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Fundamentals Exam 1 NCLEX Practice Test Questions & Answers-A 52-year-old woman is admitted with dyspnea and discomfort in her left chest with deep breaths... [Show More] . She has smoked for 35 years and recently lost over 10 lbs. Her vital signs on admission are: HR 112, BP 138/82, RR 22, tympanic temperature 36.8° C (98.2° F), and oxygen saturation 94%. She is receiving oxygen at 2 L via a nasal cannula. Which vital sign reflects a positive outcome of the oxygen therapy? A. Temperature: 37° C (98.6° F) B. Radial pulse: 112 C. Respiratory rate: 24 D. Oxygen saturation: 96% E. Blood pressure: 134/78 - D. Oxygen saturation: 96% The licensed practice nurse (LPN) provides you with the change-of-shift vital signs on four of your patients. Which patient do you need to assess first? A. 84-year-old man recently admitted with pneumonia, RR 28, SpO2 89% B. 54-year-old woman admitted after surgery for fractured arm, BP 160/86 mm Hg, HR 72 C. 63-year-old man with venous ulcers from diabetes, temperature 37.3° C (99.1° F), HR 84 D. 77-year-old woman with left mastectomy 2 days ago, RR 22, BP 148/62 - A. 84-year-old man recently admitted with pneumonia, RR 28, SpO2 89% A 55-year-old female patient was in a motor vehicle accident and is admitted to a surgical unit after repair of a fractured left arm and left leg. She also has a laceration on her forehead. An intravenous (IV) line is infusing in the right antecubital fossa, and pneumatic compression stockings are on the right lower leg. She is receiving oxygen via a simple face mask. Which sites do you instruct the nursing assistant to use for obtaining the patient's blood pressure and temperature? A. Right antecubital and tympanic membrane B. Right popliteal and rectal C. Left antecubital and oral D. Left popliteal and temporal artery - A. Right antecubital and tympanic membrane The nurse observes a nursing student taking a blood pressure (BP) on a patient. The nurse notes that the student very slowly deflates the cuff in an attempt to hear the sounds. The patient's BP range over the past 24 hours is 132/64 to 126/72 mm Hg. Which of the following BP readings made by the student is most likely caused by an incorrect technique? A. 96/40 mm Hg B. 110/66 mm Hg C. 130/90 mm Hg D. 156/82 mm Hg - C. 130/90 mm Hg As you are obtaining the oxygen saturation on a 19-year-old college student with severe asthma, you note that she has black nail polish on her nails. You remove the polish from one nail, and she asks you why her nail polish had to be removed. What is the best response? A. Nail polish attracts microorganisms and contaminates the finger sensor. B. Nail polish increases oxygen saturation. C. Nail polish interferes with sensor function. D. Nail polish creates excessive heat in sensor probe. - C. Nail polish interferes with sensor function. A patient has been hospitalized for the past 48 hours with a fever of unknown origin. His medical record indicates tympanic temperatures of 38.7° C (101.6° F) (0400), 36.6° C (97.9° F) (0800), 36.9° C (98.4° F) (1200), 37.6° C (99.6° F) (1600), and 38.3° C (100.9° F) (2000). How would you describe this pattern of temperature measurements? A. Usual range of circadian rhythm measurements B. Sustained fever pattern C. Intermittent fever pattern D. Resolving fever pattern - C. Intermittent fever pattern A patient presents in the clinic with dizziness and fatigue. The nursing assistant reports a slow but regular radial pulse of 44. What is your priority intervention? A. Request that the nursing assistant repeat the pulse check B. Call for a stat electrocardiogram (ECG) C. Assess the patient's apical pulse and evidence of a pulse deficit D. Prepare to administer cardiac-stimulating medications - C. Assess the patient's apical pulse and evidence of a pulse deficit Which patient is at highest risk for tachycardia? A. A healthy basketball player during warmup exercises B. A patient admitted with hypothermia C. A patient with a fever of 39.4° C (103° F) D. A 90-year-old male taking beta blockers - C. A patient with a fever of 39.4° C (103° F) A patient has been admitted for a cerebrovascular accident (stroke). She cannot move her right arm, and she has a right-sided facial droop. She is able to eat with her dentures in place and swallow safely. The nursing assistive personnel (NAP) reports to you that the patient will not keep the oral thermometer probe in her mouth. What direction do you provide to the NAP? A. Direct the NAP to hold the thermometer in place with her gloved hand B. Direct the NAP to switch the thermometer probe to the left sublingual pocket C. Direct the NAP to obtain a right tympanic temperature D. Direct the NAP to use a temporal artery thermometer from right to left - D. Direct the NAP to use a temporal artery thermometer from right to left The nursing assistive personnel (NAP) informs you that the electronic blood pressure machine on the patient who has recently returned from surgery following removal of her gallbladder is flashing a blood pressure of 65/46 and alarming. What is the correct order for care activities? 1. Press the start button of the electronic blood pressure machine to obtain a new reading. 2. Obtain a manual blood pressure with a stethoscope. 3. Check the patient's pulse distal to the blood pressure cuff. 4. Assess the patient's mental status. 5. Remind the patient not to bend her arm with the blood pressure cuff. A. 5, 3, 1, 4, 2 B. 3, 2, 1, 4, 5 C. 4, 1, 3, 2, 5 D. 1, 2, 4, 3, 5 E. 2, 3, 1, 4, 5 - C. 4, 1, 3, 2, 5 Which of the following patients are at most risk for tachypnea? (Select all that apply.) A. Patient just admitted with four rib fractures B. Woman who is 9 months' pregnant C. Adult who has consumed alcoholic beverages D. Adolescent waking from sleep E. Three-pack-per-day smoker with pneumonia - A. Patient just admitted with four rib fractures B. Woman who is 9 months' pregnant E. Three-pack-per-day smoker with pneumonia A healthy adult patient tells the nurse that he obtained his blood pressure in "one of those quick machines in the mall" and was alarmed that it was 152/72 when his normal value ranges from 114/72 to 118/78. The nurse obtains a blood pressure of 116/76. What would account for the blood pressure of 152/92? (Select all that apply.) A. Cuff too small B. Arm positioned above heart level C. Slow inflation of the cuff by the machine D. Patient did not remove his long-sleeved shirt E. Insufficient time between measurements - A. Cuff too small E. Insufficient time between measurements A patient is admitted for dehydration caused by pneumonia and shortness of breath. He has a history of heart disease and cardiac dysrhythmias. The nursing assistant reports his admitting vital signs to the nurse. Which measurements should the nurse reassess? (Select all that apply.) A. Right arm BP: 118/72 B. Radial pulse rate: 72 and irregular C. Temporal temperature: 37.4° C (99.3° F) D. Respiratory rate: 28 E. Oxygen saturation: 99% - B. Radial pulse rate: 72 and irregular D. Respiratory rate: 28 E. Oxygen saturation: 99% The nurse is explaining the appropriate methods for measuring an accurate temperate to an unlicensed assistive personnel (UAP). Which method, if noted by the UAP as being an appropriate method, indicated the need for further teaching? A. Taking a rectal temperature for a client who has undergone nasal surgery B. Taking an oral temperature for a client with a cough and nasal congestion C. Taking an axillary temperature for a client who has just consumed hot coffee D. Taking a temporal temperature on the neck behind the ear for a client who is diaphoretic - B. Taking an oral temperature for a client with a cough and nasal congestion [Show Less]
Fundamentals Exam 2 NCLEX Test Questions & Answers-Thirty-six hours after having surgery, a pt has a slightly elevated body temp and generalized malaise, a... [Show More] s well as pain and redness at the surgical site. Which intervention is most important to include in this pt's nursing care plan? a. document the findings and monitor the pt b. administer antipyretics, as ordered c. increase the frequency of assessment to every hour and notify the pt's primary care provider d. increase the frequency of wound care and contact the PCP for an antibiotic order - a. document the findings and monitor the pt A nurse caring patients in the PACU teaches a novice nurse how to assess and document wound drainage. Which statements accurately describe a characteristic of wound drainage? Select all that apply a. serous drainage is composed of the clear portion of the blood and serous membranes b. sanguineous drainage is composed of a large number of RBCs and looks like blood c. bright red sanguineous drainage indicates fresh bleeding and darker drainage indicates older bleeding d. purulent drainage is thin, cloudy, and watery and may have a musty or foul odor e. purulent drainage is thin, cloudy, and watery and may have a musty or foul odor f. serosanguineous drainage can be dark yellow or green depending on the causative organism - a. serous drainage is composed of the clear portion of the blood and serous membranes b. sanguineous drainage is composed of a large number of RBCs and looks like blood c. bright red sanguineous drainage indicates fresh bleeding and darker drainage indicates older bleeding d. purulent drainage is thin, cloudy, and watery and may have a musty or foul odor A pt who has a large abdominal wound suddenly calls out for help b/c she feels as though something is falling out of her incision. Inspection reveals a gaping open wound with tissue bulging outward. In which order should the nurse perform the following interventions? Arrange from first to last. a. notify the physician of the situation b. cover the exposed tissue with sterile towels moistened with sterile NSS c. place the pt in low Fowler's position - c. place the pt in low Fowler's position b. cover the exposed tissue with sterile towels moistened with sterile NSS a. notify the physician of the situation A pt, age 16, was in an automobile accident and received a would across her nose and cheek. After surgery to repair the wound, the pt says, "I am so ugly now." Based on this statement, what nursing diagnosis would be most appropriate? a. pain b. impaired skin integrity c. disturbed body image d. disturbed thought process - c. disturbed body image A pt is admitted with a non healing surgical wound. Which nursing action is most effective in preventing a wound infection? a. using sterile dressing supplies b. suggesting dietary supplements c. applying antibiotic ointment d. performing careful hand hygiene - d. performing careful hand hygiene A nurse who is changing dressings of post op pts in the hospital documents various phases of wound healing on the pt charts. Which statements accurately describe these stages? Select all that apply a. hemostasis occurs immediately after the initial injury b. a liquid called exudate is formed during the proliferative phase c. WBCs moe to the wound in the inflammatory phase d. Granulation tissue forms in the inflammatory phase e. during the inflammatory phase, the ppt has generalized body response f. A scar forms during the proliferative phase - a. hemostasis occurs immediately after the initial injury c. WBCs moe to the wound in the inflammatory phase e. during the inflammatory phase, the ppt has generalized body response The nurse assesses the wound of a pt who cut himself on the upper thigh with a chain saw. The nurse then documents the presence of biofilms in the wound. What is the effect of this condition on the wound? Select all that apply a. enhanced healing due to the presence of sugars and proteins b. delayed healing due to dead tissue present in the wound c. decreased effectiveness of antibiotics against the bacteria d. impaired skin integrity due to over hydration of the fells of the wound e. delayed healing due to cells dehydrating and dying f. decreased effectiveness of the pt's normal immune process - c. decreased effectiveness of antibiotics against the bacteria f. decreased effectiveness of the pt's normal immune process The nurse is cleaning an open abdominal wound that has unapproximated edges. What are the accurate steps in this procedure. Select all that apply a. use standard precautions or transmission-based precautions when indicated b. moisten a sterile gauze pad or swab with the prescribed cleansing agent and squeeze our excess solution c. clean the wound in full or half circles beginning on the outside working toward the center d. work outward from the incision in fines that are parallel to it from the dirty area to the clean area e. clean to at least one inch beyond the end of the new dressing if one is being applied f. clean to at least three inches beyond the wound if a new dressing is not being applied - a. use standard precautions or transmission-based precautions when indicated b. moisten a sterile gauze pad or swab with the prescribed cleansing agent and squeeze our excess solution e. clean to at least one inch beyond the end of the new dressing if one is being applied A nurse is developing a plan of care for an 86 YO woman who has bene admitted for right hip arthroplasty (hip replacement). Which assessment findings indicate a high risk for pressure ulcer development for this pt? Select all that apply a. the pt takes time to think about her response to questions b. the pt's age of 86 c. pt reports inability to control urine d. a schedule hip arthroplasty e. lab findings include BUN 12 (elderly normal 8-23 mg/dL) and creatinine .9 (adult female normal .61-1 mg/dL) f. pt reports increased pain in right hip when repositioning in bed or chair - b. the pt's age of 86 c. pt reports inability to control urine d. a schedule hip arthroplasty f. pt reports increased pain in right hip when repositioning in bed or chair A nurse is explaining to a pt the anticipated effect of the application of cold to an injured area. What response indicates that the pt understands the explanation? a. "I can expect to have more discomfort in the area where the cold is applied" b. "I should expect more drainage from the incision after the ice has been in place" c. "I should see less swelling and redness with the cold treatment" d. "My incision may bleed more when the ice is first applied" - c. "I should see less swelling and redness with the cold treatment" [Show Less]
Fundamentals Exam 3 NCLEX Test Questions & Answers (Explained)-A nurse is caring for a client who is at high risk for aspiration. Which of the following ac... [Show More] tions should the nurse take? A. Give the client thin liquids B. Instruct the client to tuck her chin while swallowing C. Have the client use a straw. D. Encourage the client to lie down and rest after meals - B exp.) tucking the chin when swallowing allows food to pass down the esophagus more easily A nurse is preparing a presentation about basic nutrients for a group of high school athletes. She should explain that which of the following nutrients provide the most energy? A. Fat B. Protein C. Glycogen D. Carbohydrates - D exp.) carbohydrates are the body's greatest energy source; providing energy for cells is their primary function. They provide glucose, which burns completely and efficiently without end products to excrete. They are also a ready source of energy, and they spare proteins for depletion. A nurse is caring for a client who requires a low-residue diet. The nurse should expect to see which of the following foods on the clients meal tray? A. Cooked barley B. Pureed broccoli C. Vanilla custard D. Lentil soup - C exp.) A low residue diet consists of foods that are low in fiber and easy to digest. Dairy products and eggs such as custard and yogurt, are appropriate. A nurse is caring for a client who weighs 80 kg (176 lbs) and 1.6 m (5 ft, 3 in tall) Calculate her body mass index (BMI) and determine whether this clients BMI indicates she is of a healthy weight, overweight, or obese. - BMI = weight (kg) / height (m2) Step 1: Clients weight (kg) and height (m) = 80 kg and 1.6 m Step 2: 1.6 X 1.6 = 2.56 m2 Step 3: 80/2.56 = 31.25 So this client is considered obese (BMI over 30 indicates obesity) A nurse in a senior center is counseling a group of older adults about their nutritional needs and considerations. Which of the following information should the nurse include? (Select all that apply). A. Older adults are more prone to dehydration than younger adults are B. Older adults need the same amount of most vitamins and minerals as younger adults do C. Many older men and women need calcium supplementation D. Older adults need more calories than they did when they were younger E. Older adults should consume a diet low in carbohydrates. - A exp.) sensations of thirst diminish with age, leaving older adults more prone to dehydration B exp.) requirements for vitamins and minerals do not change from middle to older adulthood C exp.) if older adults ingest insufficient calcium in the diet, the need supplements to help prevent bone demineralization (osteoporosis) A nurse is calculating the body mass index of a 35 year old male patient who is extremely obese. The patients height is 5'6 and his current weight is 325 lbs. What would the nurse document as his BMI? A. 50.5 B. 52.4 C. 54.5 D. 55.2` - BMI = weight in pounds (325) / height in inches (66) X height in inches (66) X 703 BMI = 52.4 A nurse is helping an overweight female patient to devise a meal plan to lose 2 pounds per week. How many calories would the patient need to deplete per day in order to accomplish this goal? A. 250 calories B. 500 calories C. 750 calories D. 1000 calories - D exp.) 1 lb (0.45 kg) of body fat equals about 3.500 calories. Therefore, to gain or lose 1 lb (0.45 kg) in a week, daily calorie intake should be increase or decreased by 500 cals a day so to lose or gain 2 lbs per week, the calorie intake should increase or decrease by 1000 cals a day A nurse is feeding an elderly patient who has dementia. Which intervention should the nurse perform to facilitate this process? A. Stroke the underside of the patients chin to promote swallowing B. Serve meals in different places at different times C. Offer a whole tray of various foods to choose from D. Avoid between-meal snacks to ensure hunger at mealtime - A exp.) to feed a patient with dementia, the nurse should stroke the underside of the patients chin to promote swallowing, serve meals in the same place and at the same time, provide one food item at a time since a whole tray may overwhelming and provide between-meal snacks that are easy to consume using the hands A 56 year old male patient who has COPD is refusing to eat. Which intervention would be most helpful in simulating his appetite? A. Administering pain meds after meals B. Encouraging food from home when possible C. Scheduling his respiratory therapy before each meal D. Reinforcing the importance of his eating exactly what is delivered to him - B. exp.) Food from home that the patient enjoys may stimulate him to eat. Pain medication should be given before meals, respiratory therapy should be scheduled after meals, and tells the patient what he must eat is no guarantee that he will comply A nurse is feeding a patient who is experiencing dysphagia. Which nursing intervention would the nurse initiate for this patient? A. Feed the patient solids first then liquids last B. Place the head of the bed at a 30 degree angle during feeding C. Puree all foods to a liquid consistency D. Provide a 30 minute rest period prior to mealtime - D. exp.) when feeding a patient who has dysphagia, the nurse should provide a 30 minute rest period prior to mealtime to promote swallowing; alternate solids and liquids when feeding the patient; sit the patient upright or, if on bedrest, elevate the head of the bed at a 90 degree angle; and initiate a nutrition consultant for diet modification and food size and/or consistency A nurse is evaluating patients to determine their need for total parenteral nutrition. (TPN) Which patients would be the best candidates for this type of nutritional support? Select all that apply A. A patient with irritable bowel syndrome who has intractable diarrhea. B. A patient with celiac disease not absorbing nutrients from the GI tract. C. A patient who is underweight and needs short term nutritional support D. A patient who is comatose and needs long term nutritional support E. A patient who has anorexia and refuses to take foods via the oral route F. A patient with burns who has not been able to eat adequately for 5 days - A, B, F A nurse is feeding a patient who states that she is feeling is nauseated and can't eat what is being offered. What would be the most appropriate initial action of the nurse in this situation? A. Remove the tray from the room B. Administer an antiemtetic and encourage the patient to take small amounts C. Explore with the patient why she does not want to eat her food D. Offer high-calorie snacks such as pudding and icecream - A exp.) the first action of the nurse when a patient ha nausea is to remove the tray from the room. The nurse may then offer small amounts of foods and liquids such as crackers or ginger ale. The nurse may also administer a prescribed antiemetic and try small amounts of food when it takes effect A 62 year old male patient has been admitted to the alcoholic referral unit in the local hospital. Based on an understanding of the effects of alcohol on the GI tract, which is a priority concern related to nutrition? A. Vitamin B malnutrition B. Obesity C. Dehydration D. Vitamin C deficiency - A exp.) the need for vitamin B is increased in alcoholics because these nutrients are used to metabolize alcohol, thus depleting their supply. A nurse is caring for a newly placed gastrostomy tube of a post op patient. Which nursing action is performed correctly? A. The nurse dips a cotton-tipped applicator into sterile saline solution and gently cleans around the insertion site B. The nurse wets a washcloth and washes the area around the tube with soap and water C. The nurse adjusts the external disk every 3 hours to avoid crusting around the tube D. The nurse tapes a gauze dressing over the site after cleaning it - A exp.) when caring for a new gastrostomy tube, the nurse would use a cotton tipped applicator dipped in sterile saline to gently cleanse the area, removing any crust or drainage. A nurse is assessing a patient who has been NPO prior to abdominal surgery. The patient is ordered a clear liquid diet for breakfast to advance to a house diet as tolerated. Which assessments would indicate to the nurse that the patient's diet should not be advanced? A. The patient consumed 75% of the liquids on her breakfast tray B. The patient tells you she is hungry C. The patients abdomen is soft, nondistended, with bowel sounds D. The patient reports fullness and diarrhea after breakfast. - D exp.) tolerance of diet can be assessed by the following: absence of nausea, vomiting and diarrhea; absence of feelings of fullness; absence of abdominal pain and distention; feelings of hunger; and the ability to consume at least 50-75% of the food on the meal tray A patient who is moved to a hospital bed following throat surgery is ordered to receive continuous tube feedings through a small-bore nasogastic tube. Following placement of the tube, which nursing action would the nurse initiate to ensure correct placement of the tube? A. Auscultate the bowel sounds B. Measure the gastric aspirate ph C. Measure the amount of residual in the tube D. order radiographic examination of the tube - D Which of the following nursing diagnoses would be most appropriate for a patient with a body mass index of 18? A. Risk for Imbalanced Nutrition: More Than Body Requirements B. Imbalanced Nutrition: More than Body Requirements C. Readiness for Enhanced Nutrition D. Imbalanced Nutrition: Less than Body Requirements - D exp.) BMI of 18 is considered underweight A nurse is inserting a nasogastric tube ordered for a patient to monitor bleeding in his GI tract. When the tube is being passed through the pharynx, the patient begins to cough and shows signs of respiratory distress. What would be the priority action of the nurse upon this assessment? A. Keep the tube in place and notify the primary HCP immediately B. Stop advancing the tube and pull it back into the nasal area C. Ask the patient if he wants the nurse to stop the procedure D. Call for help for perform CPR - B A nurse is administering a tube feeding for a patient who is post bowel surgery. When attempting to aspirate the contents, the nurse notes that the tube is clogged. What would be the nurses next action following this assessment? A. Use warm water and gentle pressure to remove the clog B. Use a stylet to unclog the tube C. Administer cola to unclog the tube D. Replace the tube with a new one - A A nurse performs surgical assessments of patients in an ambulatory care center. Which patient would the nurse report to the surgeon as possibly needing surgery to be postponed? A. A 19 year old patient who is vegan B. An elderly patient who takes daily nutritional drinks C. A 43 year old patient who takes gingko bilboa and an aspirin daily D. An infant who is breast feeding - C exp.) A patient taking gingko biloba (an herbal) aspirin and vitamin E may have to have surgery postponed due to an increase risk for excessive bleeding, because each of those substances have anticoagulant properties. A nurse is a providers office is evaluating a client who reports losing control of urine whenever she coughs, laughs, or sneezes. The client relates a history of three vaginal births, but no serious accidents or illnesses. Which of the following interventions should the nurse suggest for helping to control or eliminate the client's incontinence? (Select all that apply). A. Limit total daily fluid intake B. Decrease or avoid caffeine C. Take calcium supplements D. Avoid drinking alcohol E. Use the crede maneuver - B, D A client who has an indwelling catheter reports a need to urinate. Which of the following actions should the nurse take? A. Check to see whether the catheter is patent B. Reassure the client that it is not possible for her to urinate C. Recatheterize the bladder with a larger-gauge catheter D. Collect a urine specimen for analysis - A exp.) a clogging or kinked catheter causes the bladder to fill and stimulates the need to urinate A nurse is caring for a client who has a prescription for a 24 hr urine collection. Which of the following actions should the nurse take? A. Discard the first voiding B. Keep the urine in a single container at room temperature C. Ask the client to urinate and pour the urine into a specimen container D. Ask the client to urinate into the toilet, stop midstream, and finish urinating into the specimen container - A exp.) the nurse should discard the first voiding of the 24 hr urine specimen and note the time A nurse is reviewing factors that increase the risk of urinary tract infections with a client who has recurrent UTI's. Which of the following factors should the nurse include? (Select all that apply) A. Frequent sexual intercourse B. Lowering of testosterone levels C. Wiping from front to back D. Location of the urethra in relation to the anus E. Frequent catheterization - A, D, E A nurse is preparing to initiate a bladder-retraining program for a client who has incontinence. Which of the following actions should the nurse take? (Select all that apply) A. Establish a schedule of urinating prior to meal times B. Have the client record urination times C. Gradually increase urination intervals D. Remind the client to hold urine until the next scheduled urination time E. Provide a sterile container for urine - B, C, D A nurse caring for patients in a long-term care facility is often required to collect urine specimens from patients for lab testing. Which techniques for urine collection are performed correctly? (Select all that apply) A. The nurse catheterizes a patient to collect a sterile urine sample for routine urinalysis. B. The nurse collects a clean-catch urine specimen in the morning from a patient and stores it at room temperature until an afternoon pick up. C. The nurse collects a sterile urine specimen from the collection receptacle of a patient's indwelling catheter. D. The nurse collects about 3 mL of urine from a patient's indwelling catheter to send for a urine culture E. The nurse collects a urine specimen from a patient with urinary diversion by catheterizing the stoma. F. The nurse discards the first urine of the day when performing a 24 hr urine specimen collection on a patient. - D, E, F [Show Less]
While preparing the client for a colonoscopy, the nurse's responsibilities include: A. Explaining the risks and benefits of the exam B. Instructing t... [Show More] he client about the bowel preparation prior to the test C. Instructing the client about medication that will be used to sedate the client D. Explaining the results of the exam - B. Instructing the client about the bowel preparation prior to the test A certified nursing assistant is collecting a 24-hour urine specimen from a client. Which statement by the assistant indicates that the specimen collection will need to be restarted? A. "I used a container from the lab that has a preservative in it." B. "The client voided in it right away, and I wrote the time on the container." C. "I have the container in a plastic bucket with ice in it." D. "I told the client that every single urination must be put in the container. If one is missed, call one of us." - B. "The client voided in it right away, and I wrote the time on the container." A client is admitted with gastrointestinal bleeding. One of the earliest and most important blood tests completed will be: A. Electrolyte Panel B. Arterial Blood Gases C. Liver Panel D. Complete Blood Count - D. Complete Blood Count A client is to obtain a clean-catch urine specimen. Which statement by the client demonstrates a lack of understanding regarding the procedure? A. "I should use all of the towelettes in the kit and use each only once." B. "Urinate into the cup as soon as I start to go." C. "I don't have to fill the cup. Just get an ounce or two." D. "Put the cover on right away, without touching the inside of the cover or the cup." - B. "Urinate into the cup as soon as I start to go." The nurse is having difficulty obtaining a capillary blood sample from a client's finger to measure blood glucose using a blood glucose monitor. Which procedure will increase the blood flow to the area to ensure an adequate specimen? A. Raise the hand on a pillow to increase venous flow. B. Pierce the skin with the lancet in the middle of the finger pad. C. Wrap the finger in a warm cloth for 30--60 seconds. D. Pierce the skin at a 45-degree angle. - C. Wrap the finger in a warm cloth for 30--60 seconds. A client has a streptococcal throat infection. The White Blood Cell count is elevated. When looking at the differential, the nurse expects which type of white blood cell to be elevated? A.Eosinophils B. Monocytes C. Lymphocytes D. Neutrophils - D. Neutrophils A client is to have a thoracentesis in order to aspirate pleural fluid for biopsy. In order to prepare the client for the procedure, the nurse best positions the client in which manner? A. Lying in a lateral position with the affected lung down and back, curved into a fetal position. The head is supported with a pillow. The arms are positioned comfortably away from the chest wall. B. Lying in a 10-degree reverse Trendelenburg position with the arms over the head. Small pillows allowed under the head and arms. C. Sitting in a Fowler's position with the arms abducted and supported by pillows placed on each side of the body. The head is lying flat against the mattress. D. Sitting on the side of the bed, leaning over a bedside table with a pillow on it, arms overhead supported by the pillow - D. Sitting on the side of the bed, leaning over a bedside table with a pillow on it, arms overhead supported by the pillow A nurse cares for a client following a liver biopsy. Which nursing care plan reflects proper care? A. Position in a dorsal recumbent position, with one pillow under the head B. Bed rest for 24 hours, with a pressure dressing over the biopsy site C. Position to a right side-lying position, with a pillow under the biopsy site D. Neurological checks of lower extremities every hour - C. Position to a right side-lying position, with a pillow under the biopsy site A client reports an iodine allergy. This information is most significant if the client is scheduled for which exam? A. Lung Scan B. Computed Tomography C. Magnetic Resonance Imaging D. Intravenous Pyelogram - D. Intravenous Pyelogram Following a gastroscopy, a client asks for something to eat. The nurse correctly responds: A. "I will first check your gag reflex." B. "I will first listen for bowel sounds." C. "I will first have you cough and deep-breathe." D. "I will first listen to your lungs." - A. "I will first check your gag reflex." The nurse would call the primary care provider immediately for which laboratory result? A. Hgb = 16 g/dL for a male client. B. Hct = 22% for a female client. C. WBC = 9 x 10³/mL³ D. Platelets = 300 x 10³/mL³ - B. Hct = 22% for a female client. A 78-year-old male client needs to complete a 24-hour urine specimen. In planning his care, the nurse realizes that which measure is most important? A. Instruct the client to empty his bladder and save this voiding to start the collection. B. Instruct the client to use sterile individual containers to collect the urine. C. Post a sign stating "Save All Urine" in the bathroom. D. Keep the urine specimen in the refrigerator. - C. Post a sign stating "Save All Urine" in the bathroom. Option 3 is the most important nursing measure. This will inform the staff that the client is on a 24-hour urine collection. Option 1 is not appropriate since the first voided specimen is to be discarded. Option 2 is not an appropriate nursing measure since the specimen container is clean not sterile, and one container is needed—not individual containers. Option 4 is inappropriate because some 24-hour urine collections do not require refrigeration. The client has a urinary health problem. Which procedure is performed using indirect visualization? A. Intravenous pyelography (IVP) B. Kidneys, ureter, bladder (KUB) C. Retrograde pyelography D. Cystoscopy - B. Kidneys, ureter, bladder (KUB) A KUB is an x-ray of the kidneys, ureters, and bladder. This does not require direct visualization. Option 1 is an IVP, an intravenous pyelogram, which requires the injection of a contrast media. Option 3 is a retrograde pyelography, which requires the injection of a contrast media. Option 4 is a cytoscopy, which uses a lighted instrument (cystoscope) inserted through the urethra, resulting in direct visualization. Which noninvasive procedure provides information about the physiology or function of an organ? A. Angiography B. Computerized tomography (CT) C. Magnetic resonance imaging (MRI) D. Positron emission tomography (PET) - D. Positron emission tomography (PET) Rationale: This type of nuclear scan demonstrates the ability of tissues to absorb the chemical to indicate the physiology and function of an organ. Option 1 is an invasive procedure that focuses on blood flow through an organ. Options 2 and 3 provide information about density of tissue to help distinguish between normal and abnormal tissue of an organ. When assisting with a bone marrow biopsy, the nurse should take which action? A. Assist the client to a right side-lying position after the procedure. B. Observe for signs of dyspnea, pallor, and coughing. C. Assess for bleeding and hematoma formation for several days after the procedure. D. Stand in front of the client and support the back of the neck and knees. - C. Assess for bleeding and hematoma formation for several days after the procedure. Rationale: Bone marrow aspiration includes deep penetration into soft tissue and large bones such as the sternum and iliac crest. This penetration can result in bleeding. The client should be observed for bleeding in the days following the procedure. Option 1 is a nursing action during a liver biopsy. Option 2 is a nursing action for a thoracentesis, and Option 4 is a nursing action for a lumbar puncture. During an assessment, the nurse learns that the client has a history of liver disease. Which diagnostic tests might be indicated for this client?Select all that apply. A. Alanine aminotransferase (ALT) B. Myoglobin C. Cholesterol D. Ammonia E. Brain natriuretic peptide or B-Type natriuretic peptide (BNP) - A.Alanine aminotransferase (ALT) D. Ammonia ALT is an enzyme that contributes to protein and carbohydrate metabolism. An increase in the enzyme indicates damage to the liver.The liver contributes to the metabolism of protein, which results in the production of ammonia. If the liver is damaged, the ammonia level is increased. Options 2, 3, and 5 (myoglobin, cholesterol, and BNP) are relevant for heart disease. The nurse practitioner requests a laboratory blood test to determine how well a client has controlled her diabetes during the past 3 months. Which blood test will provide this information? A. Fasting blood glucose B. Capillary blood specimen C. Glycosylated hemoglobin D. GGT (gamma-glutamyl transferase) - C. Glycosylated hemoglobin A glycosylated hemoglobin will indicate the glucose levels for a period of time, which is indicated by the nurse practitioner. Options 1 and 2 will provide information about the current blood glucose not the past history. Option 4 is used to assess for liver disease. The client is supposed to have a fecal occult blood test done on a stool sample. The nurse is going to use the Hemoccult test. Which of the following indicates that the nurse is using the correct procedure? Select all that apply. A. Mixes the reagent with the stool sample before applying to the card. B. Collects a sample from two different areas of the stool specimen. C. Assesses for a blue color change. D. Asks a colleague to verify the pink color results. E. Asks the client if he has taken vitamin C in the past few days. - B. Collects a sample from two different areas of the stool specimen. C. Assesses for a blue color change. E. Asks the client if he has taken vitamin C in the past few days. Rationale: The nurse should obtain the stool specimen from two different areas of the stool.The nurse should observe for a blue color change, which is indicative of a positive result.The nurse should assess for the ingestion of vitamin C by the client because it is contraindicated for 3 days prior to taking the specimen. Option 1 is incorrect since the reagent is placed on the specimen after it is applied to the testing card. Option 4 is incorrect because a pink color would be considered negative and does not require verification. A primary care provider is going to perform a thoracentesis. The nurse's role will include which action? A. Place the client supine in the Trendelenburg position. B. Position the client in a seated position with elbows on the overbed table. C. Instruct the UAP to measure vital signs. D. Administer an opioid analgesic. - B. Position the client in a seated position with elbows on the overbed table. The nurse needs to collect a sputum specimen to identify the presence of tuberculosis (TB). Which nursing action(s) is/are indicated for this type of specimen? Select all that apply. A. Collect the specimen in the evening. B. Send the specimen immediately to the laboratory. C. Ask the client to spit into the sputum container. D. Offer mouth care before and after collection of the sputum specimen. E. Collect a specimen for 3 consecutive days. - B. Send the specimen immediately to the laboratory. D. Offer mouth care before and after collection of the sputum specimen. E. Collect a specimen for 3 consecutive days [Show Less]
NCLEX Questions For Fundamentals Of Nursing Exam With Rationales, All Answered-A 73-year-old patient who sustained a right hip fracture in a fall requests ... [Show More] pain medication from the nurse. Based on his injury, which type of pain is this patient most likely experiencing? 1) Phantom 2) Visceral 3) Deep somatic 4) Referred - Answer: 3) Deep somatic Rationale: Deep somatic pain originates in ligaments, tendons, nerves, blood vessels, and bones. Therefore, a hip fracture causes deep somatic pain. Phantom pain is pain that is perceived to originate from a part that was removed during surgery. Visceral pain is caused by deep internal pain receptors and commonly occurs in the abdominal cavity, cranium, and thorax. Referred pain occurs in an area that is distant to the original site. Which pain management task can the nurse safely delegate to nursing assistive personnel? 1) Asking about pain during vital signs 2) Evaluating the effectiveness of pain medication 3) Developing a plan of care involving nonpharmacologic interventions 4) Administering over-the-counter pain medications - Answer: 1) Asking about pain during vital signs Rationale: The nurse can delegate the task of asking about pain when nursing assistive personnel (NAP) obtain vital signs. The NAP must be instructed to report findings to the nurse without delay. The nurse should evaluate the effectiveness of pain medications and develop the plan of care. Administering over-the-counter and prescription medications is the responsibility of the registered nurse or licensed practical nurse. Which factor in the patient's past medical history dictates that the nurse exercise caution when administering acetaminophen (Tylenol)? 1) Hepatitis B 2) Occasional alcohol use 3) Allergy to aspirin 4) Gastric irritation with bleeding - Answer: 1) Hepatitis B Rationale: Even in recommended doses, acetaminophen can cause severe hepatotoxicity in patients with liver disease, such as hepatitis B. Patients who consume alcohol regularly should also use acetaminophen cautiously. Those allergic to aspirin or other nonsteroidal anti-inflammatory drugs (NSAIDs) can use acetaminophen safely. Acetaminophen rarely causes gastrointestinal (GI) problems; therefore, it can be used for those with a history of gastric irritation and bleeding. Which action should the nurse take before administering morphine 4.0 mg intravenously to a patient complaining of incisional pain? 1) Assess the patient's incision. 2) Clarify the order with the prescriber. 3) Assess the patient's respiratory status. 4) Monitor the patient's heart rate. - Answer: 3) Assess the patient's respiratory status. Rationale: Before administering an opioid analgesic, such as morphine, the nurse should assess the patient's respiratory status because opioid analgesics can cause respiratory depression. It is not necessary to clarify the order with the physician because morphine 4 mg IV is an appropriate dose. It is not necessary to monitor the patient's heart rate. Which action should the nurse take when preparing patient-controlled analgesia for a postoperative patient? 1) Caution the patient to limit the number of times he presses the dosing button. 2) Ask another nurse to double-check the setup before patient use. 3) Instruct the patient to administer a dose only when experiencing pain. 4) Provide clear, simple instructions for dosing if the patient is cognitively impaired. - Answer: 2) Ask another nurse to double-check the setup before patient use. Rationale: As a safeguard to reduce the risk for dosing errors, the nurse should request another nurse to double-check the setup before patient use. The nurse should reassure the patient that the pump has a lockout feature that prevents him from overdosing even if he continues to push the dose administration button. The nurse should also instruct the patient to administer a dose before potentially painful activities, such as walking. Patient-controlled analgesia is contraindicated for those who are cognitively impaired. The nurse administers codeine sulfate 30 mg orally to a patient who underwent craniotomy 3 days ago for a brain tumor. How soon after administration should the nurse reassess the patient's pain? 1) Immediately 2) In 10 minutes 3) In 15 minutes 4) In 60 minutes - Answer: 4) In 60 minutes Rationale: Codeine administered by the oral route reaches peak concentration in 60 minutes; therefore, the nurse should reassess the patient's pain 60 minutes after administration. The nurse should reassess pain after 10 minutes when administering codeine by the intramuscular or subcutaneous routes. Drugs administered by the intravenous (IV) route are effective almost immediately; however, codeine is not recommended for IV administration. Which nonsteroidal anti-inflammatory drug might be administered to inhibit platelet aggregation in a patient at risk for thrombophlebitis? 1) Ibuprofen (Motrin) 2) Celecoxib (Celebrex) 3) Aspirin (Ecotrin) 4) Indomethacin (Indocin) - Answer: 3) Aspirin (Ecotrin) Rationale: Aspirin is a unique NSAID that inhibits platelet aggregation. Low-dose aspirin therapy is commonly administered to decrease the risk of thrombophlebitis, myocardial infarction, and stroke. Ibuprofen, celecoxib, and indomethacin are NSAIDs, but they do not inhibit platelet aggregation. A client who is receiving epidural analgesia complains of nausea and loss of motor function in his legs. The nurse obtains his blood pressure and notes a drop in his blood pressure from the previous reading. Which complication is the patient most likely experiencing? 1) Infection at the catheter insertion site 2) Side effect of the epidural analgesic 3) Epidural catheter migration 4) Spinal cord damage - Answer: 3) Epidural catheter migration Rationale: The patient is exhibiting signs of epidural catheter migration, which include nausea, a decrease in blood pressure, and loss of motor function without an identifiable cause. Signs of infection at the catheter site include redness, swelling, and drainage. Loss of motor function is not a typical side effect associated with epidural analgesics. These are common signs of catheter migration, not spinal cord damage. Which of the following clients is experiencing an abnormal change in vital signs? A client whose (select all that apply): 1) Blood pressure (BP) was 132/80 mm Hg sitting and is 120/60 mm Hg upon standing 2) Rectal temperature is 97.9°F in the morning and 99.2°F in the evening 3) Heart rate was 76 before eating and is 60 after eating 4) Respiratory rate was 14 when standing and is 22 after walking - Answer: 1) Blood pressure (BP) was 132/80 mm Hg sitting and is 120/60 mm Hg upon standing 3) Heart rate was 76 before eating and is 60 after eating Rationale: The BP change is abnormal; a BP change greater than 10 mm Hg may indicate postural hypotension. The change in heart rate is abnormal; heart rate usually increases slightly after eating rather than decreasing. The temperatures are within normal range for the rectal route, and temperature increases throughout the day. It is normal to have an increased respiratory rate after exercise. The nurse assesses clients' breath sounds. Which one requires immediate medical attention? A client who has: 1) Crackles 2) Rhonchi 3) Stridor 4) Wheezes - Answer: 3) Stridor [Show Less]
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