Nursing Fundamentals Comprehensive Final Exam at Fox Valley Technical College

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Ace Your Test with Nursing Fundamentals Comprehensive Final Exam Actual Questions and Solutions - Full Set

Free Nursing Fundamentals Comprehensive Final Exam at Fox Valley Technical College Questions

1.

Which aspect of restraint use can the nurse delegate to the nursing assistive personnel?

  • A Assessing the client's status​
  • B Applying and removing the restraints​
  • C Evaluating the client's response to restraints​
  • D Determining the need for restraint

Explanation

Explanation
The Correct Answer is: B. Applying and removing the restraints.​
Nursing assistive personnel may apply or remove restraints only after the nurse has completed the assessment, determined the need, obtained an order, and provided clear instructions. This task is considered a technical skill rather than a nursing judgment. Delegating application and removal supports workflow while maintaining safety, as the nurse continues to hold responsibility for monitoring, evaluating, and documenting the client’s condition.
2.

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

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.
3.

The benefits of exercise include which of the following?

  • A Decreased respiratory movement, constipation, increased metabolic rate, and postural hypotension.​
  • B Decreased urinary stasis, decreased metabolic rate, improved joint mobility, and improved appetite.​
  • C Diminished cardiac reserve, constipation, improved muscle size and tone, and improved tolerance of stress.​
  • D Maintenance of bone density, increased ventilation, increased metabolic rate, and improved circulation.

Explanation

Explanation
The Correct Answer is: D. Maintenance of bone density, increased ventilation, increased metabolic rate, and improved circulation.​
Exercise strengthens bones, improves cardiopulmonary efficiency, enhances circulation, and increases metabolic rate. Weight-bearing activity helps maintain bone density and prevent osteoporosis. Physical activity also improves ventilation, enhances oxygen delivery, and supports better overall cardiovascular health. These combined effects make option D the correct collection of exercise benefits.
4.

A client on your unit is deteriorating, but remains alert and oriented. Three days after admission, you notice he seems depressed. He tells you, "I'm tired of being sick. I wish I could end it all." What is the most accurate way to document or record this data?

  • A Client states, "I'm tired of being sick. I wish I could end it all."​
  • B Complains he is tired of being ill and wants to die.​
  • C Does not want to live any longer because he is sick of being ill.​
  • D Appears to be depressed, possibly suicidal.

Explanation

Explanation
The Correct Answer is: A. Client states, "I'm tired of being sick. I wish I could end it all."​
This is the most accurate documentation because it uses the client's exact words without interpretation or modification. Objective charting requires verbatim quotes when a client expresses suicidal thoughts. Recording the statement precisely ensures that the healthcare team receives clear, factual, and legally sound information for immediate safety planning and intervention.
5.

All of the following interventions might be utilized to provide safe client care. Which is most important, regardless of the client's individual health issue?

  • A Keeping the client's bed in the lowest position whenever staff is not right next to the bed performing cares on the client​
  • B Setting bed alarms for all clients as this eliminates the risk of falls​
  • C Raising all 4 side rails on the bed to ensure that the client will remain safely in the bed​
  • D Checking on the client every 6 hours if other nursing duties will allow time for this

Explanation

Explanation
The Correct Answer is: A. Keeping the client's bed in the lowest position whenever staff is not right next to the bed performing cares on the client.​
Keeping the bed in the lowest position is the single most important safety intervention for all clients because it significantly reduces the severity and likelihood of injury should a fall occur. Unlike alarms or side rails, this intervention does not restrain the client or create additional hazards and is universally applicable. Lowering the bed promotes safe mobility, prevents harm, and is a consistent standard of care across all settings.
6.

Maintaining appropriate urinary output is important for appropriate urinary elimination and function of the urinary system. Which of the following hourly urine output amounts would cause the most concern related to the functioning of the urinary system and would be reported to the health care provider?

  • A 15–25 ml​
  • B 50–60 ml​
  • C 75–85 ml​
  • D 90–100 ml

Explanation

Explanation
The Correct Answer is: A. 15–25 ml.​
An hourly urine output below 30 mL is a critical indicator of inadequate kidney perfusion and potential renal impairment. Output of 15–25 mL suggests that the kidneys are not filtering properly, which could be caused by dehydration, acute kidney injury, shock, or decreased cardiac output. This is an urgent finding that must be reported immediately to prevent further renal compromise and systemic complications.
7.

Which of the following would be the most important piece of information to include in a change of shift report?

  • A The vitals were all within normal limits​
  • B The chest X-ray from two days ago was normal​
  • C There were no changes in medication orders for the client​
  • D The Foley catheter was removed 5 hours ago and the client has not voided

Explanation

Explanation
The Correct Answer is: D. The Foley catheter was removed 5 hours ago and the client has not voided.​
Failure to void within several hours after Foley catheter removal is clinically significant and may indicate urinary retention. This requires monitoring and potential intervention from the next nurse on shift. Timely reporting ensures continuity of care and prevents complications such as bladder distention or the need for re-catheterization. This information is time-sensitive, safety-related, and directly affects the plan of care.
8.

Which nutrient deficiency increases the risk for skin and tissue breakdown?

  • A Lipids​
  • B Potassium​
  • C Protein​
  • D Vitamin D

Explanation

Explanation
The Correct Answer is: C. Protein.​
Protein is essential for building, maintaining, and repairing body tissues. A deficiency leads to poor wound healing, reduced collagen synthesis, decreased skin integrity, and increased susceptibility to pressure injuries. Without adequate protein, the body cannot regenerate new tissue effectively, making the skin fragile and more prone to breakdown. Clients who are malnourished, elderly, or chronically ill are especially vulnerable to protein-related tissue damage.
9.

The nurse is caring for a patient who does not speak English. The nurse is using an interpreter to explain procedures and to answer questions that the patient may have. In performing the education, what should the nurse do?

  • A Direct questions to the interpreter to ask the patient​
  • B Leave the information with the interpreter and leave the room to allow uninterrupted communication​
  • C Look at the client when asking the questions​
  • D Ask the interpreter to summarize what was discussed after you leave the room, and tell the interpreter you will try to get back later in case there are questions

Explanation

Explanation
The Correct Answer is: C. Look at the client when asking the questions.​
Looking directly at the client while speaking promotes respect, maintains therapeutic communication, and reinforces that the conversation is between the nurse and the patient—not the nurse and the interpreter. This preserves the nurse–patient relationship, encourages trust, and helps the client feel included despite the language barrier. The interpreter facilitates communication, but the nurse must engage directly with the patient.
10.

An 89-year-old client is worried because she does not have a bowel movement every day. Which statement by the nurse reflects the best understanding of defecation patterns?

  • A "A bowel movement each day is the normal pattern for most people. We will ask for a laxative order for you."​
  • B "The number of bowel movements per week varies greatly. For some people, it can be quite normal to have only two or three bowel movements per week."​
  • C "You just need to eat more fiber to stimulate daily bowel movements. Can I get you some prunes?"​
  • D "You shouldn't worry until you have gone at least five days without a bowel movement."

Explanation

Explanation
The Correct Answer is: B. "The number of bowel movements per week varies greatly. For some people, it can be quite normal to have only two or three bowel movements per week."​
This response provides reassurance and accurate education about normal bowel patterns. Defecation frequency varies widely among individuals, especially older adults, and having a bowel movement every day is not required for healthy function. This explanation reduces anxiety while preventing unnecessary laxative use. It also respects age-related changes in GI motility and promotes realistic expectations about normal bowel habits.

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