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 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.
A nurse is caring for a client who has a fluid and electrolyte imbalance. The nurse knows that the priority goal of taking care of this client is:
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To obtain homeostasis
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To call the physician
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To listen to bowel sounds
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To change the wound dressing
Explanation
The Correct Answer is:
A. To obtain homeostasis
Detailed Explanation:
The main priority in managing a client with a fluid and electrolyte imbalance is to restore and maintain homeostasis. Fluid and electrolyte balance is essential for normal cellular function, cardiac stability, and neuromuscular activity. Imbalances can lead to life-threatening complications such as cardiac arrhythmias, hypotension, or seizures. The nurse’s focus should be on assessing intake and output, monitoring vital signs, administering prescribed fluids or electrolytes, and evaluating lab results to ensure internal equilibrium is reestablished.
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 is prepping her client for a trip to the operating room. The nurse anticipates that the physician will order which IV fluid:
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10% Dextrose
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3% NaCl
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Lactated Ringers
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0.45% NaCl
Explanation
The Correct Answer is:
C. Lactated Ringers
Detailed Explanation:
Lactated Ringer’s solution is the preferred isotonic fluid used before, during, and after surgery. It closely resembles the body’s extracellular fluid composition and helps maintain intravascular volume, electrolyte balance, and tissue perfusion during surgery. It also contains electrolytes such as sodium, potassium, calcium, and lactate, which acts as a buffer to prevent metabolic acidosis. Hypertonic or hypotonic fluids like 10% Dextrose, 3% NaCl, and 0.45% NaCl are inappropriate for surgical fluid replacement.
A client has a health care provider's order for NPO (nothing by mouth) following abdominal surgery to repair a bowel obstruction. The client has a nasogastric tube inserted to low intermittent suction. The client requires intravenous therapy for what purpose?
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Replace fluid and electrolytes
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Administer blood products
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Provide protein supplements
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Treat the client’s infection
Explanation
The Correct Answer is:
A. Replace fluid and electrolytes.
Detailed Explanation:
After abdominal surgery with an NPO order and nasogastric suction, the client loses fluids and electrolytes through gastric drainage and cannot take anything orally. Intravenous therapy maintains hydration and electrolyte balance until normal gastrointestinal function resumes. This prevents complications such as dehydration, hypovolemia, and electrolyte imbalances. Blood products or antibiotics are given only when specifically ordered, and protein supplements are not appropriate for IV administration unless total parenteral nutrition is prescribed.
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.
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 client reads the nutritional chart and follows it accurately. The nurse also notes that the client understands the need for a balanced diet and its relationship with a quick recovery. In which domain is the client demonstrating successful learning?
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Affective
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Psychomotor
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Interpersonal
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Cognitive
Explanation
The Correct Answer is:
D. Cognitive
Detailed Explanation:
The cognitive domain involves acquiring and demonstrating knowledge, comprehension, and critical thinking. By reading the nutritional chart and understanding how a balanced diet promotes faster recovery, the client is applying learned information to health behaviors. This shows comprehension and the ability to make informed decisions. The affective domain relates to emotions and attitudes, while the psychomotor domain involves physical skills, and the interpersonal domain focuses on social interactions rather than knowledge-based understanding.
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.
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