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Fundamentals of Nursing NCLEX Practice Questions Quizzes-100% correct
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Fundamentals of Nursing NCLEX Practice Questions Quiz Set 1
Fundamentals of Nursing NCLEX Practice Questions Quiz Set 1 | 75 Questions 1. 1. Question The most important nursing intervention to correct skin dryness... [Show More] is: o A. Consult the dietitian about increasing the patient’s fat intake, and take necessary measures to prevent infection. o B. Ask the physician to refer the patient to a dermatologist, and suggest that the patient wear home-laundered sleepwear. o C. Encourage the patient to increase his fluid intake, use non-irritating soap when bathing the patient, and apply lotion to the involved areas. o D. Avoid bathing the patient until the condition is remedied, and notify the physician. Incorrect Correct Answer: C. Encourage the patient to increase his fluid intake, use non-irritating soap when bathing the patient, and apply lotion to the involved areas. Dry skin will eventually crack, ranking the patient more prone to infection. To prevent this, the nurse should provide adequate hydration through fluid intake, use non irritating soaps or no soap when bathing the patient, and lubricate the patient’s skin with lotion. In most cases, dry skin responds well to lifestyle measures, such as using moisturizers and avoiding long, hot showers and baths. Moisturizers provide a seal over the skin to keep water from escaping. Apply moisturizer several times a day and after bathing. • Option B: The attending physician and dietitian may be consulted for treatment, but home-laundered items usually are not necessary. Natural fibers, such as cotton and silk, allow the skin to breathe. But wool, although natural, can irritate even normal skin. Wash clothes with detergents without dyes or perfumes, both of which can irritate the skin. • Option C: Increasing fat intake is unnecessary. Hot, dry, indoor air can parch sensitive skin and worsen itching and flaking. A portable home humidifier or one attached to the furnace adds moisture to the air inside the home. Be sure to keep the humidifier clean. It’s best to use cleansing creams or gentle skin cleansers and bath or shower gels with added moisturizers. Choose mild soaps that have added oils and fats. Avoid deodorant and antibacterial detergents, fragrance, and alcohol. • Option D: Bathing may be limited but need not be avoided entirely. Long showers or baths and hot water remove oils from the skin. Limit baths or showers to five to 10 minutes and use warm, not hot, water. 2. 2. Question When bathing a patient’s extremities, the nurse should use long, firm strokes from the distal to the proximal areas. This technique: • A. Provides an opportunity for skin assessment. • B. Avoids undue strain on the nurse. • C. Increases venous blood return. • D. Causes vasoconstriction and increases circulation. Incorrect Correct Answer: C. Increases venous blood return. Washing from distal to proximal areas stimulates venous blood flow, thereby preventing venous stasis. Good personal hygiene is essential for skin health but it also has an important role in maintaining self-esteem and quality of life. Supporting patients to maintain personal hygiene is a fundamental aspect of nursing care. • Option A: The nurse can assess the patient’s condition throughout the bath. Helping patients to wash and dress is frequently delegated to junior staff, but time spent attending to a patient’s hygiene needs is a valuable opportunity for nurses to carry out a holistic assessment (Dougherty and Lister, 2015; Burns and Day, 2012). It also allows time to address any concerns patients have and provides a valuable opportunity to assess the condition of their skin. • Option B: The nurse should feel no strain while bathing the patient. Nurses should also discuss with patients any religious and cultural issues relating to personal care (Dougherty and Lister, 2015). For example, ideally, Muslim patients should be cared for by a nurse of the same gender (Rassool, 2015), and Hindus may wish to wash before prayer (Dougherty and Lister, 2015). [Show Less]
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Fundamentals of Nursing NCLEX Practice Questions Quiz Set 2
Fundamentals of Nursing NCLEX Practice Questions Quiz Set 2 | 75 Questions 1. 1. Question Which intervention is an example of primary prevention? o ... [Show More] A. Administering digoxin (Lanoxicaps) to a patient with heart failure. o B. Administering measles, mumps, and rubella immunization to an infant. o C. Obtaining a Papanicolaou smear to screen for cervical cancer. o D. Using occupational therapy to help a patient cope with arthritis. Incorrect Correct Answer: B. Administering measles, mumps, and rubella immunization to an infant. Immunizing an infant is an example of primary prevention, which aims to prevent health problems. Primary prevention includes those preventive measures that come before the onset of illness or injury and before the disease process begins. Examples include immunization and taking regular exercise to prevent health problems developing in the future. • Option A: Administering digoxin to treat heart failure and obtaining a smear for a screening test are examples for secondary prevention, which promotes early detection and treatment of disease. Those preventive measures that lead to early diagnosis and prompt treatment of a disease, illness, or injury to prevent more severe problems developing. Here health educators such as Health Extension Practitioners can help individuals acquire the skills of detecting diseases in their early stages. • Option C: Obtaining a Papanicolau smear is a secondary prevention. Secondary prevention includes those preventive measures that lead to early diagnosis and prompt treatment of a disease, illness, or injury. This should limit disability, impairment, or dependency and prevent more severe health problems developing in the future. • Option D: Using occupational therapy to help a patient cope with arthritis is an example of tertiary prevention, which aims to help a patient deal with the residual consequences of a problem or to prevent the problem from recurring. Tertiary prevention includes those preventive measures aimed at rehabilitation following significant illness. At this level, health educators work to retrain, re-educate and rehabilitate the individual who has already had an impairment or disability. 2. 2. Question The nurse in charge is assessing a patient’s abdomen. Which examination technique should the nurse use first? • A. Auscultation • B. Inspection • C. Percussion • D. Palpation Incorrect Correct Answer: B. Inspection Inspection always comes first when performing a physical examination. It is important to begin with the general examination of the abdomen with the patient in a completely supine position. The presence of any of the following signs may indicate specific disorders. Percussion and palpation of the abdomen may affect bowel motility and therefore should follow auscultation. • Option A: The last step of the abdominal examination is auscultation with a stethoscope. The diaphragm of the stethoscope should be placed on the right side of the umbilicus to listen to the bowel sounds, and their rate should be calculated after listening for at least two minutes. Normal bowel sounds are low-pitched and gurgling, and the rate is normally 2-5/min. Absent bowel sounds may indicate paralytic ileus and hyperactive rushes (borborygmi) are usually present in small bowel obstruction and sometimes may be auscultated in lactose intolerance. • Option C: A proper technique of percussion is necessary to gain maximum information regarding the abdominal pathology. While percussing, it is important to appreciate tympany over air-filled structures such as the stomach and dullness to percussion which may be present due to an underlying mass or organomegaly (for example, hepatomegaly or splenomegaly). • Option D: The ideal position for abdominal examination is to sit or kneel on the right side of the patient with the hand and forearm in the same horizontal plane as the patient’s abdomen. There are three stages of palpation that include the superficial or light palpation, deep palpation, and organ palpation and should be performed in the same order. Maneuvers specific to certain diseases are also a part of abdominal palpation. 3. 3. Question Which statement regarding heart sounds is correct? • A. S1 and S2 sound equally loud over the entire cardiac area. • B. S1 and S2 sound fainter at the apex. • C. S1 and S2 sound fainter at the base. • D. S1 is loudest at the apex, and S2 is loudest at the base. Incorrect Correct Answer: D. S1 is loudest at the apex, and S2 is loudest at the base. The S1 sound—the “lub” sound—is loudest at the apex of the heart. It sounds longer, lower, and louder there than the S2 sounds. The S2—the “dub” sound—is loudest at the base. It sounds shorter, sharper, higher, and louder there than S1. Heart sounds are created from blood flowing through the heart chambers as the cardiac valves open and close during the cardiac cycle. Vibrations of these structures from the blood flow create audible sounds — the more turbulent the blood flow, the more vibrations that get created. • Option A: The S1 heart sound is produced as the mitral and tricuspid valves close in systole. This structural and hemodynamic change creates vibrations that are audible at the chest wall. The mitral valve closing is the louder component of S1. It also occurs sooner because of the left ventricle contracts earlier in systole. • Option B: Changes in the intensity of S1 are more attributable to forces acting on the mitral valve. Such causes include a change in left ventricular contractility, mitral structure, or the PR interval. However, under normal resting conditions, the mitral and tricuspid sounds occur close enough together not to be discernible. The most common reasons for a split S1 are [Show Less]
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Fundamentals of Nursing NCLEX Practice Questions Quiz Set 3
Fundamentals of Nursing NCLEX Practice Questions Quiz Set 3 | 75 Questions 1. 1. Question The charge nurse asks the nursing assistive personnel (NAP) t... [Show More] o give a bag bath to a patient with end-stage chronic obstructive pulmonary disease. How should the NAP proceed? o A. Bathe the patient's entire body using 8 to 10 washcloths. o B. Assist the patient to a chair and provide bathing supplies. o C. Saturate a towel and blanket in a plastic bag, and then bathe the patient. o D. Assist the patient to the bathtub and provide a bath chair. Incorrect Correct Answer: A. Bathe the patient’s entire body using 8 to 10 washcloths. A towel bath is a modification of the bed bath in which the NAP places a large towel and a bath blanket into a plastic bag, saturates them with a commercially prepared mixture of moisturizer, non rinse cleaning agent, and water; warms in them in a microwave, and then uses them to bathe the patient. A bag bath is a modification of the towel bath, in which the NAP uses 8 to 10 washcloths instead of a towel or blanket. Each part of the patient’s body is bathed with a fresh cloth. • Option B: A bag bath is not given in a chair or in the tub. The bag bath is one alternative to the traditional bed bath used in some nursing homes. The bath is performed with a series of 10 washcloths and a no-rinse liquid cleanser. Close the door and windows to prevent cold drafts and wash hands with warm water before beginning. • Option C: Moisten the washcloths with water and put in a plastic bag with the cleanser. Warm the bag in the microwave for 60 to 90 seconds. Test the temperature of the clothes before touching a resident with them and be careful when you open the bag, as steam can burn. • Option D: Take the bag to the resident’s bedside. When you are not cleaning a body part, keep it covered. Only expose as much of the resident’s body as necessary to adequately clean him or her. Be especially sensitive to exposing genitals, buttocks, and breasts. Bathing can be an extremely stressful experience for residents, so try to make it as easy as possible. 2. 2. Question For a morbidly obese patient, which intervention should the nurse choose to counteract the pressure created by the skin folds? • A. Cover the mattress with a sheepskin. • B. Keep the linens wrinkle free. • C. Separate the skin folds with towels. • D. Apply petrolatum barrier creams. Incorrect Correct Answer: C. Separate the skin folds with towels. Separating the skin folds with towels relieves the pressure of skin rubbing on skin. Skin folds, in particular, may be difficult for the patient to clean thoroughly; the abdominal folds and groins may be ignored, leading to an increased risk of skin breakdown in these areas. • Option A: Sheepskins are not recommended for use at all. Skin folds present a challenge in the management of patients who are morbidly obese. The weight from excess adipose tissue in skinfold areas can have an increased risk of skin injury such as friction, maceration, skin tears and pressure ulcer development. • Option B: Skin folds and areas vulnerable to skin injury should be cleaned and dried several times a day. Alcohol-based lotions and harsh soaps, as well as talcum powders, should be avoided in these areas. If necessary, dry cloths to absorb moisture can be left in skin folds in between washing and drying of the skin folds. • Option D: Petrolatum barrier creams are used to minimize moisture caused by incontinence. Patient hydration should also be considered in the nutrition plan for the patients and the health of their skin. 3. 3. Question A client exhibits all of the following during a physical assessment. Which of these is considered a primary defense against infection? • A. Fever • B. Intact skin • C. Inflammation • D. Lethargy Incorrect Correct Answer: B. Intact skin Intact skin is considered a primary defense against infection. Usually, the skin prevents invasion by microorganisms unless it is damaged (for example, by an injury, insect bite, or burn). Mucous membranes, such as the lining of the mouth, nose, and eyelids, are also effective barriers. Typically, mucous membranes are coated with secretions that fight microorganisms. For example, the mucous membranes of the eyes are bathed in tears, which contain an enzyme called lysozyme that attacks bacteria and helps protect the eyes from infection. Fever, the inflammatory response, and phagocytosis (a process of killing pathogens) are considered secondary defenses against infection. • Option A: Body temperature increases as a protective response to infection and injury. An elevated body temperature (fever) enhances the body’s defense mechanisms, although it can cause discomfort. A part of the brain called the hypothalamus controls body temperature. Fever results from an actual resetting of the hypothalamus’s thermostat. The body raises its temperature to a higher level by moving (shunting) blood from the skin surface to the interior of the body, thus reducing heat loss. • Option C: Any injury, including an invasion by microorganisms, causes inflammation in the affected area. Inflammation, a complex reaction, results from many different conditions. During inflammation, the blood supply [Show Less]
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Fundamentals of Nursing NCLEX Practice Questions Quiz Set 4
Fundamentals of Nursing NCLEX Practice Questions Quiz Set 4 | 75 Questions 1. 1. Question All of the following can cause tachycardia except: o A. Fe... [Show More] ver o B. Exercise o C. Sympathetic nervous system stimulation o D. Parasympathetic nervous system stimulation Incorrect Correct Answer: D. Parasympathetic nervous system stimulation Parasympathetic nervous system stimulation of the heart decreases the heart rate as well as the force of contraction, rate of impulse conduction and blood flow through the coronary vessels. Fever, exercise, and sympathetic stimulation all increase the heart rate. The parasympathetic nervous system (PNS) releases the hormone acetylcholine to slow the heart rate. Such factors as stress, caffeine, and excitement may temporarily accelerate your heart rate, while meditating or taking slow, deep breaths may help to slow your heart rate. • Option A: Tachypnea and tachycardia develop, and the patient becomes dehydrated because of sweating and vapor losses from the increased respiratory rate. Many manifestations of fever are related to the increased metabolic rate, increased need for oxygen, and use of body proteins as an energy source. • Option B: Often, ventricular tachycardia will occur during the recovery period post exercise due to increased levels of adrenaline. In a study conducted in 1991, it was found that 70% of patients tested experienced idiopathic ventricular tachycardia as a result of exercise. Exercising for any duration will increase your heart rate and will remain elevated for as long as the exercise is continued. At the beginning of exercise, your body removes the parasympathetic stimulation, which enables the heart rate to gradually increase. As you exercise more strenuously, the sympathetic system “kicks in” to accelerate your heart rate even more. • Option C: Heart rate is controlled by the two branches of the autonomic (involuntary) nervous system. The sympathetic nervous system (SNS) and the parasympathetic nervous system (PNS). The sympathetic nervous system (SNS) releases the hormones (catecholamines – epinephrine and norepinephrine) to accelerate the heart rate. 2. 2. Question Palpating the midclavicular line is the correct technique for assessing: • A. Baseline vital signs • B. Systolic blood pressure • C. Respiratory rate • D. Apical pulse Incorrect Correct Answer: D. Apical pulse The apical pulse (the pulse at the apex of the heart) is located on the midclavicular line at the fourth, fifth, or sixth intercostal space. Assessing whether the rhythm of the pulse is regular or irregular is essential. The pulse could be regular, irregular, or irregularly irregular. Changes in the rate of the pulse, along with changes in respiration is called sinus arrhythmia. In sinus arrhythmia, the pulse rate becomes faster during inspiration and slows down during expiration. Irregularly irregular pattern is more commonly indicative of processes like atrial flutter or atrial fibrillation. • Option A: Baseline vital signs include pulse rate, temperature, respiratory rate, and blood pressure. Vital signs are an objective measurement for the essential physiological functions of a living organism. They have the name “vital” as their measurement and assessment is the critical first step for any clinic evaluation. The first set of clinical examinations is an evaluation of the vital signs of the patient. • Option B: Blood pressure is typically assessed at the antecubital fossa. The arm should be supported at the heart level. Unsupported arm leads to 10 mmHg to the pressure readings. The patient’s blood pressure should get checked in each arm, and in younger patients, it should be tested in an upper and lower extremity to rule out the coarctation of the aorta. • Option C: Respiratory rate is assessed best by observing chest movement with each inspiration and expiration. The respiratory rate is the number of breaths per minute. The normal breathing rate is about 12 to 20 beats per minute in an average adult. In the pediatric age group, it is defined by the particular age group. Parameters important here again include its rate, depth of breathing, and its pattern rate of breathing is a crucial parameter. 3. 3. Question The absence of which pulse may not be a significant finding when a patient is admitted to the hospital? • A. Apical • B. Radial • C. Pedal • D. Femoral Incorrect Correct Answer: C. Pedal Because the pedal pulse cannot be detected in 10% to 20% of the population, its absence is not necessarily a significant finding. However, the presence or absence of the pedal pulse should be documented upon admission so that changes can be identified during the hospital stay. Absent peripheral pulses may be indicative of peripheral vascular disease (PVD). PVD may be caused by atherosclerosis, which can be complicated by an occluding thrombus or embolus. This may be life-threatening and may cause the loss of a limb. • Option A: Apical pulse rate is indicated during some assessments, such as when conducting a cardiovascular assessment and when a client is taking certain cardiac medications (e.g., digoxin). Sometimes the apical pulse is auscultated pre and post medication administration. It is also a best practice to assess apical pulse in infants and children up to five years of age because radial pulses are difficult to palpate and count in this [Show Less]
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Fundamentals of Nursing NCLEX Practice Questions Quiz Set 5
Fundamentals of Nursing NCLEX Practice Questions Quiz Set 5 | 75 Questions 1. 1. Question Once a nurse assesses a client’s condition and identifies a... [Show More] ppropriate nursing diagnoses, a: o A. Plan is developed for nursing care. o B. Physical assessment begins. o C. List of priorities is determined. o D. Review of the assessment is conducted with other team members. Incorrect Correct Answer: A. Plan is developed for nursing care. The planning stage is where goals and outcomes are formulated that directly impact patient care based on EDP guidelines. These patient-specific goals and the attainment of such assist in ensuring a positive outcome. Nursing care plans are essential in this phase of goal setting. • Option B: Assessment is the first step and involves critical thinking skills and data collection; subjective and objective. Subjective data involves verbal statements from the patient or caregiver. Objective data is measurable, tangible data such as vital signs, intake and output, and height and weight. • Option C: A nursing diagnosis encompasses Maslow’s Hierarchy of Needs and helps to prioritize and plan care based on patient-centered outcomes. In 1943, Abraham Maslow developed a hierarchy based on basic fundamental needs innate for all individuals. • Option D: Data may come from the patient directly or from primary caregivers who may or may not be direct relation family members. Friends can play a role in data collection. Electronic health records may populate data and assist in assessment. 2. 2. Question Planning is a category of nursing behaviors in which: • A. The nurse determines the health care needed for the client. • B. The physician determines the plan of care for the client. • C. Client-centered goals and expected outcomes are established. • D. The client determines the care needed. Incorrect Correct Answer: C. Client-centered goals and expected outcomes are established. The planning stage is where goals and outcomes are formulated that directly impact patient care based on EDP guidelines. These patient-specific goals and the attainment of such assist in ensuring a positive outcome. • Option A: Nursing care plans are essential in this phase of goal setting. Care plans provide a course of direction for personalized care tailored to an individual’s unique needs. Overall condition and comorbid conditions play a role in the construction of a care plan. • Option B: As explored by Salmond and Echevarria, healthcare is changing, and the traditional roles of nurses are transforming to meet the demands of this new healthcare environment. Nurses are in a position to promote change and impact patient delivery care models in the future. • Option D: Care plans enhance communication, documentation, reimbursement, and continuity of care across the healthcare continuum. Critical thinking skills will play a vital role as nurses develop plans of care for these patient populations with multiple comorbidities and embrace this challenging healthcare arena. 3. 3. Question Priorities are established to help the nurse anticipate and sequence nursing interventions when a client has multiple problems or alterations. Priorities are determined by the client’s: • A. Physician • B. Non-Emergent, non-life-threatening needs • C. Future well-being. • D. Urgency of problems Incorrect Correct Answer: D. Urgency of problems Triage of patients involves looking for signs of serious illness or injury. These emergency signs are connected to the Airway – Breathing – Circulation/Consciousness – Dehydration and are easily remembered as ABCD. If the client does not have any emergency signs, the health worker proceeds to assess the client for priority conditions. This should not take more than a few seconds. Some of these signs will have been noticed during the ABCD triage and others need to be rechecked. • Option A: All clinical staff involved in the care of the sick should be prepared to carry out a rapid assessment to identify the few clients who are severely ill and require emergency treatment. • Option B: Triage is the process of rapidly examining sick children when they first arrive in order to place them in one of the following categories: those with EMERGENCY SIGNS who require immediate emergency treatment; those with PRIORITY SIGNS who should be given priority in the queue so they can be rapidly assessed and treated without delay; and those who have no emergency or priority signs and are NON-URGENT cases. These clients can wait their turn in the queue for assessment and treatment. The majority of sick clients will be non-urgent and will not require emergency treatment. • Option C: Ideally, all clients should be checked on their arrival by a person who is trained to assess how ill they are. This person decides whether the client will be seen immediately and receive life-saving treatment, or will be seen soon, or can safely wait for his or her turn to be examined. 4. 4. Question A client-centered goal is a specific and measurable behavior or response that reflects a client’s: • A. Desire for specific health care interventions. [Show Less]
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Fundamentals of Nursing NCLEX Practice Questions Quiz Set 6
Fundamentals of Nursing NCLEX Practice Questions Quiz Set 6 | 75 Questions 1. 1. Question The nurse is caring for an elderly woman who has had a fractu... [Show More] red hip repaired. In the first few days following the surgical repair, which of the following nursing measures will best facilitate the resumption of activities for this client? o A. Arranging for the wheelchair o B. Asking her family to visit o C. Assisting her to sit out of bed in a chair qid o D. Encouraging the use of an overhead trapeze Incorrect Correct Answer: D. Encouraging the use of an overhead trapeze. Exercise is important to keep the joints and muscles functioning and to prevent secondary complications. Using the overhead trapeze prevents hazards of immobility by permitting movement in bed and strengthening of the upper extremities in preparation for ambulation. Facilitates movement during hygiene or skincare and linen changes; reduces the discomfort of remaining flat in bed. “Post position” involves placing the uninjured foot flat on the bed with the knee bent while grasping the trapeze and lifting the body off the bed. • Option A: Sitting in a wheelchair would require too great hip flexion initially. Place in supine position periodically if possible, when traction is used to stabilize lower limb fractures. Reduces the risk of flexion contracture of the hip. • Option B: Asking her family to visit would not facilitate the resumption of activities. Provide footboard, wrist splints, trochanter, or hand rolls as appropriate. Useful in maintaining a functional position of extremities, hands, and feet, and preventing complications (contractures, foot drop). • Option C: Sitting in a chair would cause too much hip flexion. The client initially needs to be in a low Fowler’s position or taking a few steps (as ordered) with the aid of a walker. Encourage the use of isometric exercises starting with the unaffected limb. Isometrics contract muscles without bending joints or moving limbs and help maintain muscle strength and mass. Note: These exercises are contraindicated while acute bleeding and edema are present. 2. 2. Question Which of the following is the most important nursing order in a client with major head trauma who is about to receive bolus enteral feeding? • A. Measure intake and output • B. Check albumin level • C. Monitor glucose levels • D. Increase enteral feeding Incorrect Correct Answer: A. Measure intake and output It is important to measure intake and output, which should be equal. Water given before feeding will present a hyperosmotic diuresis. I and O measures assess fluid balance. A urinary catheter is inserted to assess the adequacy of renal perfusion. The kidney requires 20% to 25% of cardiac output; commonly, it’s the first organ to show the effects of impaired perfusion or intravascular volume. • Option B: Osmotherapy aims to increase the osmolality of the intravascular space, which in turn helps mobilize excess fluid from brain tissue. If ICP increases, mannitol (an osmotic diuretic) may be given to decrease cerebral edema, transiently increase intravascular volume, and improve cerebral blood flow. • Option C: Low peripheral oxygen saturation values or low arterial blood oxygen values (as shown by arterial blood gas testing) should be avoided. Maintaining adequate brain tissue oxygenation seems to improve patient outcomes. • Option D: Enteral feedings are hyperosmotic agents pulling fluid from cells into the vascular bed. Initially, a nasogastric or orogastric tube is inserted to decompress the stomach and reduce the aspiration risk. (Typically, the nasal route is avoided as it can obstruct sinus drainage, leading to sinusitis or VAP). 3. 3. Question The pathological process causing esophageal varices is/are: • A. Ascites and edema • B. Systemic hypertension • C. Portal hypertension • D. Dilated veins and varicosities Incorrect Correct Answer: C. Portal hypertension Esophageal varices result from increased portal hypertension. In portal hypertension, the liver cannot accept all of the fluid from the portal vein. The excess fluid will backflow to the vessels with lesser pressure, such as esophageal veins or rectal veins causing esophageal varices or hemorrhoids. • Option A: Portal hypertension causes portocaval anastomosis to develop to decompress portal circulation. Normal portal pressure is between 5-10 mmHg but in the presence of portal obstruction, the pressure may be as high as 15-20 mmHg. Since the portal venous system has no valves, resistance at any level between the splanchnic vessels and the right side of the heart results in retrograde flow and elevated pressure. • Option B: Esophageal varices are dilated submucosal distal esophageal veins connecting the portal and systemic circulations. They form due to portal hypertension, which commonly is a result of cirrhosis, resistance to portal blood flow, and increased portal venous blood inflow. • Option D: Intrahepatic vasoconstriction due to decreased nitric oxide production, and increased release of endothelin-1 (ET-1), angiotensinogen, and eicosanoids. Increased portal flow is caused by hyperdynamic circulation due to splanchnic arterial vasodilation through mediators such as nitric oxide, prostacyclin, and TNF. 4. 4. Question Which of the following interventions will help lessen the effect of GERD (acid reflux)? • A. Elevate the head of the bed on 4-6 inch blocks. • B. Lie down after eating. • C. Increase fluid intake just before bedtime. • D. Wear a girdle. Incorrect Correct Answer: A. Elevate the head of the bed on 4-6 inch blocks. Elevation of the head of the bed allows gravity to assist in decreasing the backflow of acid into the esophagus. The fluid does not flow uphill. Instruct to remain in an upright position at least 2 hours after meals; avoiding eating 3 hours before bedtime. Helps control reflux and causes less irritation from reflux action into the esophagus. The other three options all increase fluid backflow into the esophagus through position or increasing abdominal pressure. • Option B: Avoid placing the patient in a supine position, have the patient sit upright after meals. Supine position after meals can increase regurgitation of acid. Elevate HOB while in bed. To prevent aspiration by preventing the gastric acid to flow back into the esophagus. • Option C: Instruct patient regarding eating small amounts of bland food followed by a small amount of water. Instruct to remain in an upright position at least 1–2 hours after meals, and to avoid eating within 2–4 hours of bedtime. Gravity helps control reflux and causes less irritation from reflux action into the esophagus. • Option D: Instruct the patient to avoid bending over, coughing, straining at defecations, and other activities that increase reflux. Promotes comfort by the decrease in intra-abdominal pressure, which reduces the reflux of gastric contents. 5. 5. Question The main benefit of therapeutic massages is: • A. To help a person with swollen legs to decrease fluid retention. • B. To help a person with duodenal ulcers feel better. • C. To help damaged tissue in a diabetic to heal. • D. To improve circulation and muscle tone. Incorrect Correct Answer: D. To improve circulation and muscle tone. Particularly in elderly adults, therapeutic massage will help improve circulation and muscle tone as well as the personal attention and social interaction that a good massage provides. Damaged or strained muscle fibers release inflammatory chemicals to aid the healing process, but these chemicals cause significant pain and discomfort in the process. At least one study, which looked at the effects of massage on post-exercise tissue inflammation, suggests that even 10 minutes of massage can reduce signs of inflammation and improve cell processes, thereby promoting healing, with effects lasting several hours after the massage. • Option A: Massage only the hands, feet, or scalp of patients with sepsis, fever over 100[degrees]F, nausea or vomiting, sickle cell crisis, HIV crisis, a complicated or high-risk pregnancy, crepitus, edema, thrombocytopenia, or meningitis. • Option B: When patients have fragile skin, or the potential for skin breakdown, apply only light pressure, using enough lotion or oil to minimize friction. For patients with a previous injury, chronic pain, or scar tissue, frequently ask them how the massage feels, and adjust both pressure and massage technique to the patients’ preferences. • Option C: A massage is contraindicated in any condition where massage to damaged tissue can dislodge a blood clot. Although massage is associated with few adverse effects, nurses should be careful to avoid areas near open wounds, any stage of pressure ulcer, reddened or swollen areas, rashes, incisions, thromboses, iv lines, drains, shunts, and tubes. 6. 6. Question Which of the following foods should be avoided by clients who are prone to develop heartburn as a result of gastroesophageal reflux disease (GERD)? • A. Lettuce • B. Eggs • C. Chocolate • D. Butterscotch Incorrect Correct Answer: C. Chocolate Ingestion of chocolate can reduce lower esophageal sphincter (LES) pressure leading to reflux and clinical symptoms of GERD. Ingesting cocoa can cause a surge of serotonin. This surge can cause the esophageal sphincter to relax and gastric contents to rise. Caffeine and theobromine in chocolate may also trigger acid reflux. All of the other foods do not affect LES pressure. • Option A: Vegetables are naturally low in fat and sugar, and they help reduce stomach acid. Good options include green beans, broccoli, asparagus, cauliflower, leafy greens, potatoes, and cucumbers. • Option B: Egg whites are a good option. Stay away from egg yolks, though, which are high in fat and may trigger reflux symptoms. Reflux symptoms may result from stomach acid touching the esophagus and causing irritation and pain. • Option D: The foods the patient eats affect the amount of acid the stomach produces. Eating the right kinds of food is key to controlling acid reflux or GERD, a severe, chronic form of acid reflux. Sources of healthy fats include avocados, walnuts, flaxseed, olive oil, sesame oil, and sunflower oil. Reduce the intake of saturated fats and trans fats and replace them with these healthier unsaturated fats. 7. 7. Question Which of the following should be included in a plan of care for a client receiving total parenteral nutrition (TPN)? • A. Withhold medications while the TPN is infusing. • B. Change TPN solution every 24 hours. • C. Flush the TPN line with water prior to initiating nutritional support. • D. Keep the client on complete bed rest during TPN therapy. Incorrect Correct Answer: B. Change TPN solution every 24 hours. TPN solutions should be changed every 24 hours in order to prevent bacterial overgrowth due to the hypertonicity of the solution. Because the central venous catheter needs to remain in place for a long time, a strict sterile technique must be used during the insertion and maintenance of the TPN line. The TPN line should not be used for any other purpose. External tubing should be changed every 24 hours with the first bag of the day. In-line filters have not been shown to decrease complications. Dressings should be kept sterile and are usually changed every 48 hours using strict sterile techniques. [Show Less]
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Fundamentals of Nursing NCLEX Practice Questions Quiz Set 7
Fundamentals of Nursing NCLEX Practice Questions Quiz Set 7 | 75 Questions 1. 1. Question The most important nursing intervention to correct skin dryness... [Show More] is: o A. Consult the dietitian about increasing the patient’s fat intake, and take necessary measures to prevent infection. o B. Ask the physician to refer the patient to a dermatologist, and suggest that the patient wear home-laundered sleepwear. o C. Encourage the patient to increase his fluid intake, use non-irritating soap when bathing the patient, and apply lotion to the involved areas. o D. Avoid bathing the patient until the condition is remedied, and notify the physician. Incorrect Correct Answer: C. Encourage the patient to increase his fluid intake, use non-irritating soap when bathing the patient, and apply lotion to the involved areas. Dry skin will eventually crack, ranking the patient more prone to infection. To prevent this, the nurse should provide adequate hydration through fluid intake, use non irritating soaps or no soap when bathing the patient, and lubricate the patient’s skin with lotion. In most cases, dry skin responds well to lifestyle measures, such as using moisturizers and avoiding long, hot showers and baths. Moisturizers provide a seal over the skin to keep water from escaping. Apply moisturizer several times a day and after bathing. • Option B: The attending physician and dietitian may be consulted for treatment, but home-laundered items usually are not necessary. Natural fibers, such as cotton and silk, allow the skin to breathe. But wool, although natural, can irritate even normal skin. Wash clothes with detergents without dyes or perfumes, both of which can irritate the skin. • Option C: Increasing fat intake is unnecessary. Hot, dry, indoor air can parch sensitive skin and worsen itching and flaking. A portable home humidifier or one attached to the furnace adds moisture to the air inside the home. Be sure to keep the humidifier clean. It’s best to use cleansing creams or gentle skin cleansers and bath or shower gels with added moisturizers. Choose mild soaps that have added oils and fats. Avoid deodorant and antibacterial detergents, fragrance, and alcohol. • Option D: Bathing may be limited but need not be avoided entirely. Long showers or baths and hot water remove oils from the skin. Limit baths or showers to five to 10 minutes and use warm, not hot, water. 2. 2. Question When bathing a patient’s extremities, the nurse should use long, firm strokes from the distal to the proximal areas. This technique: • A. Provides an opportunity for skin assessment. • B. Avoids undue strain on the nurse. • C. Increases venous blood return. • D. Causes vasoconstriction and increases circulation. Incorrect Correct Answer: C. Increases venous blood return. Washing from distal to proximal areas stimulates venous blood flow, thereby preventing venous stasis. Good personal hygiene is essential for skin health but it also has an important role in maintaining self-esteem and quality of life. Supporting patients to maintain personal hygiene is a fundamental aspect of nursing care. • Option A: The nurse can assess the patient’s condition throughout the bath. Helping patients to wash and dress is frequently delegated to junior staff, but time spent attending to a patient’s hygiene needs is a valuable opportunity for nurses to carry out a holistic assessment (Dougherty and Lister, 2015; Burns and Day, 2012). It also allows time to address any concerns patients have and provides a valuable opportunity to assess the condition of their skin. • Option B: The nurse should feel no strain while bathing the patient. Nurses should also discuss with patients any religious and cultural issues relating to personal care (Dougherty and Lister, 2015). For example, ideally, Muslim patients should be cared for by a nurse of the same gender (Rassool, 2015), and Hindus may wish to wash before prayer (Dougherty and Lister, 2015). • Option D: It improves circulation but does not result in vasoconstriction. Bed bathing is not as effective as showering or bathing and should only be undertaken when there is no alternative (Dougherty and Lister, 2015). If a bed bath is required, it is important to offer patients the opportunity to participate in their own care, which helps to maintain their independence, self-esteem and dignity. 3. 3. Question Vivid dreaming occurs in which stage of sleep? • A. Stage I non-REM • B. Rapid eye movement (REM) stage • C. Stage II non-REM • D. Delta stage Incorrect Correct Answer: B. Rapid eye movement (REM) stage Other characteristics of rapid eye movement (REM) sleep are deep sleep (the patient cannot be awakened easily), depressed muscle tone, and possibly irregular heart and respiratory rates. This is the stage associated with dreaming. Interestingly, the EEG is similar to an awake individual, but the skeletal muscles are atonic and without movement. The exception is the eye and diaphragmatic breathing muscles, which remain active. The breathing rate is altered though, being more erratic and irregular. This stage usually starts 90 minutes after falling asleep, and each of the REM cycles gets longer throughout the night. The first period typically lasts 10 minutes, and the final one can last up to an hour. • Option A: Non-REM sleep is a deep, restful sleep without dreaming. This is the lightest stage of sleep and starts when more than 50% of the alpha waves are replaced with low-amplitude mixed-frequency (LAMF) activity. There is muscle tone present in the skeletal muscle and breathing tends to occur at a regular rate. This stage tends to last 1 to 5 minutes, consisting of around 5% of the total cycle. • Option C: This stage represents deeper sleep the heart rate and body temperature drop. It is characterized by the presence of sleep spindles, K-complexes, or both. These sleep spindles will activate the superior temporal gyri, anterior cingulate, insular cortices, and the thalamus. The K-complexes show a transition into a deeper sleep. Stage 2 sleep lasts around 25 minutes in the initial cycle and lengthens with each successive cycle, eventually consisting of about 50% of total sleep. • Option D: Delta stage, or slow-wave sleep, occurs during non-REM Stages III and IV and is often equated with quiet sleep. This is considered the deepest stage of sleep and is characterized by a much slower frequency with high amplitude signals known as delta waves. This stage is the most difficult to awaken from, and for some people, even loud noises (over 100 decibels) will not awaken them. As people get older, they tend to spend less time in this slow, delta wave sleep and more time stage N2 sleep. This is the stage when the body repairs and regrows its tissues, builds bone and muscle, and strengthens the immune system. 4. 4. Question The natural sedative in meat and milk products (especially warm milk) that can help induce sleep is: • A. Flurazepam • B. Temazepam • C. Methotrimeprazine • D. Tryptophan Incorrect Correct Answer: D. Tryptophan Tryptophan is a natural sedative; flurazepam (Dalmane), temazepam (Restoril), and methotrimeprazine (Levoprome) are hypnotic sedatives. Protein foods such as milk and milk products contain the sleep-inducing amino acid tryptophan. Having warm milk at bedtime is a good way to work towards reaching the recommended number of servings of Milk and Alternatives each day, and can be a comforting way to unwind. Tryptophan is an amino acid that promotes sleep and is found in small amounts in all protein foods. It is a precursor to the sleep-inducing compounds serotonin (a neurotransmitter), and melatonin (a hormone which also acts as a neurotransmitter). • Option A: Flurazepam (marketed under the brand names Dalmane and Dalmadorm) is a drug which is a benzodiazepine derivative. It possesses anxiolytic, anticonvulsant, hypnotic, sedative and skeletal muscle relaxant properties. It produces a metabolite with a long half-life, which may stay in the bloodstream for days. • Option B: Temazepam is used on a short-term basis to treat insomnia (difficulty falling asleep or staying asleep). Temazepam is in a class of medications called benzodiazepines. It works by slowing activity in the brain to allow sleep. • Option C: Levomepromazine (also known as methotrimeprazine) is used to treat severe mental/mood disorders (such as schizophrenia, bipolar disorder). It works by helping to restore certain natural substances in the brain. Levomepromazine belongs to a class of drugs known as phenothiazines. It can help the client to think clearly and take part in everyday life. It is also used to treat anxiety disorders, a certain sleep problem (insomnia), nausea/vomiting, and pain. This medication has calming, relaxing, and pain-relieving effects. 5. 5. Question Nursing interventions that can help the patient to relax and sleep restfully include all of the following except: • A. Have the patient take a 30- to 60-minute nap in the afternoon. • B. Turn on the television in the patient’s room. • C. Provide quiet music and interesting reading material. • D. Massage the patient’s back with long strokes. Incorrect Correct Answer: A. Have the patient take a 30- to 60-minute nap in the afternoon. Napping in the afternoon is not conducive to nighttime sleeping. There are few considerations about naps. For example, a short daytime nap of 15-30 minutes can be restorative for elders and will not interfere with nighttime sleep. On the other hand, insomniacs are cautioned to avoid naps. Quiet music, watching [Show Less]
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Fundamentals of Nursing NCLEX Practice Questions Quiz Set 8
Fundamentals of Nursing NCLEX Practice Questions Quiz Set 8| 75 Questions 1. 1. Question The best explanation of what Title VI of the Civil Rights Act ... [Show More] mandates is the freedom to: o A. Pick any physician and insurance company despite one’s income. o B. Receive free medical benefits as needed within the county of residence. o C. Have equal access to all health care regardless of race and religion. o D. Have basic care with a sliding scale payment plan from all healthcare facilities. Incorrect Correct Answer: C. Have equal access to all health care regardless of race and religion. Title VI of the Civil Rights Act of 1964 states that “No person in the United States shall, on the ground of race, color, or national origin, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving Federal financial assistance.” • Option A: The Affordable Care Act puts consumers back in charge of their health care. Under the law, a new “Patient’s Bill of Rights” gives the American people the stability and flexibility they need to make informed choices about their health. Through this bill, the client may choose the primary care physician he wants from his plan’s network. • Option B: Since the Patient’s Bill of Rights was enacted, the Affordable Care Act has provided additional rights and protections. The health care law covers preventive care at no cost. Clients may be eligible for recommended preventive health services without a copayment. • Option D: Under the Patient’s Bill of Rights, a client’s premium dollars are ensured to be spent on primary healthcare, not on administrative costs. Also, the bill removes insurance company barriers to emergency services that are outside of their health plan’s network. 2. 2. Question Which statement would best explain the role of the nurse when planning care for a culturally diverse population? The nurse will plan care to: • A. Include care that is culturally congruent with the staff from predetermined criteria. • B. Focus only on the needs of the client, ignoring the nurse’s beliefs and practices. • C. Blend the values of the nurse that are for the good of the client and minimize the client’s individual values and beliefs during care. • D. Provide care while aware of one’s own bias, focusing on the client’s individual needs rather than the staff’s practices. Incorrect Correct Answer: D. Provide care while aware of one’s own bias, focusing on the client’s individual needs rather than the staff’s practices Without understanding one’s own beliefs and values, a bias or preconceived belief by the nurse could create an unexpected conflict or an area of neglect in the plan of care for a client (who might be expecting something totally different from the care). During assessment values, beliefs, practices should be identified by the nurse and used as a guide to identify the choices by the nurse to meet specific needs/outcomes of that client. Therefore identification of values, beliefs, and practices allows for planning meaningful and beneficial care specific for this client. • Option A: As nurses strive to learn more about becoming culturally sensitive nurses, they should also let others know what they are doing and why. Encourage co-workers to provide more culturally competent care. Approach sharing awareness with openness and positivity, rather than from a critical point of view. • Option B: Cultural competency in the health care sector supports positive patient outcomes and improves medical research accuracy. Cultural competence is learning about how cultural differences may impact healthcare decisions and being able to modify care to align with that patient’s culture. • Option C: Active listening in the healthcare community is imperative, especially when individuals of different racial or cultural backgrounds are involved. It’s important that patients feel heard and validated, particularly when they are in a vulnerable position. 3. 3. Question Which factor is least significant during assessment when gathering information about cultural practices? • A. Language, timing • B. Touch, eye contact • C. Biocultural needs • D. Pain perception, management expectations Incorrect Correct Answer: C. Biocultural needs Cultural practices do not influence biocultural needs because they are inborn risks that are related to a biological need and not a learned cultural belief or practice. Culturally competent healthcare professionals learn about different groups and the values that drive them. They develop nonjudgmental acceptance of cultural and noncultural differences in patients and coworkers, using diversity as a strength that empowers them to achieve mutually acceptable healthcare goals. • Option A: When a patient doesn’t speak English and there is no interpreter, spend more time visiting to allay patients’ anxiety. Learn key phrases from the family and use flashcards to enhance communication. When all else fails, sign language does work. Remember that making the effort shows the patient that you care. You are using the language of the heart and building trust. • Option B: Both the clinician and the interpreter must pay particular attention to nonverbal feedback during communication with the patient to ensure understanding of the patient’s concerns and desires. During the exchange, the clinician and the interpreter must be able to convey caring and support to gain patients’ confidence and trust, particularly when they are revealing sensitive information. • Option D: Culture influences patients’ perceptions of illness, pain, and healing. These perceptions may conflict with clinicians’ views based on the medical model. Keep an open mind and listen actively to what patients say about their illness. 4. 4. Question Transcultural nursing implies: • A. Using a comparative study of cultures to understand similarities and differences across human groups to provide specific individualized care that is culturally appropriate. • B. Working in another culture to practice nursing within their limitations. • C. Combining all cultural beliefs into a practice that is a non-threatening approach to minimize cultural barriers for all clients’ equality of care. • D. Ignoring all cultural differences to provide the best-generalized care to all clients. Incorrect Correct Answer: A. Using a comparative study of cultures to understand similarities and differences across human groups to provide specific individualized care that is culturally appropriate Transcultural care means that by understanding and learning about specific cultural practices the nurse can integrate these practices into the plan of care for a specific individual client who has the same beliefs or practices to meet the client’s needs in a holistic manner of care. • Option B: Nurses should explore new ways of providing cultural care in multicultural societies, understand how culture affects health-illness definitions, and build a bridge for the gap between the caring process and the individuals in different cultures. • Option C: The individuals’ beliefs about health, attitudes, and behaviors, past experiences, treatment practices, in short, their culture, play a vital role in improving health, preventing and treating diseases. Health workers must collect cultural data to understand the attitudes of coping with illness, health promotion, and protection. • Option D: Nurses should offer acceptable and affordable care for the individuals under the conditions of the day. Knowing what cultural practices are done in the target communities and identifying the cultural barriers to offering quality health care positively affects the caring process. 5. 5. Question What should the nurse do when planning nursing care for a client with a different cultural background? The nurse should: • A. Allow the family to provide care during the hospital stay so no rituals or customs are broken. • B. Identify how these cultural variables affect the health problem. • C. Speak slowly and show pictures to make sure the client always understands. • D. Explain how the client must adapt to hospital routines to be effectively cared for while in the hospital. Incorrect Correct Answer: B. Identify how these cultural variables affect the health problem. Without assessment and identification of the cultural needs, the nurse cannot begin to understand how these might influence the health problem or health care management. Culture is influential at many levels in health, ranging from the formation of new diagnostic groups to the diagnosis of disease to the determination of what is called a disease or no symptoms and disease cues • Option A: The transcultural approach should be considered in a wide range of subjects, starting from asking if there are any religious practices to be followed or done by the patient during the hospitalization, and writing the signs in the hospital in two different languages. • Option C: Health culture is concerned with every individual’s or the [Show Less]
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