Nursing Fundamentals Comprehensive Final Exam at Fox Valley Technical College
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Free Nursing Fundamentals Comprehensive Final Exam at Fox Valley Technical College Questions
You are providing care for a client admitted with a seizure disorder. Which are appropriate interventions to include on the care plan? (Select all that apply – you will choose 3 of the 6 options)
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A When family is present, it is OK for the bed to be elevated and all the side rails down
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B The bed should stay in low position, side rails should be elevated and pads applied to the bedrails, head board and foot board.
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C If you are with the client when he has a seizure, insert a tongue depressor and leave for help and send the nursing assistive personnel in to monitor the client
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D If you are with the client when he has a seizure, make a note of the time, loosen restrictive clothing, turn on the side and monitor characteristics of the seizure
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E When seizure ends, if not already done, turn on side, reorient as needed, stay with client as he may be confused, sleepy, provide hygiene as needed
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F When seizure ends allow the client to get up as desired and tell him he can eat or drink anything he wants
Explanation
The Correct Answers are:
B. The bed should stay in low position, side rails should be elevated and pads applied to the bedrails, head board and foot board.
D. If you are with the client when he has a seizure, make a note of the time, loosen restrictive clothing, turn on the side and monitor characteristics of the seizure.
E. When seizure ends, if not already done, turn on side, reorient as needed, stay with client as he may be confused, sleepy, provide hygiene as needed.
B. The bed should stay in low position, side rails should be elevated and pads applied to the bedrails, head board and foot board.
This intervention ensures safety and prevents injury if a seizure occurs. Keeping the bed low reduces fall risk, and padded rails prevent trauma to the head and limbs during uncontrolled movements. This is standard seizure precaution care.
D. If you are with the client when he has a seizure, make a note of the time, loosen restrictive clothing, turn on the side and monitor characteristics of the seizure.
These are essential actions during an active seizure. Timing the event helps determine if it becomes an emergency. Turning the client on their side protects the airway and prevents aspiration. Loosening tight clothing improves breathing, and observing characteristics helps guide treatment decisions. E. When seizure ends, if not already done, turn on side, reorient as needed, stay with client as he may be confused, sleepy, provide hygiene as needed.
During the postictal phase, clients often experience confusion, fatigue, and loss of bowel or bladder control. Staying with the client maintains safety, prevents falls, and supports reorientation. Side positioning continues to protect the airway.
Which of the following most accurately describes nursing diagnoses? A nursing diagnosis:
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A is based upon objective data only
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B is the same thing as the client's medical diagnosis
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C identifies a client's response to a health problem
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D is a statement of action that will be taken
Explanation
The Correct Answer is: C. identifies a client's response to a health problem.
A nursing diagnosis focuses on how the client responds to actual or potential health problems. Unlike a medical diagnosis, which identifies the disease itself, a nursing diagnosis describes human responses such as pain, anxiety, impaired skin integrity, or risk for falls. This allows nurses to plan individualized interventions that address the client's specific needs and promote optimal outcomes.
When communicating with clients, nurses should pay attention to the congruence of the communication. Congruence is:
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A Considering values or standards that influence behavior and communication.
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B Using correct body language and attentive listening skills
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C Using proxemics or appropriate spacing to facilitate communication.
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D The matching of the verbal and nonverbal aspects of communication
Explanation
The Correct Answer is: D. The matching of the verbal and nonverbal aspects of communication.
Congruence refers to the consistency between what a person says and what their body language communicates. When verbal and nonverbal messages match, communication is clear, trustworthy, and easier for the client to interpret. Nurses use congruent communication to build rapport, reduce confusion, and provide emotionally safe interactions. Observing congruence helps the nurse detect true feelings and respond therapeutically.
You are caring for a client who is being treated for acute sepsis. The family is concerned as normally the client is alert and oriented, but today the client is confused and just not themselves. You educate the family that when clients have conditions like an infection or metabolic disturbances such as low oxygen levels, they can have a condition called:
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A A chronic, progressive disease
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B Delirium
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C A very concerning sign that death may be approaching
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D An acute reversible state
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E Dementia
Explanation
The Correct Answer is: B. Delirium.
Delirium is an acute, reversible condition characterized by sudden confusion, disorientation, and changes in behavior. It is commonly triggered by infection, metabolic imbalance, hypoxia, or sepsis. The client transitioning quickly from alert to confused is classic for delirium. With proper treatment of the underlying cause, symptoms often improve or resolve, making delirium the correct and most accurate answer.
Which of the following are effects of immobility on the body?
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A A sense of well-being, increased muscle strength, increased metabolic rate, and increased appetite.
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B Disuse osteoporosis, increased size and strength of muscles, diminished cardiac reserve, and increased metabolic rate.
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C Improved the appetite, increased the heart rate, decreased respiratory movement, and decreased metabolic rate.
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D Urinary stasis, anorexia, stiffness of the joints, and venous vasodilation and stasis.
Explanation
The Correct Answer is: D. Urinary stasis, anorexia, stiffness of the joints, and venous vasodilation and stasis.
These findings accurately describe the harmful physiological effects of immobility. When a client is immobile, urine does not drain effectively (urinary stasis), increasing infection risk. Appetite often decreases (anorexia). Joints stiffen due to lack of movement, and blood pools in the veins, leading to venous stasis and higher risk of deep-vein thrombosis. These are classic negative consequences of prolonged inactivity.
Which of the following approaches is essential when delivering culturally sensitive care?
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A A nonjudgmental attitude.
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B Detailed and complete knowledge of the client's culture
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C Fluency in the client's native language
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D Technical skill competence
Explanation
The Correct Answer is: A. A nonjudgmental attitude.
A nonjudgmental attitude is essential because it allows the nurse to approach clients with openness, respect, and cultural humility. This attitude supports therapeutic communication, reduces bias, and creates an environment in which clients feel comfortable expressing their beliefs and needs. Cultural sensitivity does not require mastery of every culture—it requires respect, curiosity, and the willingness to understand each client without imposing assumptions.
When assessing the client's closed chest drainage system, the nurse notes that there is no bubbling in the suction control chamber as there should be as it is hooked to external suction. See area outlined in blue on chest tube drainage system below:
Which of the following actions should the nurse take?
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A Continue to monitor the client as maybe the situation will rectify itself with time.
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B Add more water to the suction control chamber of the drainage system.
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C Verify that the suction is on and attached and check the tubing for leaks.
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D Milk the chest tube and dislodge any clots in the tubing that are occluding it.
Explanation
The Correct Answer is: C. Verify that the suction is on and attached and check the tubing for leaks.
No bubbling in the suction control chamber means the suction may not be connected, may be off, or there may be a leak preventing proper suction generation. The first action is to verify the suction is functioning and ensure all tubing connections are intact. Without establishing suction, the chest tube cannot maintain negative pressure, risking fluid accumulation and impaired lung expansion.
A nurse is preparing a presentation on healthy nutrition for a group of adults. Which of the following would be correct to include: (Select all that apply – You will choose 4 of the 8 options)
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A "Carbohydrates should be your main source of energy as the body digests them more easily and quickly than proteins or lipids."
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B "You should try to eat about the same amount of carbohydrates, proteins and lipids in a day."
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C "If you are vegetarian, you will be getting plenty of complete proteins in your diet."
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D "Fiber helps prevent constipation, helps you feel full longer so prevents overeating and it can help prevent some condition like diverticulosis or diabetes ."
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E "Proteins help us move, build and repair body tissue, function in the immune system and act as enzymes."
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F "Protein is found in very few body tissues so you don't need to eat it every day."
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G "Lipids are needed in very limited amounts and all forms of them will cause heart disease so use care when eating them."
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H "Lipids are needed to absorb the fat-soluble vitamins, provide essential fatty acids, help us maintain our body temperature and help form some hormones."
Explanation
The Correct Answers are:
A. "Carbohydrates should be your main source of energy as the body digests them more easily and quickly than proteins or lipids."
D. "Fiber helps prevent constipation, helps you feel full longer so prevents overeating and it can help prevent some condition like diverticulosis or diabetes."
E. "Proteins help us move, build and repair body tissue, function in the immune system and act as enzymes."
H. "Lipids are needed to absorb the fat-soluble vitamins, provide essential fatty acids, help us maintain our body temperature and help form some hormones."
A. "Carbohydrates should be your main source of energy as the body digests them more easily and quickly than proteins or lipids."
Carbohydrates are the body’s preferred energy source because they break down quickly into glucose. They fuel the brain, muscles, and organs and are more efficiently used for energy than proteins or fats. A healthy diet typically includes carbohydrates as the major energy-providing nutrient, ideally from high-fiber, whole-food sources. D. "Fiber helps prevent constipation, helps you feel full longer so prevents overeating and it can help prevent some condition like diverticulosis or diabetes."
Fiber adds bulk to stool to prevent constipation, helps stabilize blood sugar, and promotes satiety, reducing overeating. It also lowers cholesterol and reduces the risk of diverticulosis. Adequate fiber is a key component of a healthy diet and supports both digestive and metabolic health.
E. "Proteins help us move, build and repair body tissue, function in the immune system and act as enzymes."
Proteins are essential structural and functional molecules. They repair tissues, build muscle, form antibodies, create enzymes and hormones, and support immune functioning. Without daily protein intake, muscle loss, poor healing, and immune compromise may occur.
H. "Lipids are needed to absorb the fat-soluble vitamins, provide essential fatty acids, help us maintain our body temperature and help form some hormones."
Lipids are crucial for absorbing vitamins A, D, E, and K. They provide essential fatty acids that the body cannot produce, help regulate temperature by providing insulation, and form the basis of many hormones. Lipids support brain function, cell structure, and overall health when consumed in proper amounts.
You are caring for an elderly patient that has fallen at home and has a fractured hip. The patient is oriented to person, place, and time. Which risk factors place this patient at risk for developing a pressure injury while hospitalized? (Select all that apply – you will choose 2 of the 4 options.)
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A Increase in pain sensation due to fall
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B Impaired mobility
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C Forces from friction and shear
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D Alteration in level of consciousness
Explanation
The Correct Answers are:
B. Impaired mobility
C. Forces from friction and shear
Explanation
B. Impaired mobility
A fractured hip significantly limits movement. When a client cannot reposition independently, pressure remains on bony prominences for prolonged periods, leading to tissue ischemia and breakdown. Elderly clients are at especially high risk due to decreased muscle mass, thinner skin, and reduced circulation. Impaired mobility is one of the strongest predictors of pressure injury development in hospitalized patients.
C. Forces from friction and shear
Friction and shear occur when the client is pulled up in bed or slides down in a semi-Fowler’s position. These forces damage superficial tissues and blood vessels, greatly increasing pressure injury risk. In a patient with limited mobility, these mechanical forces occur more frequently and with greater impact, making prevention essential.
The nurse is preparing a client for a computed tomography (CT) scan of the abdomen. The nurse understands that to enhance client understanding, communication should be direct, simple and clear. Which statement by the nurse is best to provide education to the client? (You can assume all of these are true statements.)
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A "You will need to remain NPO for the 8 hours prior to your CT scan."
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B "You cannot have anything to eat or drink for 8 hours before your test."
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C "You will need to be NPO and drink this contrast medium before your test."
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D "You may need to void before you go down to the department for your CT scan."
Explanation
The Correct Answer is: B. "You cannot have anything to eat or drink for 8 hours before your test."
This statement is the most direct, simple, and clear. It uses plain language that any client can easily understand without needing medical terminology. The phrase “cannot have anything to eat or drink” removes ambiguity and improves comprehension, ensuring the client understands the NPO requirement before the CT scan. Clear, simple phrasing supports health literacy and enhances patient adherence to pre-procedure instructions.
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