Fundamentals of Nursing NCLEX RN Exam Practice Q&A Set 6 | 75 Questions
1. 1. Question
The nurse is caring for an elderly woman who has had a
... [Show More] fractured 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.
o 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.
o 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).
o 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?
o A. Measure intake and output
o B. Check albumin level
o C. Monitor glucose levels
o 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.
o 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.
o 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.
o 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:
o A. Ascites and edema
o B. Systemic hypertension
o C. Portal hypertension
o 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.
o 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.
o 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.
o 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)?
o A. Elevate the head of the bed on 4-6 inch blocks.
o B. Lie down after eating.
o C. Increase fluid intake just before bedtime.
o 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.
o 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.
o 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.
o 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:
o A. To help a person with swollen legs to decrease fluid retention.
o B. To help a person with duodenal ulcers feel better.
o C. To help damaged tissue in a diabetic to heal.
o 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.
o 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.
o 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.
o 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)?
o A. Lettuce
o B. Eggs
o C. Chocolate
o 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.
o 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.
o 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.
o 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)?
o A. Withhold medications while the TPN is infusing.
o B. Change TPN solution every 24 hours.
o C. Flush the TPN line with water prior to initiating nutritional support.
o 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.
o Option A: Medication therapy can continue during TPN therapy. Progress of patients with a TPN line should be followed on a flowchart. An interdisciplinary nutrition team, if available, should monitor patients. Weight, complete blood count, electrolytes, and blood urea nitrogen should be monitored often (eg, daily for inpatients). Plasma glucose should be monitored every 6 hours until patients and glucose levels become stable. Fluid intake and output should be monitored continuously. When patients become stable, blood tests can be done much less often.
o Option C: Flushing is not required because the initiation of TPN does not require a client to remain on bed rest during therapy. Catheter-related sepsis rates have decreased since the introduction of guidelines that emphasize sterile techniques for catheter insertion and skincare around the insertion site. The increasing use of dedicated teams of physicians and nurses who specialize in various procedures including catheter insertion also has accounted for a decrease in catheter-related infection rates.
o Option D: However, other clinical conditions of the client may affect mobility issues and warrant the client’s being on bed rest. Place the client in a semi-Fowler’s or high-Fowler’s position. Maintaining the head of the bed elevated will promote ease in breathing. This position also allows the pooling of fluid in the bases and for gas exchange to be more available to the lung tissue.
8. 8. Question
Which of the following should be included in a plan of care for a client who is lactose intolerant?
o A. Remove all dairy products from the diet.
o B. Frozen yogurt can be included in the diet.
o C. Drink small amounts of milk on an empty stomach.
o D. Spread out selection of dairy products throughout the day.
Incorrect
Correct Answer: B. Frozen yogurt can be included in the diet.
Clients who are lactose intolerant can digest frozen yogurt. Yogurt products are formed by bacterial action, and this action assists in the digestion of lactose. The freezing process further stops bacterial action so that limited lactase activity remains. Some people who are lactose-intolerant can eat some kinds of yogurt without problems, especially yogurt with live cultures.
o Option A: Elimination of all dairy products can lead to significant clinical deficiencies of other nutrients. Be sure to get enough calcium in the diet, especially if the client avoids milk products completely. To get enough calcium, the client would need to eat calcium-rich foods as often as someone would drink milk. Calcium is very important because it keeps bones strong and reduces the risk of osteoporosis.
o Option C: Drinking milk on an empty stomach can exacerbate clinical symptoms. Drinking milk with a meal may benefit the client because other foods, (especially fat) may decrease transit time and allow for increased lactase activity. Limit the amount of milk and milk products in the diet. Try to drink 1 glass of milk each day. Drink small amounts several times a day. All types of milk contain the same amount of lactose.
Option D: Although individual tolerance should be acknowledged, spreading out the use of known dairy products will usually exacerbate clinical symptoms. Eat or drink milk and milk products along with other foods. For some people, combining solid food (like cereal) with a dairy product (like milk) can reduce symptoms. [Show Less]