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QUESTION #1
Fundamentals of Nursing Exam 1 Fundamentals
The nurse assesses a client’s wound and determines the exudate to be purulent. Which of the following actions should the nurse take to interrupt the portal-of-exit link in the chain of infection?
A Wash the hands before providing care to a client.
B Position a commode next to a client’s bed.
C Provide education about a balanced diet.
D Change the dressing when it is soiled.

Explanations

A
Hand hygiene interrupts the mode of transmission, not the portal of exit. It does not stop organisms from leaving the wound
B
This addresses elimination convenience and safety, not infection control. It does not affect organism exit from the wound.
C
Nutrition supports immunity but does not interrupt the chain of infection. It has no effect on the portal of exit.
D
Covering and changing soiled dressings contain wound drainage and prevent organisms from leaving the body. This directly interrupts the portal of exit.
QUESTION #2
Fundamentals of Nursing Exam 1 Fundamentals
A client has a wound that is healing by secondary intention. Which solution to cleanse the wound and dressing should the nurse expect will be prescribed to support wound healing?
A Normal saline and a gauze dressing
B Normal saline and a wet-to-moist dressing
C Povidone-iodine and a dry sterile dressing
D Half peroxide and half normal saline and a wet-to-dry dressing

Explanations

A
Dry gauze does not maintain a moist wound environment. Moisture is needed to promote granulation tissue in secondary intention healing.
B
Normal saline is noncytotoxic, and wet-to-moist dressings maintain a moist environment that supports granulation and epithelialization. This is ideal for secondary intention wounds.
C
Povidone-iodine is cytotoxic to healing tissue and can delay wound healing. Dry dressings also inhibit granulation.
D
Hydrogen peroxide damages healthy tissue, and wet-to-dry dressings are used for debridement, not ongoing healing.
QUESTION #3
Fundamentals of Nursing Exam 1 Fundamentals
The nurse is caring for a group of hospitalized clients. Which should the nurse do first to prevent client infections?
A Provide small bedside bags to dispose of used tissues.
B Encourage staff to avoid coughing near clients.
C Administer antibiotics as prescribed.
D Identify clients at risk.

Explanations

A
Providing tissue disposal helps reduce spread, but it is a specific intervention implemented after risk is recognized. It is not the first step.
B
Encouraging cough etiquette is important, but broad prevention begins with knowing who is most vulnerable. This is not the initial priority.
C
Antibiotics treat infection; they do not prevent infection in most cases. Prevention requires assessment before treatment.
D
Identifying clients at risk allows targeted prevention strategies to be applied appropriately. Assessment always precedes intervention.
QUESTION #4
Fundamentals of Nursing Exam 1 Fundamentals
The nurse is educating a client about immunity. Which client statement reflects an understanding of how vaccines provide protection against pathogens?
A “The vaccine antibodies surround and destroy the virus.”
B “My body produces antigens to fight the pathogens.”
C “My cells are stimulated to produce antibodies.”
D “The vaccine reacts to the virus to destroy it.”

Explanations

A
Vaccines do not provide antibodies that directly destroy viruses (with rare exceptions like passive immunity). Protection comes from the body’s own immune response.
B
The body produces antibodies, not antigens, to fight pathogens. Antigens are parts of pathogens or vaccines that trigger the immune response.
C
Vaccines stimulate the immune system to produce antibodies and memory cells. This allows faster protection upon future exposure.
D
Vaccines do not directly react with or destroy viruses. They prime the immune system instead.
QUESTION #5
Fundamentals of Nursing Exam 1 Fundamentals
The nurse is caring for a client with ringworm. Which statement by the client indicates they understand the mode of transmission?
A “I need to wear gloves when scooping the litter box.”
B “I will wear gloves when playing with my kitten.”
C “I will avoid undercooked meat from now on.”
D “I need to stay at home until I am healed.”

Explanations

A
Wearing gloves for the litter box relates to toxoplasmosis risk, not ringworm transmission. Ringworm is not spread via cat feces.
B
Ringworm is a fungal infection spread by direct contact with infected animals or people. Wearing gloves when handling a kitten helps prevent transmission.
C
Avoiding undercooked meat is related to foodborne illnesses, not fungal skin infections. This does not address ringworm spread.
D
Ringworm does not require strict isolation at home. Transmission is prevented with hygiene and avoiding direct contact.
QUESTION #6
Fundamentals of Nursing Exam 1 Fundamentals
Which condition places a client at the highest risk for developing an infection?
A Implantation of a prosthetic device
B Burns over more than 20% of the body
C Presence of an indwelling urinary catheter
D More than two puncture sites from laparoscopic surgery

Explanations

A
Prosthetic devices increase infection risk, but the risk is localized and generally controlled with sterile technique and prophylaxis. It is not the highest risk listed.
B
Large burns destroy the skin barrier and impair immune function, creating a major portal for infection. This places the client at extremely high risk for systemic infection.
C
Catheters increase infection risk, but the risk is lower and more localized compared to extensive burns.
D
Small surgical punctures pose minimal infection risk when compared with major tissue damage.
QUESTION #7
Fundamentals of Nursing Exam 1 Fundamentals
The nurse is obtaining a client’s blood pressure. Which information is most important for the nurse to document?
A Staff member who took the blood pressure
B Client’s tolerance of having the blood pressure taken
C Client’s body position if the client is not in a sitting position
D Which head of a dual-head stethoscope was used to obtain the reading

Explanations

A
The identity of the staff member is not clinically relevant to interpreting the blood pressure reading. It does not affect accuracy.
B
Client tolerance is not necessary to interpret or trend blood pressure values. It is not essential documentation.
C
Body position significantly affects blood pressure readings. Documenting position ensures accurate interpretation and comparison of readings.
D
The stethoscope head used does not influence the recorded blood pressure value. This information is not clinically necessary.
QUESTION #8
Fundamentals of Nursing Exam 1 Fundamentals
The nurse is working with an unlicensed assistant. Which of the following tasks can the nurse assign to the assistant?
A Auscultation of breath sounds
B Auscultation of apical pulse
C Inspection of dressing for type of drainage
D Inspection of IV site for infiltration

Explanations

A
Auscultation of breath sounds requires assessment and interpretation. This task must be performed by a licensed nurse.
B
Counting an apical pulse is a routine, standardized skill that can be delegated when the assistant is trained. The nurse remains responsible for interpreting the findings.
C
Identifying the type of drainage requires assessment judgment, not just observation. This is a nursing responsibility.
D
Assessing an IV site for infiltration requires clinical judgment and decision-making. It should not be delegated to unlicensed personnel.
QUESTION #9
Fundamentals of Nursing Exam 1 Fundamentals
Which is common to the collection of all specimens for culture and sensitivity tests, regardless of their source?
A Preservative media must be used.
B Two specimens should be obtained.
C Surgical asepsis must be maintained.
D A morning specimen should be collected.

Explanations

A
Some specimens require transport media, but not all cultures use preservative media. This is source-dependent.
B
Multiple specimens are not always required for culture and sensitivity testing. One properly collected specimen is often sufficient.
C
Sterile technique is essential for all culture collections to prevent contamination and ensure accurate results. This applies regardless of specimen source.
D
Morning specimens are required only for certain tests, such as sputum or urine studies. This is not universal.
QUESTION #10
Fundamentals of Nursing Exam 1 Fundamentals
The emergency department nurse is caring for a client who is diagnosed with hypothermia. Which factor present in the client’s history may have precipitated this condition?
A Heatstroke
B Inability to sweat
C Excessive exercise
D High alcohol intake

Explanations

A
Heatstroke is associated with hyperthermia, not hypothermia. It represents excessive heat retention.
B
Lack of sweating impairs heat loss and predisposes to hyperthermia. It does not cause hypothermia.
C
Exercise increases body heat production. It does not typically lead to hypothermia.
D
Alcohol causes peripheral vasodilation, increasing heat loss and impairing temperature regulation. It is a common risk factor for hypothermia.
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