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
A nurse educator on a medical–surgical unit is reviewing isolation procedures and PPE usage with a group of new nurses. Which of the following correctly identifies the type of precautions or isolation needed for each situation? SATA.
- A Administering an IM vaccine to a patient – Standard precautions
- B Transferring a patient with a seeping infected rash from a gurney to the bed – Contact precautions
- C Performing clean wound care to an almost fully healed wound – Standard precautions
- D Assisting a client with infectious diarrhea to the bathroom – Contact precautions
Explanation
The Correct Answers are:
A. Administering an IM vaccine to a patient – Standard precautions
B. Transferring a patient with a seeping infected rash from a gurney to the bed – Contact precautions
C. Performing clean wound care to an almost fully healed wound – Standard precautions
D. Assisting a client with infectious diarrhea to the bathroom – Contact precautions
Explanation
A. Administering an IM vaccine to a patient – Standard precautions
IM injections are covered by standard precautions because they involve minimal exposure to bloodborne pathogens. Hand hygiene and gloves are sufficient. No airborne, droplet, or contact risks are present, making standard precautions the correct and evidence-based choice.
B. Transferring a patient with a seeping infected rash from a gurney to the bed – Contact precautions
A draining, infected rash is considered a moist wound with a high risk of spreading organisms through direct or indirect contact. Gloves and gown are required. Contact precautions prevent transmission of organisms such as MRSA, VRE, and wound infections.
C. Performing clean wound care to an almost fully healed wound – Standard precautions
A nearly healed wound has minimal drainage and low infection risk. Standard precautions—hand hygiene and gloves—are adequate. No additional PPE or special isolation is required unless active drainage or organism-specific precautions are involved.
D. Assisting a client with infectious diarrhea to the bathroom – Contact precautions
Infectious diarrhea spreads via the fecal–oral route and contaminates surfaces easily. Contact precautions (gown and gloves) are required to prevent spread of pathogens including C. difficile, Norovirus, and Rotavirus. Standard precautions alone are not enough for infectious diarrhea.
While conducting the initial home health visit with the family of a new infant, the nurse notices a soiled looking red string tied around the infant's neck. Which is the most appropriate action for the nurse to take being mindful of both safety and cultural considerations?
- A Immediately remove the string and explain that it is a choking hazard
- B Ask the family the meaning of the string and assist in moving it to a safer location on the infant.
- C Leave the string as it is obviously important to the family.
- D Inform the family that objects like this offer no protection and then remove it
Explanation
The Correct Answer is: B. Ask the family the meaning of the string and assist in moving it to a safer location on the infant.
This response respects the family’s cultural beliefs while addressing infant safety. Asking about the meaning of the string shows cultural sensitivity, avoids assumptions, and opens communication. Helping the family reposition it to a safer location—such as tying it on the wrist instead of the neck—maintains cultural practices without compromising the infant’s safety. This approach balances safety, respect, and therapeutic rapport.
The quality and risk nurse in the local hospital is performing a hospital survey on Never Events or Serious Reportable Events. Which of the following statements would the nurse use to best describe this type of event?
- A "It involves only events in the operating room area involving the use of unsafe equipment."
- B "It is an event that can cause serious injury or death to a client that should never happen in a hospital."
- C "It is an analysis to try to understand the causes of events."
- D "It is a specific event that enables a hospital to maximize reimbursement from Medicare and Medicaid."
Explanation
The Correct Answer is: B. "It is an event that can cause serious injury or death to a client that should never happen in a hospital."
Never Events are serious, preventable patient-safety incidents that result in significant harm or death and should never occur in a properly functioning healthcare environment. These include wrong-site surgeries, retained foreign objects, and severe medication errors. They indicate a breakdown in safety systems and require immediate reporting, investigation, and corrective action. This definition aligns with national patient-safety standards and regulatory guidelines.
Unless complications develop, you know the wound will heal by:
- A Primary intention
- B Secondary intention
- C Delayed closure
- D Tertiary intention
Explanation
The Correct Answer is: A. Primary intention.
The image shows a wound that has been surgically closed with sutures. Wounds that are clean, have minimal tissue loss, and are well-approximated (edges brought together) heal by primary intention. This method promotes faster healing, minimal scarring, and lower risk of infection. Surgical incisions with sutures, staples, or adhesive strips are classic examples of wounds healing by primary intention.
Which of the following is the biggest inhibitor to effective communication?
- A Being defensive when discussing nursing care.
- B Giving false reassurances.
- C Failing to listen attentively.
- D Passing judgment on the client.
Explanation
The Correct Answer is: C. Failing to listen attentively.
Failing to listen attentively is the biggest inhibitor to effective communication because it prevents the nurse from understanding the client’s concerns, needs, and emotional state. Without active listening, information is missed, trust is weakened, and therapeutic communication breaks down. Listening is the foundation of all nurse-client interaction, making inattentiveness the most damaging barrier to communication effectiveness.
A nurse is preparing a presentation on delegation in nursing for new RNs. Which of the following are correct information or points to include in the presentation? (Select all that apply – you will choose 5 of the 9 options)
- A Delegation is legal by both LPNs and RNs in Wisconsin
- B Delegation is transferring the ability to do a task to another
- C Delegation is collaborating with other health care providers to make decisions
- D The person who does the delegated task is responsible for evaluating the outcome
- E Even though delegation allows another to do the task, the RN is accountable or responsible for how it is done and evaluating the results
- F An RN should delegate tasks based upon the education and ability of the person to whom the task will be assigned and still needs to provide supervision
- G There are really no times when a RN could not delegate a task to another
- H There are rights of delegation to follow which include the right task, the right circumstances, the right person, the right directions or communication and the right supervision
- I As an RN, you should not delegate assessment, initial education, or evaluation
Explanation
The Correct Answers are:
B. Delegation is transferring the ability to do a task to another
E. Even though delegation allows another to do the task, the RN is accountable or responsible for how it is done and evaluating the results
F. An RN should delegate tasks based upon the education and ability of the person to whom the task will be assigned and still needs to provide supervision
H. There are rights of delegation to follow which include the right task, the right circumstances, the right person, the right directions or communication and the right supervision
I. As an RN, you should not delegate assessment, initial education, or evaluation
B. Delegation is transferring the ability to do a task to another
This is a correct definition. Delegation allows another qualified person—usually UAP or LPN—to perform a specific task while the RN maintains accountability for the outcome.
E. Even though delegation allows another to do the task, the RN is accountable or responsible for how it is done and evaluating the results
This is essential. Responsibility for the outcome of delegated tasks always remains with the RN, even if someone else performs the activity.
F. An RN should delegate tasks based upon the education and ability of the person to whom the task will be assigned and still needs to provide supervision
Delegation depends on the skill level, training, and competency of the delegatee. The RN must also ensure appropriate supervision and follow-up.
H. There are rights of delegation… right task, right circumstances, right person, right directions/communication, right supervision
These are the Five Rights of Delegation, the foundation of safe delegation in nursing practice.
I. As an RN, you should not delegate assessment, initial education, or evaluation
Assessment, teaching, and evaluation require critical thinking and professional judgment. These tasks can never be delegated to UAPs or LPNs.
Which of the following characterizes sleep and sleep patterns?
- A Sleep is a state of total unconsciousness
- B Sleep occurs in cycles with 3 stages of nonrapid eye movement and then a time of rapid eye movement
- C The amount of time a person sleeps is not important as long as they complete one sleep cycle a night
- D The amount of deep sleep a person will get increases with age and thus older adults need more sleep than children
Explanation
The Correct Answer is: B. Sleep occurs in cycles with 3 stages of nonrapid eye movement and then a time of rapid eye movement.
Normal sleep follows predictable cycles consisting of three NREM stages followed by REM sleep. These stages repeat several times throughout the night, supporting physical restoration, memory consolidation, and emotional regulation. Understanding this structure helps nurses recognize sleep disturbances and educate clients appropriately. Sleep is not a single uniform state but a patterned physiological process essential for health.
What are some strategies a new nurse can use to develop skills in achieving cultural competence? (Select all that apply – you will choose 2 of the 4 options)
- A Read the literature and study nursing theories and principles pertaining to culture
- B Take advantage of as many opportunities as possible to interact with persons from diverse cultures
- C Recognize that persons from different cultures have different healthcare practices but for safety purposes, need to follow the same nursing plan of care for all people
- D Understand all the practices of all cultures worldwide so he can choose the best interventions
Explanation
The Correct Answers are:
A. Read the literature and study nursing theories and principles pertaining to culture
B. Take advantage of as many opportunities as possible to interact with persons from diverse cultures
A. Read the literature and study nursing theories and principles pertaining to culture
Reading and studying culturally relevant theories helps nurses understand how cultural beliefs influence health behaviors, decision-making, communication styles, and expectations in healthcare. This foundational knowledge strengthens the nurse’s ability to assess, interpret, and respond to culturally diverse needs. It builds awareness, reduces bias, and equips the nurse to deliver culturally sensitive and individualized care. B. Take advantage of as many opportunities as possible to interact with persons from diverse cultures
Direct interaction with culturally diverse individuals helps nurses gain real-world experience, improve communication skills, and develop cultural humility. Exposure to different beliefs, practices, and perspectives enhances understanding and reduces assumptions. These practical encounters help the nurse build confidence, empathy, and respect for cultural differences in patient care.
When should the nurse collect evaluation data for this outcome: The client will maintain a urine output of at least 30 mLs each hour.
- A At the end of the shift
- B Every 24 hours
- C Every 4 hours
- D Every hour
Explanation
The Correct Answer is: D. Every hour.
The stated outcome requires the client to maintain at least 30 mL of urine output per hour. Because the outcome specifies an hourly minimum, the nurse must measure and evaluate urine output every hour to determine whether the goal is being met. Hourly monitoring is essential for assessing renal perfusion, fluid balance, and early signs of kidney compromise or shock.
The nurse is providing care to a client with diarrhea. Appropriate interventions to include on the care plan for this condition would be: (Select all that apply – you will choose 6 of the 10 options)
- A Encourage fiber intake
- B Encourage sips of water or electrolyte drinks as tolerated
- C Encourage bland foods or the BRAT diet
- D Assess lung sounds daily
- E Assess bowel sounds every shift and prn
- F Only assess skin if client complains of pain
- G Assess perineal/rectal skin every shift and prn
- H Educate client to take antidiarrheal medications as soon as diarrhea occurs
- I Educate the client on appropriate hand hygiene
- J Monitor amount or number of stools and consistency of stool every shift
Explanation
The Correct Answers are:
B. Encourage sips of water or electrolyte drinks as tolerated
C. Encourage bland foods or the BRAT diet
E. Assess bowel sounds every shift and prn
G. Assess perineal/rectal skin every shift and prn
I. Educate the client on appropriate hand hygiene
J. Monitor amount or number of stools and consistency of stool every shift
B. Encourage sips of water or electrolyte drinks as tolerated
Diarrhea causes fluid and electrolyte loss, putting clients at risk for dehydration. Encouraging oral fluids such as water or electrolyte solutions helps replace lost volume, restore electrolyte balance, and maintain hydration. Frequent sipping is better tolerated than large amounts. This intervention is essential for preventing complications such as hypovolemia and orthostatic hypotension. C. Encourage bland foods or the BRAT diet
Bland foods (bananas, rice, applesauce, toast) are easier on the gastrointestinal system and can help firm stools. These foods are low in fiber, reduce bowel stimulation, and help decrease the frequency of diarrhea. This diet is recommended temporarily until stools begin to normalize.
E. Assess bowel sounds every shift and prn
Monitoring bowel sounds helps determine GI motility trends and the effectiveness of interventions. Hyperactive bowel sounds may indicate irritation, while the absence of bowel sounds could signal complications such as ileus. Regular assessment ensures early detection of worsening or improving conditions.
G. Assess perineal/rectal skin every shift and prn
Frequent diarrhea exposes skin to moisture and digestive enzymes, causing irritation and breakdown. Regular inspection allows early identification of redness, excoriation, or breakdown so prompt interventions can prevent infection or worsening skin damage.
I. Educate the client on appropriate hand hygiene
Diarrheal illnesses can spread easily, especially if caused by infectious agents. Teaching proper handwashing after toileting and before eating helps prevent transmission and protects both the client and others from infection. Hand hygiene is an essential infection-control measure.
J. Monitor amount or number of stools and consistency of stool every shift
Tracking stool frequency and characteristics helps evaluate hydration status, disease progression, and response to treatments. It also helps identify patterns, worsening symptoms, or development of complications such as blood or mucus in the stool.
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