EXACT Clinical Nursing Fundamental Exam practice questions with answers from nursing exams. Students report word-for-word matches with actual tests.
Nursing Exams
Detailed Answer Explanations Well-structured questions covering all topics, accompanied by organized images.
Purchase For $30/monthEXACT Clinical Nursing Fundamental Exam practice questions with answers from nursing exams. Students report word-for-word matches with actual tests.
A client with a viral upper respiratory infection tells the nurse, "I am so angry because the nurse practitioner would not give me any antibiotics." What would be the most appropriate response by the nurse
"Let me talk to the provider and see what we can do."
"I understand your frustration. You need an antibiotic .. "
"Let me teach you about antibiotics and their usage."
"Why do you think you need an antibiotic?"
The correct answer is C: Let me teach you about antibiotics and their usage.
Explanation of the Correct Answer:
This response is appropriate because it provides patient education about the proper use of antibiotics. Viral infections, such as a viral upper respiratory infection (common cold), do not respond to antibiotics, which are only effective against bacterial infections. Educating the patient helps prevent the misuse of antibiotics, reduces antibiotic resistance, and aligns with evidence-based practice. This approach also acknowledges the patient's frustration while guiding them toward a better understanding of their condition.
Explanation of Incorrect Options:
A) Let me talk to the provider and see what we can do.– This response reinforces the patient’s misconception that antibiotics might be necessary. It also undermines the provider's clinical judgment, as the nurse practitioner has already determined that antibiotics are not needed.
B) I understand your frustration. You need an antibiotic . – This is incorrect because it provides false information. The patient does not need an antibiotic for a viral infection, and this response goes against proper medical guidelines.
C) Why do you think you need an antibiotic? – While this response encourages the patient to express their concerns, it may come across as challenging or dismissive rather than supportive and educational. It does not directly address the patient’s frustration or correct their misunderstanding.
Summary:
The best response is "Let me teach you about antibiotics and their usage." This answer educates the patient about why antibiotics are not effective for viral infections and promotes appropriate medication use. The other options either provide misinformation, fail to address the patient's misunderstanding, or undermine the provider’s decision.
During a health history interview, a client tells the nurse that they do not feel that they completely empty the bladder when they void. How would the nurse report these findings to the provider
Patient reports urinary frequency.
Patient has an enlarged prostate.
"Patient reports urinary retention.
Patient with complaints of urinary incontinence.
Correct Answer C: Patient reports urinary retention.
Rationale:
Urinary retention is the inability to completely empty the bladder, which aligns with the client’s report of not feeling like they completely empty their bladder when they void. This condition can be caused by an enlarged prostate, neurological issues, medications, or bladder dysfunction.
Why the Other Options Are Incorrect:
Patient reports urinary frequency.
Urinary frequency refers to frequent urination, not difficulty emptying the bladder.
The patient did not report increased frequency, only incomplete bladder emptying.
Patient has an enlarged prostate.
While an enlarged prostate (BPH) is a common cause of urinary retention in men, the nurse cannot diagnose the condition.
The nurse should report symptoms rather than assume a medical diagnosis
Patient with complaints of urinary incontinence.
Urinary incontinence is involuntary urine leakage, which is different from the sensation of incomplete bladder emptying.
The patient did not report leaking urine, so this is inaccurate.
Summary:
The correct way to report the patient’s concern is "Patient reports urinary retention," as it accurately reflects their symptom of incomplete bladder emptying without assuming a diagnosis.
Why is deep breathing and coughing important after surgery
It helps prevent lung complications such as atelectasis and pneumonia.
It reduces the risk of bleeding at the surgical site.
It eliminates the need for pain medication by promoting relaxation.
It is only necessary for patients who have undergone lung surgery.
Correct Answer:
A. It helps prevent lung complications such as atelectasis and pneumonia.
Explanation of the Correct Answer:
After surgery, patients are at increased risk of lung complications, particularly atelectasis (lung collapse) and pneumonia due to reduced mobility, anesthesia effects, and pain-related shallow breathing. Deep breathing and coughing exercises are essential to prevent these issues by:
Expanding the Lungs (Preventing Atelectasis):
During surgery, anesthesia causes shallow breathing and reduced lung expansion, leading to lung collapse (atelectasis).
Deep breathing exercises fully inflate the lungs, keeping the alveoli open and functional.
Clearing Mucus (Preventing Pneumonia):
Postoperative patients may produce excess mucus due to intubation, anesthesia, or lying in bed for prolonged periods.
Coughing helps clear secretions, reducing the risk of mucus accumulation that can lead to infection (pneumonia).
Improving Oxygenation and Circulation:
Deep breathing enhances oxygen delivery to tissues, promoting healing and recovery.
It also prevents hypoxia (low oxygen levels), which can cause complications such as confusion, dizziness, or delayed wound healing.
Reducing Postoperative Complications:
Engaging in incentive spirometry (a device-assisted deep breathing exercise) improves lung expansion and strengthens respiratory muscles.
Preventing respiratory infections reduces hospital stays and improves patient outcomes.
Explanation of Incorrect Answers:
Option B: It reduces the risk of bleeding at the surgical site.
While proper breathing techniques can improve circulation, deep breathing and coughing are not directly linked to reducing surgical site bleeding. Instead, techniques like avoiding excessive movement and following post-op precautions help manage bleeding risks.
Option C: It eliminates the need for pain medication by promoting relaxation.
While deep breathing can help with relaxation and mild pain relief, it does not eliminate the need for pain medications. Most post-surgical patients still require analgesics to manage discomfort effectively.
Option D: It is only necessary for patients who have undergone lung surgery.
Deep breathing and coughing are important for all surgical patients, not just those who had lung procedures. Any patient receiving general anesthesia or on bed rest is at risk of lung complications, making these exercises essential regardless of the surgery type.
Summary:
Deep breathing and coughing exercises are crucial after surgery to prevent lung complications such as atelectasis and pneumonia. These techniques help expand the lungs, clear mucus, improve oxygenation, and enhance overall recovery. All surgical patients benefit from these exercises, not just those with lung-related procedures.
The provider has notified the patient and family that the patient will be started on parenteral nutrition. The patient asks if their family can go get them a milkshake since the provider said they could have nutrition. What is the best response by nurse at this time
"No, we will be putting in a tube that will go from your nose to your stomach to help you eat"
"Let me have the provider come explain to you what parenteral nutrition is."
"Unfortunately, no. We are going to be providing you with nutrition through your vein."
"Yes! I am sure you are excited to finally eat something, Let's set the head of the bed up."
The correct answer is C: Unfortunately, no. We are going to be providing you with nutrition through your vein.
Explanation of the Correct Answer:
Parenteral nutrition (PN) is a method of delivering nutrients intravenously (through the veins) rather than through the digestive system. It is used for patients who cannot absorb or tolerate oral or enteral (tube-fed) nutrition. This response directly and clearly explains to the patient that PN is not the same as eating food orally and that their nutrition will come through an IV, not through traditional means like drinking a milkshake.
Explanation of Incorrect Answers:
A) No, we will be putting in a tube that will go from your nose to your stomach to help you eat.– Incorrect
This describes enteral nutrition (feeding tube), not parenteral nutrition.
Enteral nutrition delivers food directly into the gastrointestinal (GI) tract, while PN bypasses the digestive system entirely.
B) BLet me have the provider come explain to you what parenteral nutrition is." – Incorrect
While it is important for the provider to educate the patient, the nurse is fully capable of explaining the basics of PN.
Delaying the explanation could lead to increased confusion or anxiety for the patient.
D) Yes! I am sure you are excited to finally eat something. Let's set the head of the bed up. – Incorrect
This response provides misinformation, as PN does not involve eating food orally.
It could cause false hope for the patient, leading to frustration when they realize they cannot consume food normally.
Summary:
Parenteral nutrition delivers nutrients intravenously, bypassing the digestive system. The best nursing response should be clear, direct, and informative, ensuring that the patient understands they will not be eating food orally but receiving nutrition through their veins.
Why are leg exercises and early ambulation important after surgery
They help prevent blood clots and improve circulation.
They increase pain levels and should be avoided.
They are only necessary for younger patients, not older adults.
They are only important for patients who had orthopedic surgery.
Correct Answer: They help prevent blood clots and improve circulation.
Explanation of the Correct Answer:
After surgery, patients are at an increased risk of developing deep vein thrombosis (DVT), pulmonary embolism, and poor circulation due to prolonged immobility. Leg exercises and early ambulation are critical in preventing these complications.
Key Benefits of Leg Exercises and Early Ambulation:
Prevents Blood Clots (DVT and Pulmonary Embolism):
Surgery increases the risk of venous thromboembolism (VTE) because immobility slows blood flow, leading to clot formation.
Leg exercises, such as ankle pumps and foot circles, help maintain blood circulation and prevent clotting.
Improves Circulation and Oxygenation:
Movement helps restore normal blood flow, preventing pooling in the legs.
It also enhances oxygen delivery to tissues, reducing complications like pressure ulcers and infections.
Reduces Postoperative Complications:
Early ambulation decreases the risk of pulmonary complications, such as pneumonia and atelectasis (lung collapse), by encouraging deep breathing.
It also helps with bowel motility, preventing postoperative constipation and ileus (intestinal blockage).
Speeds Up Recovery and Reduces Muscle Stiffness:
Staying in bed for too long leads to muscle atrophy and joint stiffness.
Movement restores muscle strength, reduces pain, and helps patients regain independence.
Explanation of Incorrect Answers:
Option B: They increase pain levels and should be avoided.
This is incorrect because while movement may cause mild discomfort initially, it actually helps reduce pain in the long term by improving circulation and preventing stiffness. Pain management strategies, such as analgesics and deep breathing exercises, can be used to facilitate early ambulation.
Option C: They are only necessary for younger patients, not older adults.
This is incorrect because older adults are actually at higher risk of complications, such as DVT, pneumonia, and muscle deconditioning, due to reduced mobility. Leg exercises and ambulation are especially critical in geriatric patients to prevent these risks.
Option D: They are only important for patients who had orthopedic surgery.
This is incorrect because early movement is beneficial for all surgical patients, not just those with orthopedic procedures. Even patients undergoing abdominal, cardiac, or neurological surgeries benefit from mobilization to prevent complications and promote recovery.
Summary:
Leg exercises and early ambulation are essential for postoperative recovery because they help prevent blood clots, improve circulation, reduce complications like pneumonia and constipation, and promote faster healing. While movement may cause mild discomfort, it is necessary for a safe and effective recovery, especially in older adults and high-risk patients.
Arterial blood gases on a client with pneumonia indicate the client is in respiratory acidosis. In order to best improve this acid-base imbalance, the nurse implements which of the following interventions
Restrict oral fluid intake to water only
Ambulate client in hallways twice a shift
Encourage frequent cough and deep breathing exercises
Medicate with nonopiate pain medication frequently for intercostal muscle pain
The correct answers are
C. Encourage frequent cough and deep breathing exercises and
D. Medicate with non-opiate pain medication frequently for intercostal muscle pain.
Explanation of the Correct Answers
The patient has respiratory acidosis, which means CO₂ retention due to inadequate ventilation. Pneumonia can cause hypoventilation by increasing lung secretions, leading to poor gas exchange. The goal is to improve ventilation and gas exchange to eliminate CO₂.
C. Encourage frequent cough and deep breathing exercises
Correct because coughing and deep breathing help clear secretions, improve alveolar ventilation, and reduce CO₂ retention.
Incentive spirometry, repositioning, and breathing exercises (e.g., pursed-lip breathing) can improve oxygenation and ventilation.
D. Medicate with non-opiate pain medication frequently for intercostal muscle pain
Correct because pain can limit deep breathing and coughing, worsening CO₂ retention.
Non-opiate pain medications (e.g., acetaminophen, NSAIDs) help manage pain without causing respiratory depression, which opioids might worsen.
Explanation of Why the Other Options Are Incorrect
A. Restrict oral fluid intake to water only
Incorrect because pneumonia patients need adequate hydration to keep lung secretions thin and easier to clear.
Restricting fluids can lead to thicker mucus, worsening gas exchange and CO₂ retention.
B. Ambulate client in hallways twice a shift
Incorrect in the acute phase. While mobility is beneficial once the patient stabilizes, an acutely ill pneumonia patient may be too compromised to tolerate exertion.
The priority is to improve ventilation first (e.g., breathing exercises, secretion clearance) before encouraging ambulation.
E. Give magnesium
Incorrect unless the patient has hypomagnesemia.
Magnesium is important for muscle function, but it is not a primary treatment for respiratory acidosis.
Excess magnesium can cause respiratory depression, worsening CO₂ retention.
Summary
To correct respiratory acidosis in pneumonia, the priority is to improve ventilation by clearing lung secretions and ensuring deep breathing. The best interventions are encouraging cough and deep breathing (C) and treating pain (D) to allow for effective breathing.
The nurse has received a report for the following patients. Which patient should be seen first
89-year-old with dementia and NG tube with continuous tube feeding.
43-year-old with anorexia and nausea for two days who is tolerating a clear liquid diet.
73-year-old with hypoactive bowel sounds one day post cholecystectomy.
65-year-old who has dysphagia after suffering from a stroke who is NPO.
The correct answer is D: 65-year-old who has dysphagia after suffering from a stroke who is NPO.
Explanation of the Correct Answer:
This patient should be seen first because dysphagia (difficulty swallowing) after a stroke places them at high risk for aspiration, which can lead to aspiration pneumonia or airway obstruction. Ensuring that they are following NPO (nothing by mouth) orders and assessing for any signs of aspiration or respiratory distress is a priority for patient safety. In post-stroke patients, swallowing difficulties can worsen suddenly, making early assessment crucial.
Explanation of Incorrect Options:
A) 89-year-old with dementia and NG tube with continuous tube feeding – While an NG tube requires monitoring, continuous tube feeding is a standard intervention. If there were signs of intolerance (e.g., vomiting, abdominal distension, or aspiration risk), this patient might be prioritized higher. However, there is no immediate indication of distress or complication.
B) 43-year-old with anorexia and nausea for two days who is tolerating a clear liquid diet – This patient is stable since they are able to tolerate liquids. Mild anorexia and nausea do not pose an immediate life-threatening risk compared to aspiration risk in the stroke patient.
C) 73-year-old with hypoactive bowel sounds one day post-cholecystectomy – Hypoactive bowel sounds are a common postoperative finding, especially after abdominal surgery. While monitoring for paralytic ileus is necessary, this condition is not immediately life-threatening, and the patient does not have symptoms of bowel obstruction or distress.
D) Summary:
The 65-year-old post-stroke patient with dysphagia should be seen first due to the high risk of aspiration and respiratory complications. The other patients, while requiring monitoring, do not present with urgent or life-threatening conditions at this time.
A 36-year-old woman enters the emergency department with severe burns and cuts on her face after an auto accident in a car driven by her fiancé of 3 months. Three weeks later, her fiancé has not yet contacted her. The patient states that she is very busy and she is too tired to have visitors anyway. The patient frequently lies with her eyes closed and head turned away. What do these data suggest
There is no disturbance in self-concept.
This patient has ego strength and high self-esteem but may have a disturbance of body image.
The area of self-esteem has very low priority at this time and should be ignored until much later.
It is probable that there are disturbances in self-esteem and body image
Correct Answer D: It is probable that there are disturbances in self-esteem and body image.
Explanation of the Correct Answer:
The patient has suffered severe burns and cuts on her face, which likely impact her body image due to visible changes in her appearance.
The lack of contact from her fiancé for three weeks may contribute to feelings of rejection, abandonment, and low self-worth, indicating a disturbance in self-esteem.
Her behavior, such as lying with her eyes closed and turning her head away, suggests withdrawal, avoidance, and emotional distress, which are common signs of body image disturbance and low self-esteem.
Her statement about being "too tired" to have visitors may be a defense mechanism to avoid social interactions due to feelings of shame, embarrassment, or emotional pain.
Given these signs, it is highly probable that she is struggling with both self-esteem and body image issues, making this the most appropriate answer.
Explanation of Incorrect Answers:
A: There is no disturbance in self-concept.
Incorrect because the patient is exhibiting multiple signs of emotional distress, including withdrawal and avoidance behaviors.
Major physical trauma, especially facial injuries, frequently affects body image and self-concept.
The absence of a response from her fiancé may further impact her self-worth, making it unlikely that she has no disturbance in self-concept
B: This patient has ego strength and high self-esteem but may have a disturbance of body image.
Incorrect because there is no evidence that she has high self-esteem or strong ego strength.
While a disturbance in body image is likely, her withdrawal, avoidance, and possible emotional distress suggest that her self-esteem is also affected.
A person with high self-esteem would likely show more adaptive coping mechanisms and not avoid social interactions completely.
C: The area of self-esteem has very low priority at this time and should be ignored until much later.
Incorrect because self-esteem and body image disturbances should be addressed early, even while the patient is still in the recovery phase.
Ignoring emotional distress can lead to depression, anxiety, and poor adjustment to long-term changes in appearance and self-concept.
Holistic nursing care requires addressing both physical recovery and emotional well-being simultaneously.
Summary:
This patient is likely experiencing both self-esteem and body image disturbances due to her severe facial injuries and lack of contact from her fiancé. Her withdrawal, avoidance behaviors, and reluctance to have visitors indicate emotional distress. Nursing interventions should focus on assessing her emotional well-being, providing psychological support, and promoting a positive self-image early in the recovery process.
A patient has salmonella and diarrhea. The nurse suspects the potassium values may be dropping when the patient complains of
headache
leg cramps
nausea
burning with urination
The correct answer is B: leg cramps.
Explanation of the Correct Answer
B. Leg cramps
Correct because potassium (K⁺) is essential for muscle function, including skeletal muscle contraction.
A drop in potassium (hypokalemia) can cause muscle cramps, weakness, and spasms, commonly felt in the legs.
Diarrhea leads to excessive potassium loss, putting the patient at risk for hypokalemia.
Explanation of Why the Other Options Are Incorrect
A. Headache
Incorrect because headaches are not a classic symptom of hypokalemia.
Dehydration from diarrhea may cause a headache, but it is not a direct indicator of low potassium.
C. Nausea
Incorrect because nausea can occur for many reasons, including infection, dehydration, or electrolyte imbalances, but leg cramps are a more specific sign of hypokalemia.
D. Burning with urination
Incorrect because this is typically a symptom of a urinary tract infection (UTI) or bladder irritation, not hypokalemia.
Summary
When a patient with salmonella and diarrhea complains of leg cramps (B), the nurse should suspect dropping potassium levels (hypokalemia), as diarrhea causes potassium loss.
A 70-year-old patient who has had a number of strokes refuses further life-sustaining interventions, including artificial nutrition and hydration. She is competent, understands the consequences of her actions, is not depressed, and persists in refusing treatment. Her health care provider is adamant that she cannot be allowed to die this way, and her daughter agrees. An ethics consult has been initiated. Who would be the appropriate decision maker
The patient
The patient's daughter
The patient's health care provider
The ethics consult team
Correct Answer:
Option a: The patient
Explanation of the Correct Answer:
A competent adult has the legal and ethical right to refuse medical treatment, even if that treatment is life-sustaining.
This patient has demonstrated capacity (she understands her decision and its consequences), is not influenced by depression, and has persistently refused interventions.
Autonomy is a fundamental principle in medical ethics, which means the patient’s decision must be respected.
Even though the provider and daughter disagree, they cannot override the patient’s wishes.
Explanation of Incorrect Answers:
Option b: The patient's daughter
Family members do not have the authority to override a competent adult’s decision.
If the patient were incapacitated, a designated healthcare proxy or next of kin might make decisions, but this does not apply here.
Option c: The patient's health care provider
A physician’s role is to provide medical advice and treatment options, not to force interventions against a competent patient’s wishes.
If the provider cannot accept the decision, they may consult the ethics committee or transfer care to another provider.
Option d: The ethics consult team
An ethics committee provides guidance and recommendations, but it does not have the authority to make decisions for a competent patient.
Their role would be to facilitate discussions and ensure ethical considerations are addressed.
Summary:
The patient is the appropriate decision-maker because she is competent and has the right to refuse medical treatment, including life-sustaining interventions. Neither the daughter, healthcare provider, nor ethics committee has the authority to override her decision.
Trusted by thousands of nursing students worldwide for exam success.
