FUNDAMENTALS EXAM 1 NEWEST 2025 ACTUAL EXAM COMPLETE QUESTIONS AND CORRECT DETAILED ANSWER, Exams of Medicine

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FUNDAMENTALS EXAM 1 NEWEST 2025 ACTUAL

EXAM COMPLETE QUESTIONS AND CORRECT

DETAILED ANSWERS (VERIFIED ANSWERS)

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1. which action related to measuring body temp correlates to assessment step in the nursing process?: - identify current medications impacting the temp assessment
   • determines site last used for the temp assessment
   • review most recently obtained temp measurement
2. in which patient would the tympanic membrane be used as a site for temp measurement?: - adults who do not mind removing their hearing aids

• persons in respiratory distress

3. public health nurse has recorded diastolic & systolic BP for 5 patients. which reading indicates hypertension?: - 160/
   • 145/
   • 138/
   • 125/ (systolic over 130 or diastolic over 80)
4. which task can be delegated to the assistive personnel (AP)?: - reporting significant changes in the pt
   • considering factors related to pt's history
   • obtaining pulse measurement @ appropriate times
   5. which statement is true regarding pulse rate of an older adult?: - it takes longer for heart rate to rise in older adults during illness

6. when measuring axillary temp of a pt, how can the nurse ensure proper positioning of probe against blood vessels in axilla?: - by placing probe into center of axilla

• by lowering arm over the probe
• by placing arm across the chest

7. which factor is likely to give false high reading of BP during BP measurement?: - small sized cuff - arm not supported

• uneven wrapping of cuff

8. which range would be average core temp of older adults?: - 95F - 97F (35C = 36.1C)
9. which mechanisms occur when body temp drops below set point?: - muscle shivering

• narrowing blood vessels
• voluntary muscle contraction

10. during which step in nursing process would the nurse teach a pt abt meaning of O2 saturation readings?: - implementation (involves nurse performing interventions like teaching)
11. where would the nurse locate the pulse to auscultate BP?: - groove b/t biceps & triceps muscles @ antecubital fossa

• brachial pulse

12. which factors are probable causes of low BP?: - hemorrhage

• myocardial infarction

13. which rationale would explain the nurse removing black nail polish from fingernail of pt before measuring O2 saturation?: - nail polish interferes w sensor fx
14. while assessing pt, nurse finds an abnormal radial pulse. which pulse would the nurse assess next?: - apical
15. pt has family history of hypertension. which action would the nurse plan to help pt reduce risk of hypertension?: - discourage smoking

• discourage heavy alcohol intake
• encourage regular exercise

16. in which pt conditions would nurse avoid using an electronic BP device?: - seizures
    • shivering
    • irregular heart rate
    • sever hypotension
17. which body parts are most susceptible to frostbite?: - earlobes & fingers
    18. which factors explain why older adults are sensitive to temp extremes?: - poor vasomotor control
    • reduced subcutaneous fat
    • inefficient temp control mechanisms
    19. for which pts would the nurse pull ear pinna backward, up & out during temp assessment at tympanic site?: - adults over 65 years old
    20. which skill is implemented by nurses during planning phase to prevent falls in pts?: - gathering equipment & performing hand hygiene
    21. at 10AM an adult pt was restrained after physically assaulting another pt on the unit. which monitoring parameter will the nurse incorporate into plan of care?: - assess pts psychological status @10: (nurse checks restraints every 15 mins including psychological status)
    22. which factors contribute to an increase in falls in older pts?: - anticonvulsants
    • anticoagulants
    • antidepressants
18. RNs teach assistive personnel abt preventing falls in health care settings. which statement made by AP indicates effective learning?: - use specific environmental precautions
    • use fall prevention measures that match the pts mobility limits
    • report pt behaviors that are precursors to falls to the RN
19. how would the nurse support a culture of safety?: - complete incident reports when appropriate
    • complete incident reports for a near miss

• communicate product concerns to an immediate supervisor

25. the RN is teaching a nursing student abt procedure related accidents. which statement made by the nursing student indicates need for further teaching?: - Accidents are mainly caused by misuse of equipment
26. a 62 yr old woman is being discharged home w her husband after surgery for a hip fracture from a fall at home. which info would the nurse consider when providing discharge teaching abt home safety to this pt & her husband?: - a safe environment promotes pt activity
27. which is an example of The Joint Commissions 2021 national patient safety goals?: - use correct identifiers for patient identification
28. to ensure safe use of O2 in the home by a pt, which teaching would the nurse include?: - smoking is prohibited around O

• do not use electrical equipment around O
• special precautions may be required when traveling w O

29 the RN is teaching a nursing student abt guidelines to follow to ensure safety while caring for a pt who is at risk of falls. which statement made by the nursing student indicates the need for further teaching?: - anticipate pt's fall risks before choosing fall prevention strategies (should assess NOT anticipate)

30. the RN is teaching a nursing student abt safety for equipment related accidents. which statement by the nursing student indicates the need for further learning?: - make regular safety check of equipment (engineering/maintenance staff safety check equipment NOT nurses)
31. which nursing activity is performed during safety planning for a pt?: - consult w occupational & physical therapists on assistive devices

• select interventions that improve safety of pt's home environment

32. the senior nurse is discussing w student nurses the serious reportable events included on the national quality forum list. which environmental event would be discussed?: - pt death by burns from agency equipment

• pt death associated w falls
• pt death by electrocution (environmental factors, which means NOT assault!!)

33. the nurse is caring for an older adult in the home & is concerned abt risk of injury in this pt. which activity would the nurse do to assess risk of injury in this pt?: - perform home hazard appraisal

• inquire abt pt's visual acuity
• observe pt's posture & balance

34. which question asked by the nurse is useful for evaluating a pt's perception of safety?: - are you still afraid of falling?

• do you feel safer as a result of the changes @ home?

35. a pt is experiencing a seizure during acute hospitalization. which measure facilitates breathing & reduces risk of musculoskeletal injury?: - loosen pt gown
    • hold limbs loosely
    • place something soft under the head
36. which pt would need temporary restraint?: - confused pts
    • pts who repeatedly fall
    • pts trying to remove medical devices
    37. which factor is the greatest risk of injury for an ADOLESCENT?: - Automobile accidents, suicide, substance abuse
    38. which instruction would the nurse give to the pt abt having. afire extinguisher in their home?: - kids should NOT have access to it
    • place one on each level of home near an exit
    • place in clear view
    • keep it away from stoves & heating appliances
    39. which info would the nurse give to a pt abt using a fire extinguisher?: - fire extinguisher should be used only when fire is confined to small areas
    40. of which common cause of death in elderly population would the nurse be aware?: - falls, hypothermia, heatstroke (older adults more vulnerable to temp changes)
    41. nurse notes a pt has a diagnosis of risk for fall owning to left sided weakness, impairing their gait. which intervention will nurse anticipate implementing to address the nursing diagnosis?: - explain fall risks associated w pt's stroke
    42. which outcome would nurse include when preparing plan of care for a pt w risk of falling?: - the pt remains injury free for 1 month
    43. what would a pt follow if their skin or clothing was burning?: - stop, drop, & roll

44. the nurse is teaching a nursing student abt spine deformities. which statement is true abt spine deformities?: KYPHOSIS: increased convexity in curvature of thoracic spine LORDOSIS: exaggeration of anterior convex curve of lumbar spine SCOLIOSIS: lateral S or C shaped spinal column w vertebral rotation 45 which hormone contributes to metabolic activity?: - thyroid, pancreatic, gastrointestinal hormones
45. nurse is caring for a pt w paralysis. nurse understands that foot-drop is common but preventable complication in these pts. what statement is true abt foot-drop?: - foot-drop is a type of debilitating contracture

• pt is unable to lift toes off ground
• pt w left/right side paralysis are at increased risk of developing foot-drop

47. nurse is caring for bedridden pt. nurse understands that immobility results in many metabolic changes. what metabolic change is found in this pt?: - negative nitrogen balance

• decreased BMR
• decreased appetite & slowed peristalsis

48. nurse is caring for pt who has been immobile for 1 month bc of quadriplegia. what risks should the nurse be ready for?: - risk of atelectasis

• risk of hypostatic pneumonia
• risk of ineffective coughing

49. nurse understands that an immobile pt is at high risk of thrombus formation. what factor may contribute to this risk?: - alteration or slowing of blood flow

• damage to blood vessel walls
• alteration of constituents in blood

50. pt sustained a severe injury in a car accident. pt in unable to perform any movement. what metabolic change would be found bc of immobility?: - calcium imbalance
    • gastrointestinal disturbances
    • alteration in protein metabolism
51. nurse is reviewing data of a pt w severe joint pain. which question asked by the nurse help assess joint mobility?: - does your joint pain worsen if you walk?

• have you noticed any swelling of the joints?

52 nurse understands the increased risk of musculoskeletal injuries from lifting objects, pushing beds, & bathing/feeding pts. what measure would the nurse do to prevent injury?: - bend @ the knees

• maintain erect trunk & bent knees
• get assistance w moving pts
• keep weight to be lifted as close to body as possible

53. home care nurse is preparing the home of a pt who is being discharged after a stroke. the pt is cooperative & can ambulate w a cane. what features in the pt's house must be corrected & removed for pt's safety?: - three- legged stool on wheels in the kitchen

• braided throw rugs in entry hallway & b/t bedroom & bathroom

54. RN is teaching a nursing student abt developmental changes that occur bc of immobility. what statement by the nursing student indicates the need for further learning?: - immobilization can lead to social isolation w infants (leads to social isolation w adolescents)
55. what assessment finding indicates atelectasis from immobility?: - hypoven- tilation (results from blocked bronchioles by secretions & collapsed distal lunch tissue)
56. RN is teaching a nursing student abt developmental changes in older adults. what statement made by the nursing student indicates the need for further learning?: - prolonged immobilization in older adults delays gross motor skills

• immobilization in older adults is only caused by degenerative diseases

57. what assistive device would the nurse use to reduce surface area & friction when pts are unable to assist w moving up in bed?: - full-body swing
58. what is a common trouble area for a pt in the supine position?: - extended elbows

• unsupported feet
• externally rotated hips 59 what condition puts pt at high risk of complications when bedridden & immobile?: - arthritis
• spinal cord injury
• diabetes

60. RN is giving instructions to nursing student abt interventions performed while moving a pt. what given instruction by the RN should be prioritized?: - determine effects of illness on exertion (some conditions like CV disease may contradict exertion)
61. what finding may indicate metabolic change as a result of immobility?:

• delayed wound healing (rate of healing affected by nutritional intake & nutrient absorption)

62. nurse is caring for different pts. pt w what condition may benefit from logrolling?: - spinal cord injury (pt needs to remain laying straight w/o moving spine)
63. what pt condition is a contraindication for antiembolic stockings?: - skin lesions - gangrene

• recent vein ligation (compromises circulation & worsens their condition)

64. the nurse uses a trochanter roll or sandbag when performing which intervention?: - placing pt in supported supine position

• placing pt in supported fowler's position

65. what device should the nurse use to prevent external rotation of hips when pt is in supine position?: - trochanter roll
66. the RN is teaching a nursing student abt interventions to take when pt avoids moving. what statements by the nursing student indicate need for further learning?: - i should consult an occupational therapist

• i should increase the freq of turning

67. the nurse put antiembolic stockings on the legs of a pt. what should the nurse check after applying the stockings?: - femoral pulse
    • temperature of skin
    • color of skin 68 what circumstance can cause contracture of a joint?: - muscle fibers become shortened bc of disuse
    69. what condition is observed by placing a pt in lateral recumbent position?: - lateral flexion of neck (increased cervical flexion observed in fowlers position)
    70. the RN is teaching a nursing student abt the interventions made w immobilized pts who are at risk for impaired skin integrity. what statement made by the student nurse indicates need for further learning?: - i should reposition the pt freq when they are awake (doesn't depend on if they are awake or not)
    71. what is true abt isometric contractions?: - muscle tension increases, but no muscles shorten

• they improve activity tolerance

72. nurse is caring for a pt who has been immobile after spinal surgery. what urinary change is likely to occur within first 72 postoperative hours?: - urinary output decreases

• urinary stasis occurs
  • risk of UTI increases
  73. the nurse suspects DVT in a pt. what factors of virchow's triad may lead to this condition?: - increased platelet activity
  74. what positioning aid is contradicted in a pt w spastic paralysis?: - rolled washcloths (don't keep thumb well abducted)
  75. what nursing action prevents tension on spinal column & adduction of hips while logrolling a pt?: - placing small pillows behind pt's knees