg IM daily for 6 days. Progesterone is available in a vial labeled 50 mg/mL. How many milliliters should the nurse administer each day? (TYPE NUMBERS ONLY. Round to the nearest tenth. Use a leading zero if applicable. Do not use a trailing zero.)
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0.05
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0.1
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0.2
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0.5
Explanation
The Correct Answer is:
B. 0.1
Detailed Explanation:
Use the formula:
Volume to administer=Desired dose÷Available dose×Volume on hand
5÷50×1=0.1mL
Therefore, the nurse should administer 0.1 mL of progesterone intramuscularly each day for 6 days. This delivers the prescribed 5 mg dose accurately and safely, following proper medication calculation and administration principles.
The health care provider is concerned that the client has hypokalemia. During the physical examination, which question should the nurse ask the client?
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"Have you been having swelling in your legs?"
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"Have you been experiencing difficulty breathing?"
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"Have you been experiencing chest pain?"
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"Have you been experiencing heart palpitations?"
Explanation
The Correct Answer is:
D. "Have you been experiencing heart palpitations?"
Detailed Explanation:
Hypokalemia (low serum potassium) can cause cardiac rhythm disturbances because potassium is vital for normal electrical conduction in the heart. Patients may experience heart palpitations, irregular heartbeat, or feelings of skipped beats. Assessing for these symptoms helps identify potential cardiac complications early. Prompt recognition and treatment are essential to prevent life-threatening arrhythmias or cardiac arrest.
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