Nursing fundamentals questions with answers.

1) A nurse is reinforcing teaching with a client about breast self-examination (BSE). Which of the following statements by the client indicated an understanding of the teaching?

1. a) I should begin my BSE by looking at my breasts while standing in front of the mirror.
2. b) I should perform my BSE each month on the first day of my menstrual cycle.
3. c) I should expect a small amount of white discharge when I gently squeeze my nipples.
4. d) I should feel each of my breasts at the same time to check for any differences.”

Answer. a) I should begin my BSE by looking at my breasts while standing in front of the mirror.

Answer and Explanation

• The client should begin their BSE by standing in front of the mirror and inspecting the appearance of each breast. The client should observe for symmetry and changes in appearance. The nurse should instruct the client to report to the provider any indications of dimpling, puckered skin, rashes or scaling of the skin, or nipple discharge. These findings, or any other changes, warrant further assessment by the provider. Nursing fundamentals questions with answers.

Why the other options are incorrect:

• The client should perform a BSE each month 4 to 7 days after menstruation ends. During this time of the menstrual cycle, the client’s breasts are less tender than at the beginning of the cycle. Performing the
• BSE when the breasts are less tender allows the client to perform a more thorough self-examination and increases the likelihood that they will detect changes or abnormalities.
• The client should gently squeeze each nipple during the BSE to check for any discharge. The nurse should instruct the client to report any discharge from their nipples to the provider. After childbirth, the client might have clear yellow discharge from the nipples. Otherwise, this finding warrants further assessment by the provider.

2) A nurse is planning to use the nursing process to care for a client who is experiencing grief. Which of the following actions should the nurse take first?

1. a) Establish whether the client’s grieving is healthy or complicated.
2. b) Develop client-specific goals and outcomes.
3. c) Incorporate the treatment into the client’s care.
4. d) Determine whether coping strategies were successful.

Answer and Explanation
Answer. a) Establishing whether the client’s grieving is healthy or complicated is the first step in the nursing process when caring for a client experiencing grief. This step falls under the assessment phase of the nursing process and is essential for understanding the client’s needs and planning appropriate care. Nursing fundamentals questions with answers.

Why the other options are incorrect:

• Developing client-specific goals and outcomes comes after the assessment phase in the planning stage of the nursing process. While important, it is not the first action the nurse should take in this situation.
• Incorporating the treatment into the client’s care occurs during the implementation phase of the nursing process and follows assessment and planning. This is not the first action.
• Determining whether coping strategies were successful is part of the evaluation phase of the nursing process, which occurs after the implementation of care. It is not the first step in this situation. Now, let’s proceed to the final question.

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3) A nurse is providing postmortem care for a client. Which of the following actions should the nurse take?

1. a) Remove the client’s dentures.
2. b) Increase the lights in the client’s room.
3. c) Place the head of the client’s bed flat.
4. d) Wash the client’s body.

Answer and Explanation

Answer. c) Placing the head of the client’s bed flat is a standard practice in postmortem care. This helps to prevent blood pooling and discoloration of the body. It is part of the process of preparing the body for family viewing or transfer to a mortuary.
Why the other options are incorrect:

• Removing the client’s dentures is not typically a part of immediate postmortem care. Dentures are usually left in place to maintain the natural shape of the client’s face, especially if the family will view the body.
• Increasing the lights in the client’s room is not a standard procedure in postmortem care. The focus is on creating a respectful and dignified environment, which may include dimming the lights if it contributes to a peaceful setting.
• Washing the client’s body is indeed a part of postmortem care. The body should be gently cleansed, which helps to present a respectful appearance and also serves to remove any soiling that occurred at the time of death. Nursing fundamentals questions with answers.

4) A nurse is assisting with teaching a class about stress. The nurse should include that which of the following is a manifestation of prolonged stress?

1. a) Impaired immune function
2. b) Decreased blood pressure
3. c) Hypoglycemia
4. d) Anemia

Answer and Explanation

Answer. a) Prolonged stress can lead to impaired immune function. When a person is stressed, the body’s stress response can suppress the immune system, making it less effective at fighting off infections. This is because stress hormones like cortisol can inhibit the production and function of white blood cells, such as lymphocytes, which are crucial for the immune response. Additionally, chronic stress can lead to inflammation and reduce the body’s ability to respond to immunological challenges, increasing the risk of illness and infection.

Why the other options are incorrect:

• Decreased blood pressure is not typically a manifestation of prolonged stress. In fact, stress can lead to increased blood pressure due to the release of stress hormones that cause vasoconstriction and an increase in heart rate. Over time, this can contribute to hypertension and cardiovascular problems.
• Hypoglycemia, or low blood sugar, is not a direct manifestation of prolonged stress. However, stress can affect blood sugar levels. For individuals with diabetes, stress can make it harder to control blood sugar as stress hormones can cause blood sugar levels to rise. In non-diabetic individuals, stress typically does not cause hypoglycemia.
• Anemia, a condition characterized by a lack of healthy red blood cells, is not a direct result of prolonged stress. Anemia can be caused by a variety of factors, including nutritional deficiencies, chronic diseases, or genetic conditions, but it is not commonly linked to stress. Nursing fundamentals questions with answers.

5) A nurse is reinforcing teaching regarding bladder retraining with a client who has urinary incontinence. Which of the following statements by the client indicated an understanding of the teaching?

1. a) I should go to the bathroom whenever I feel the urge to void.
2. b) I will increase my intake of drinks that contain citrus juices.
3. c) I will keep a diary of my voiding patterns each day.
   d) I will limit my fluid intake between the hours of 10:00 a.m. and 2:00 p.m.”
   Answer and Explanation

Answer. c) I will keep a diary of my voiding patterns each day.

In order to help track the effectiveness of bladder retraining, the client should keep a diary of their voiding patterns each day. This will not only assist in evaluating the effectiveness of the retraining program but will make the client more aware of usual voiding times to help avoid instances of incontinence.
Why the other options are incorrect:

• During initial bladder training, the client should go to the bathroom to void at regularly set intervals. Initially, the client should attempt to restrict voiding to once every 2 to 3 hr during waking hours and every 4 to 6 hr during the night
• The client should avoid excessive intake of beverages containing caffeine, citrus juices, and artificial sweeteners to prevent urinary frequency and
• The client should consume liquids between the hours of 0600 and 1800 to promote urinary continence. Limiting fluid intake overnight and taking prescribed diuretics in the early morning will help the client to prevent incontinence during the night.

6) A nurse is performing a straight catheterization of a client in order to obtain a urine specimen for culture and sensitivity. Which of the following actions should the nurse make?

1. a) Collect urine specimen from the catheter port.
2. b) Use a sterile specimen container for collection.
3. c) Ensure sterile water is used to inflate the balloon.
4. d) Unwrap the catheter kit before washing the client’s perineal area. –

Answer and Explanation

Answer. b) Use a sterile specimen container for collection.

When collecting a urine specimen via straight catheterization, it is important to use a sterile specimen container to maintain the integrity of the sample and prevent contamination. Using a non-sterile container can introduce bacteria and affect the accuracy of the culture and sensitivity results.

The other options mentioned are incorrect: 

• Using sterile water to inflate the balloon: This action is relevant when inflating the balloon of an indwelling urinary catheter, but in a straight catheterization, there is no balloon involved.
• Instructing the client to clean from front to back with an antiseptic solution: This instruction is appropriate for cleaning the urethral meatus before inserting an indwelling urinary catheter, but in a straight catheterization, the nurse performs the procedure using sterile technique and does not require the client to clean themselves.
• Collecting urine from the catheter’s port: In a straight catheterization, the nurse collects urine directly from the catheter tube using a sterile syringe or collection container, rather than from a separate port.

7) A nurse on a pediatric unit is teamed with assistive personnel (AP) for the upcoming shift. Which of the following assignments is within the range of function for the AP?

1. a) Feeding formula to an infant
2. b) Evaluating an adolescent’s understanding of dietary needs

Answer and Explanation

Answer. a) Feeding formula to an infant

• When determining who can perform a certain task, the nurse should assign clients based on the legal scope of practice of available personnel.
• Formula-feeding an infant is an appropriate task for the nurse to delegate to the AP.
• When determining who can perform a certain task, the nurse should assign clients based on the legal scope of practice of available personnel.
• Evaluation is part of the nursing process and requires professional education. It is not an appropriate task to delegate to an AP.
• When determining who can perform a certain task, the nurse should assign clients based on the legal scope of practice of available personnel.
• Providing instruction requires assessment of the client’s ability and readiness to learn. It is not an appropriate task to delegate to an AP.
• When determining who can perform a certain task, the nurse should assign clients based on the legal scope of practice of available personnel.
• Interpreting data is part of the nursing process and requires professional education. It is not an appropriate task to delegate to an AP

8) A nurse is providing end-of-life care to a client who has a metastatic lung cancer. Which of the following interventions should the nurse take to support the client’s family? Nursing fundamentals questions with answers.

1. a) Discourage family members from long visits so the client can rest.
2. b) Avoid discussing the manifestations of impending death with the client’s family.
3. c) Encourage family members to feed the client.
4. d) Encourage the family to offer the client a back massage. –

Answer and Explanation

Answer. d) Encourage the family to offer the client a back massage.

• The nurse should encourage the client’s family to continue to touch the client through the use of massage, holding the client’s hand, or brushing the client’s hair because this provides reassurance and comfort for both client and family.

The other options mentioned are incorrect: 

• The nurse should encourage family members to remain with a client who is at the end of life. This can involve making exceptions to visitation policies and providing privacy for the family. Supporting the grieving family is important during end-of-life care.
• The nurse should discuss manifestations of impending death with the client’s family to reduce anxiety, stress, and fear.
• The nurse should reinforce with the client’s family that, in the last days of life, clients often develop anorexia or feel nauseated by food, and eating can cause pain and discomfort. In addition, the nutrients in food are not able to be absorbed as the client’s body is shutting down.

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9) A nurse is preparing to transfer a client who has unilateral weakness from the bed to a bedside commode. Which of the following pieces of equipment should the nurse use to transfer the client?

1. a) Mechanical lift
2. b) Quad cane
3. c) Slide board
4. d) Walker

Answer and Explanation

Answer. b) Quad cane

• The nurse should provide a quad cane for a client who has unilateral weakness because it promotes mobility and independence while maintaining safety. The quad cane provides more support than a traditional cane.

The other options mentioned are incorrect: 

• The nurse should use a mechanical lift to transfer a client who is unable to assist the nurse. The nurse should not lift more than 15.88 kg (35 lb) of the client’s weight without the use of an assistive device in order to reduce the risk of injury to the nurse and maintain safety for the client.
• The nurse should use a slide board to transfer a client from the bed to a stretcher. The slide board helps to reduce friction while moving a client. The slide board is placed under a draw sheet for a client who is lying supine.
• The nurse should provide a walker for a client who has adequate strength in both arms to move the walker forward. A client who has unilateral weakness cannot perform this function and requires a different piece of equipment for assistance when moving from the bed to a bedside commode.

10) A nurse is collecting data from a client who has an acute infection and is shivering. The client’s temperature is 40.2 C (104.4 F). Which of the following actions should the nurse take?

1. a) Give the client a cold sponge bath.
2. b) Bathe the client with an alcohol and water solution.
3. c) Request a prescription for an antipyretic medication.
4. d) Apply ice packs directly to the skin of client’s groin area.

Answer and Explanation

Answer. c) Request a prescription for an antipyretic medication.

• The nurse should implement actions to reduce the client’s body temperature without causing the client to experience further shivering. Methods of restoring a normal body temperature include the administration of antipyretics like ibuprofen and acetaminophen. Antipyretic medications serve to increase the heat lost by the client’s body, which helps to reduce fever. Antipyretics can be used along with a hypothermia blanket and a bath sheet as a skin barrier to achieve additional temperature reduction.

The other options mentioned are incorrect: 

• Give the client a cold sponge bath. The nurse should avoid giving the client a cold sponge bath because this action could increase the client’s shivering. If a sponge bath is used, the bath should be performed with tepid water. However, this therapy can increase the risk of shivering, which is counterproductive to restoration of a normal body temperature.
• Bathe the client with an alcohol and water solution. The nurse should avoid bathing the client with an alcohol and water solution. This action is not recommended because of the risk of increased shivering, which is counterproductive to restoration of a normal body temperature. The alcohol in the bath can also remove moisture from the client’s skin.
• Apply ice packs directly to the skin of client’s groin area. The nurse should avoid applying ice packs to the client’s groin and axillae. This action is not recommended because of the risk of increased shivering, which is counterproductive to restoration of a normal body temperature. There should always be a cloth barrier between ice packs and the client’s skin to insulate the skin from damage that can occur due to the extreme cold.

11) A nurse is caring for a client who states, “I did not take my medication because my partner forgot to remind me.” The nurse should identify that the client is demonstrating which of the following defense mechanisms?

1. a) Identification
2. b) Denial
3. c) Displacement
4. d) Rationalization

Answer and Explanation

Answer. d) Rationalization. Rationalization is a defense mechanism where the person uses logical or plausible explanations to justify or excuse their actions or behaviors, to avoid facing the true motives or reasons.

The other options mentioned are incorrect: 

• Identification is a defense mechanism where the person adopts the characteristics or behaviors of someone else, usually someone more powerful or successful, to cope with feelings of inadequacy or insecurity.
• Denial is a defense mechanism where the person refuses to accept or acknowledge the reality of a situation or a problem, to avoid dealing with the negative emotions or consequences.
• Displacement is a defense mechanism where the person transfers their feelings or impulses from the original source to a less threatening or more acceptable one, to reduce the anxiety or guilt.