Fundamentals of Nursing
Which action occurs during the implementation phase of ADPIE?
A. Collecting data
B. Setting goals
C. Administering medication
D. Evaluating outcomes
C. Administering medication
A patient with chest pain is suspected of having a Myocardial Infarction. Which medication should the nurse administer first?
A. Morphine
B. Oxygen
C. Nitroglycerin
D. Aspirin
A nurse is assessing a patient 1 hour after delivery. The uterus is boggy and soft. What is the priority nursing action?
A. Notify the provider
B. Massage the fundus
C. Administer pain medication
D. Encourage breastfeeding
B. Massage the fundus
A patient with ARDS is on mechanical ventilation. Which position improves oxygenation the most?
A. Supine
B. Trendelenburg
C. Prone
D. High-Fowler’s
C. Prone
Which of these snacks should a patient on MAOIs avoid?
A. Cottage cheese and fresh strawberries
B. Salami and aged parmesan cheese
C. Apple slices with peanut butter
D. Yogurt and blueberries
B. Salami and parmesan cheese
A nurse is caring for a patient who reports shortness of breath. What is the priority action by the nurse?
A. Offer the patient water
B. Raise the head of the bed
C. Document the finding
D. Provide patient education
B. Raise the head of the bed
A patient is taking Lisinopril. Which side effect should the nurse monitor?
A. Dry cough
B. Bradycardia
C. Hyperglycemia
D. Tinnitus
A. Dry cough
Which fetal heart rate pattern suggests fetal distress?
A. Early decelerations
B. Variable decelerations
C. Late decelerations
D. Accelerations
C. Late decelerations
A patient with traumatic brain injury has an ICP monitor. The nurse notes:
ICP 24 mmHg
BP 150/90
HR 55
Which intervention is highest priority?
A. Administer osmotic diuretic
B. Elevate HOB 30°
C. Maintain head midline
D. Hyperventilate patient
A. Mannitol (Osmotic Diuretic)
Which behavior is an example of a positive symptom of schizophrenia?
A. Flat affect
B. Social withdrawal
C. Hallucinations
D. Anhedonia
C. Hallucinations
Which infection requires a negative pressure room?
A. MRSA
B. TB
C. C.Diff
D. Influenza
B. TB
A patient is prescribed Ferrous Sulfate. Which statement indicates correct understanding?
A. “I will take this medication with milk.”
B. “I should take this with orange juice.”
C. “I will stop taking it if my stool turns dark.”
D. “I should take it only at bedtime.”
B. I should take this with orange juice
Which condition is a contraindication for live vaccines?
A. Mild cold
B. Low-grade fever
C. Severe immunodeficiency
D. Previous mild rash
C. Severe Immunideficiency
Patient with muffled heart sounds, hypotension, distended neck veins. First intervention?
A. Administer fluids
B. Prepare for pericardiocentesis
C. Oxygen therapy
D. Give vasopressors
B. Prepare for pericardiocentesis
A patient is prescribed SSRIs for depression. Which statement indicates correct understanding?
A. “I can stop taking the medication once I feel better.”
B. “I may not notice improvement for 4–6 weeks.”
C. “SSRIs will make me sleep more at first.”
D. “I should avoid talking to my therapist while on SSRIs.”
B. No improvement for weeks
Which interventions prevent pressure injuries?
A. Reposition every 2 hours
B. Keep skin clean and dry
C. Massage reddened areas
D. Use pressure-relieving devices
E. Encourage mobility
A, B, D, E
6. Pharmacology – Insulin
Which insulin has the fastest onset?
A. Insulin Glargine
B. Regular Insulin
C. NPH Insulin
D. Insulin Lispro
D. Insulin Lispro
A newborn is diagnosed with Tetralogy of Fallot. Which clinical sign is expected?
A. Diaphoreses
B. Cyanosis
C. Bounding peripheral pulses
D. Bradycardia
B. Cyanosis
Which is included in the first hour sepsis bundle? (SATA)
A. Obtain blood cultures
B. Administer broad-spectrum antibiotics
C. Give IV fluids 30 mL/kg
D. Monitor lactate
E. Start norepinephrine
A, B, C, D
Patient asks about ECT. Which statement is correct?
A. “I’ll be awake and alert.”
B. “I may experience temporary memory loss.”
C. “I can drive home after the procedure.”
D. “It permanently cures mental illness.”
B. Memory loss
Which patient is at the highest risk for falls?
A. A 25-year-old with a fractured leg
B. A 40-year-old with pneumonia
C. A 78-year-old taking sedative medications
D. A 50-year-old with hypertension
C. A 78 yr old taking sedative medications
A nurse is assessing a patient admitted. The nurse notes the following findings:
Muscle tremors
Hyperactive deep tendon reflexes
Cardiac dysrhythmias
Positive Chvostek sign
Seizure activity
Which electrolyte imbalance should the nurse suspect?
A. Hypokalemia
B. Hypomagnesemia
C. Hypernatremia
D. Hypercalcemia
B. Hypomagnesemia
A 38-week patient presents with:
Sudden severe abdominal pain
Dark vaginal bleeding
Firm, tender uterus
FHR 80 bpm
Which action is highest priority?
A. Start IV fluids
B. Monitor vital signs
C. Prepare for emergency cesarean
D. Administer pain medication
C. Prepare for emergency C-section
What does a positive Murphy’s sign indicate?
A. Liver failure
B. Gallbladder inflammation
C. Pancreatitis
D. Appendicitis
B. Gallbladder Inflammation
Patient on haloperidol reports stiffness and tremors. Priority action?
A. Stop medication
B. Document findings
C. Administer anticholinergic as prescribed
D. Reassure patient symptoms are normal
C. Anticholinergics