NCLEX Practice Exam for Fundamentals of Nursing #02 In Text Mode: All questions and answers are given for reading and answering at your own pace.
Question 1. Which of the following signs and symptoms would the nurse expect to find when assessing an Asian patient for postoperative pain following abdominal surgery?
A). Changing position every 2 hours.
B). Decreased blood pressure and heart rate and shallow respirations.
C). Immobility, diaphoresis, and avoidance of deep breathing or coughing.
D). Quiet crying.
Question 1 Answer: C). Immobility, diaphoresis, and avoidance of deep breathing or coughing.
Question 1 Explanation: An Asian patient is likely to hide his pain. Consequently, the nurse must observe for objective signs. In an abdominal surgery patient, these might include immobility, diaphoresis, and avoidance of deep breathing or coughing, as well as increased heart rate, shallow respirations (stemming from pain upon moving the diaphragm and respiratory muscles), and guarding or rigidity of the abdominal wall. Such a patient is unlikely to display emotion, such as crying.
Question 2. Certain substances increase the amount of urine produced. These include:
B). Kaolin with pectin (Kaopectate).
C). Urinary analgesics.
D). Caffeine-containing drinks, such as coffee and cola..
Question 2 Answer: D). Caffeine-containing drinks, such as coffee and cola..
Question 2 Explanation: Fluids containing caffeine have a diuretic effect. Beets and urinary analgesics, such as pyridium, can color urine red. Kaopectate is an anti diarrheal medication.
Question 3. Which of the following patients is at greatest risk for developing pressure ulcers?
A). An apathetic 63-year old COPD patient receiving nasal oxygen via cannula.
B). An alert, chronic arthritic patient treated with steroids and aspirin.
C). A confused 78-year old patient with congestive heart failure (CHF) who requires assistance to get out of bed..
D). An 88-year old incontinent patient with gastric cancer who is confined to his bed at home.
Question 3 Answer: D). An 88-year old incontinent patient with gastric cancer who is confined to his bed at home.
Question 3 Explanation: Pressure ulcers are most likely to develop in patients with impaired mental status, mobility, activity level, nutrition, circulation and bladder or bowel control. Age is also a factor. Thus, the 88-year old incontinent patient who has impaired nutrition (from gastric cancer) and is confined to bed is at greater risk.
Question 4. The most common deficiency seen in alcoholics is:
C). Pantothenic acid.
Question 4 Answer: D). Thiamine.
Question 4 Explanation: Chronic alcoholism commonly results in thiamine deficiency and other symptoms of malnutrition.
Question 5. Which of the following is the most common cause of dementia among elderly persons?
A). Multiple sclerosis.
B). Parkinson’s disease.
C). Amyotrophic lateral sclerosis (Lou Gerhig’s disease).
D). Alzheimer’s disease.
Question 5 Answer: D). Alzheimer’s disease.
Question 5 Explanation: Alzheimer;s disease, sometimes known as senile dementia of the Alzheimer’s type or primary degenerative dementia, is an insidious; progressive, irreversible, and degenerative disease of the brain whose etiology is still unknown. Parkinson’s disease is a neurologic disorder caused by lesions in the extrapyramidial system and manifested by tremors, muscle rigidity, hypokinesis, dysphagia, and dysphonia. Multiple sclerosis, a progressive, degenerative disease involving demyelination of the nerve fibers, usually begins in young adulthood and is marked by periods of remission and exacerbation. Amyotrophic lateral sclerosis, a disease marked by progressive degeneration of the neurons, eventually results in atrophy of all the muscles; including those necessary for respiration.
Question 6. When a patient in the terminal stages of lung cancer begins to exhibit loss of consciousness, a major nursing priority is to:
A). Insert an airway.
B). Elevate the head of the bed.
C). Protect the patient from injury.
D). Withdraw all pain medications.
Question 6 Answer: C). Protect the patient from injury.
Question 6 Explanation: Ensuring the patient’s safety is the most essential action at this time. The other nursing actions may be necessary but are not a major priority.
Question 7. For a rectal examination, the patient can be directed to assume which of the following positions?
A). All of the above.
D). Horizontal recumbent.
Question 7 Answer: A). All of the above.
Question 7 Explanation: All of these positions are appropriate for a rectal examination. In the genupectoral (knee-chest) position, the patient kneels and rests his chest on the table, forming a 90 degree angle between the torso and upper legs. In Sims’ position, the patient lies on his left side with the left arm behind the body and his right leg flexed. In the horizontal recumbent position, the patient lies on his back with legs extended and hips rotated outward.
Question 8. Which of the following is an example of nursing malpractice?
A). The nurse administers the wrong medication to a patient and the patient vomits. This information is documented and reported to the physician and the nursing supervisor..
B). The nurse assists a patient out of bed with the bed locked in position; the patient slips and fractures his right humerus..
C). The nurse administers penicillin to a patient with a documented history of allergy to the drug. The patient experiences an allergic reaction and has cerebral damage resulting from anoxia..
D). The nurse applies a hot water bottle or a heating pad to the abdomen of a patient with abdominal cramping..
Question 8 Answer: C). The nurse administers penicillin to a patient with a documented history of allergy to the drug. The patient experiences an allergic reaction and has cerebral damage resulting from anoxia..
Question 8 Explanation: The three elements necessary to establish a nursing malpractice are nursing error (administering penicillin to a patient with a documented allergy to the drug), injury (cerebral damage), and proximal cause (administering the penicillin caused the cerebral damage). Applying a hot water bottle or heating pad to a patient without a physician’s order does not include the three required components. Assisting a patient out of bed with the bed locked in position is the correct nursing practice; therefore, the fracture was not the result of malpractice. Administering an incorrect medication is a nursing error; however, if such action resulted in a serious illness or chronic problem, the nurse could be sued for malpractice.
Question 9. Studies have shown that about 40% of patients fall out of bed despite the use of side rails; this has led to which of the following conclusions?
A). Side rails are ineffective.
B). Side rails are a deterrent that prevent a patient from falling out of bed..
C). Side rails should not be used.
D). Side rails are a reminder to a patient not to get out of bed.
Question 9 Answer: D). Side rails are a reminder to a patient not to get out of bed.
Question 9 Explanation: Since about 40% of patients fall out of bed despite the use of side rails, side rails cannot be said to prevent falls; however, they do serve as a reminder that the patient should not get out of bed. The other answers are incorrect interpretations of the statistical data.
Question 10. A prescribed amount of oxygen s needed for a patient with COPD to prevent:
A). Cardiac arrest related to increased partial pressure of carbon dioxide in arterial blood (PaCO2).
B). Circulatory overload due to hypervolemia.
C). Inhibition of the respiratory hypoxic stimulus.
D). Respiratory excitement.
Question 10 Answer: C). Inhibition of the respiratory hypoxic stimulus.
Question 10 Explanation: Delivery of more than 2 liters of oxygen per minute to a patient with chronic obstructive pulmonary disease (COPD), who is usually in a state of compensated respiratory acidosis (retaining carbon dioxide (CO2)), can inhibit the hypoxic stimulus for respiration. An increased partial pressure of carbon dioxide in arterial blood (PACO2) would not initially result in cardiac arrest. Circulatory overload and respiratory excitement have no relevance to the question.
Question 11. A patient is kept off food and fluids for 10 hours before surgery. His oral temperature at 8 a.m. is 99.8 F (37.7 C) This temperature reading probably indicates:
Question 11 Answer: D). Dehydration.
Question 11 Explanation: A slightly elevated temperature in the immediate preoperative or post operative period may result from the lack of fluids before surgery rather than from infection. Anxiety will not cause an elevated temperature. Hypothermia is an abnormally low body temperature.
Question 12. A registered nurse reaches to answer the telephone on a busy pediatric unit, momentarily turning away from a 3 month-old infant she has been weighing. The infant falls off the scale, suffering a skull fracture. The nurse could be charged with:
Question 12 Answer: A). Malpractice.
Question 12 Explanation: Malpractice is defined as injurious or unprofessional actions that harm another. It involves professional misconduct, such as omission or commission of an act that a reasonable and prudent nurse would or would not do. In this example, the standard of care was breached; a 3-month-old infant should never be left unattended on a scale.
Question 13. The nurse’s most important legal responsibility after a patient’s death in a hospital is:
A). Ensuring that the attending physician issues the death certification.
B). Obtaining a consent of an autopsy.
C). Labeling the corpse appropriately.
D). Notifying the coroner or medical examiner.
Question 13 Answer: C). Labeling the corpse appropriately.
Question 13 Explanation: The nurse is legally responsible for labeling the corpse when death occurs in the hospital. She may be involved in obtaining consent for an autopsy or notifying the coroner or medical examiner of a patient’s death; however, she is not legally responsible for performing these functions. The attending physician may need information from the nurse to complete the death certificate, but he is responsible for issuing it.
Question 14. To assess the kidney function of a patient with an indwelling urinary (Foley) catheter, the nurse measures his hourly urine output. She should notify the physician if the urine output is:
A). 64 ml in 2 hours.
B). 125 ml in 4 hours.
C). Less than 30 ml/hour.
D). 90 ml in 3 hours.
Question 14 Answer: C). Less than 30 ml/hour.
Question 14 Explanation: A urine output of less than 30ml/hour indicates hypovolemia or oliguria, which is related to kidney function and inadequate fluid intake.
Question 15. An additional Vitamin C is required during all of the following periods except:
A). Young adulthood.
Question 15 Answer: A). Young adulthood.
Question 15 Explanation: Additional Vitamin C is needed in growth periods, such as infancy and childhood, and during pregnancy to supply demands for fetal growth and maternal tissues. Other conditions requiring extra vitamin C include wound healing, fever, infection and stress.
Question 16. The correct sequence for assessing the abdomen is:
A). Percussions, palpation, and auscultation.
B). Tympanic percussion, measurement of abdominal girth, and inspection.
C). Assessment for distention, tenderness, and discoloration around the umbilicus..
D). Auscultation, percussion, and palpation.
Question 16 Answer: D). Auscultation, percussion, and palpation.
Question 16 Explanation: Because percussion and palpation can affect bowel motility and thus bowel sounds, they should follow auscultation in abdominal assessment. Tympanic percussion, measurement of abdominal girth, and inspection are methods of assessing the abdomen. Assessing for distention, tenderness and discoloration around the umbilicus can indicate various bowel-related conditions, such as cholecystitis, appendicitis and peritonitis.
Question 17. Which of the following vascular system changes results from aging?
A). Increased peripheral resistance of the blood vessels.
B). All of the above.
C). Increased work load of the left ventricle.
D). Decreased blood flow.
Question 17 Answer: B). All of the above.
Question 17 Explanation: Aging decreases elasticity of the blood vessels, which leads to increased peripheral resistance and decreased blood flow. These changes, in turn, increase the work load of the left ventricle.
Question 18. The family of an accident victim who has been declared brain-dead seems amenable to organ donation. What should the nurse do?
A). Tell them the body will not be available for a wake or funeral.
B). Encourage them to sign the consent form right away.
C). Listen to their concerns and answer their questions honestly.
D). Discourage them from making a decision until their grief has eased.
Question 18 Answer: C). Listen to their concerns and answer their questions honestly.
Question 18 Explanation: The brain-dead patient’s family needs support and reassurance in making a decision about organ donation. Because transplants are done within hours of death, decisions about organ donation must be made as soon as possible. However, the family’s concerns must be addressed before members are asked to sign a consent form. The body of an organ donor is available for burial.
Question 19. A male patient who had surgery 2 days ago for head and neck cancer is about to make his first attempt to ambulate outside his room. The nurse notes that he is steady on his feet and that his vision was unaffected by the surgery. Which of the following nursing interventions would be appropriate?
A). Accompany the patient for his walk..
B). Consult a physical therapist before allowing the patient to ambulate.
C). Discourage the patient from walking in the hall for a few more days.
D). Encourage the patient to walk in the hall alone.
Question 19 Answer: A). Accompany the patient for his walk..
Question 19 Explanation: A hospitalized surgical patient leaving his room for the first time fears rejection and others staring at him, so he should not walk alone. Accompanying him will offer moral support, enabling him to face the rest of the world. Patients should begin ambulation as soon as possible after surgery to decrease complications and to regain strength and confidence. Waiting to consult a physical therapist is unnecessary.
Question 20. If a patient’s blood pressure is 150/96, his pulse pressure is:
Question 20 Answer: C). 54.
Question 20 Explanation: The pulse pressure is the difference between the systolic and diastolic blood pressure readings – in this case, 54.
Question 21. Mrs. Lim begins to cry as the nurse discusses hair loss. The best response would be:
A). “Your hair is really pretty”.
B). “Don’t worry. It’s only temporary”.
C). “Why are you crying? I didn’t get to the bad news yet”.
D). “I know this will be difficult for you, but your hair will grow back after the completion of chemotheraphy”.
Question 21 Answer: D). “I know this will be difficult for you, but your hair will grow back after the completion of chemotheraphy”.
Question 21 Explanation: “I know this will be difficult” acknowledges the problem and suggests a resolution to it. “Don’t worry..” offers some relief but doesn’t recognize the patient’s feelings. “..I didn’t get to the bad news yet” would be inappropriate at any time. “Your hair is really pretty” offers no consolation or alternatives to the patient.
Question 22. High-pitched gurgles head over the right lower quadrant are:
A). Normal bowel sounds.
B). A sign of decreased bowel motility.
C). A sign of abdominal cramping.
D). A sign of increased bowel motility.
Question 22 Answer: A). Normal bowel sounds.
Question 22 Explanation: Hyperactive sounds indicate increased bowel motility; two or three sounds per minute indicate decreased bowel motility. Abdominal cramping with hyperactive, high pitched tinkling bowel sounds can indicate a bowel obstruction.
Question 23. The four main concepts common to nursing that appear in each of the current conceptual models are:
A). Person, health, nursing, support systems.
B). Person, environment, health, nursing.
C). Person, nursing, environment, medicine.
D). Person, health, psychology, nursing.
Question 23 Answer: B). Person, environment, health, nursing.
Question 23 Explanation: The focus concepts that have been accepted by all theorists as the focus of nursing practice from the time of Florence Nightingale include the person receiving nursing care, his environment, his health on the health illness continuum, and the nursing actions necessary to meet his needs.
Question 24. A patient about to undergo abdominal inspection is best placed in which of the following positions?
Question 24 Answer: B). Supine.
Question 24 Explanation: The supine position (also called the dorsal position), in which the patient lies on his back with his face upward, allows for easy access to the abdomen. In the prone position, the patient lies on his abdomen with his face turned to the side. In the Trendelenburg position, the head of the bed is tilted downward to 30 to 40 degrees so that the upper body is lower than the legs. In the lateral position, the patient lies on his side.
Question 25. The absence of which pulse may not be a significant finding when a patient is admitted to the hospital?
Question 25 Answer: B). Pedal.
Question 25 Explanation: 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. Absence of the apical, radial, or femoral pulse is abnormal and should be investigated.
Question 26. If nurse administers an injection to a patient who refuses that injection, she has committed:
A). Assault and battery.
D). None of the above.
Question 26 Answer: A). Assault and battery.
Question 26 Explanation: Assault is the unjustifiable attempt or threat to touch or injure another person. Battery is the unlawful touching of another person or the carrying out of threatened physical harm. Thus, any act that a nurse performs on the patient against his will is considered assault and battery.
Question 27. A 38-year old patient’s vital signs at 8 a.m. are axillary temperature 99.6 F (37.6 C); pulse rate, 88; respiratory rate, 30. Which findings should be reported?
A). Pulse rate and temperature.
B). Temperature only.
C). Temperature and respiratory rate.
D). Respiratory rate only.
Question 27 Answer: C). Temperature and respiratory rate.
Question 27 Explanation: Under normal conditions, a healthy adult breathes in a smooth uninterrupted pattern 12 to 20 times a minute. Thus, a respiratory rate of 30 would be abnormal. A normal adult body temperature, as measured on an oral thermometer, ranges between 97° and 100°F (36.1° and 37.8°C); an axillary temperature is approximately one degree lower and a rectal temperature, one degree higher. Thus, an axillary temperature of 99.6°F (37.6°C) would be considered abnormal. The resting pulse rate in an adult ranges from 60 to 100 beats/minute, so a rate of 88 is normal.
Question 28. In Maslow’s hierarchy of physiologic needs, the human need of greatest priority is:
Question 28 Answer: D). Oxygen.
Question 28 Explanation: Maslow, who defined a need as a satisfaction whose absence causes illness, considered oxygen to be the most important physiologic need; without it, human life could not exist. According to this theory, other physiologic needs (including food, water, elimination, shelter, rest and sleep, activity and temperature regulation) must be met before proceeding to the next hierarchical levels on psychosocial needs.
Question 29. Which of the following parameters should be checked when assessing respirations?
A). All of the above.
Question 29 Answer: A). All of the above.
Question 29 Explanation: The quality and efficiency of the respiratory process can be determined by appraising the rate, rhythm, depth, ease, sound, and symmetry of respirations.
Question 30. The physician orders the administration of high-humidity oxygen by face mask and placement of the patient in a high Fowler’s position. After assessing Mrs. Paul, the nurse writes the following nursing diagnosis: Impaired gas exchange related to increased secretions. Which of the following nursing interventions has the greatest potential for improving this situation?
A). Continue administering oxygen by high humidity face mask.
B). Encourage the patient to increase her fluid intake to 200 ml every 2 hours.
C). Place a humidifier in the patient’s room..
D). Perform chest physiotheraphy on a regular schedule.
Question 30 Answer: B). Encourage the patient to increase her fluid intake to 200 ml every 2 hours.
Question 30 Explanation: Adequate hydration thins and loosens pulmonary secretions and also helps to replace fluids lost from elevated temperature, diaphoresis, dehydration and dyspnea. High- humidity air and chest physiotherapy help liquefy and mobilize secretions.
Question 31. The most appropriate nursing order for a patient who develops dyspnea and shortness of breath would be…
A). Allow a 1 hour rest period between activities.
B). Maintain the patient in an orthopneic position as needed.
C). Maintain the patient on strict bed rest at all times.
D). Administer oxygen by Venturi mask at 24%, as needed.
Question 31 Answer: B). Maintain the patient in an orthopneic position as needed.
Question 31 Explanation: When a patient develops dyspnea and shortness of breath, the orthopneic position encourages maximum chest expansion and keeps the abdominal organs from pressing against the diaphragm, thus improving ventilation. Bed rest and oxygen by Venturi mask at 24% would improve oxygenation of the tissues and cells but must be ordered by a physician. Allowing for rest periods decreases the possibility of hypoxia.
Question 32. The physician orders a maintenance dose of 5,000 units of subcutaneous heparin (an anticoagulant) daily. Nursing responsibilities for Mrs. Mitchell now include:
A). Reviewing daily activated partial thromboplastin time (APTT) and prothrombin time..
B). Assessing the patient for signs and symptoms of frank and occult bleeding.
C). All of the above.
D). Reporting an APTT above 45 seconds to the physician.
Question 32 Answer: C). All of the above.
Question 32 Explanation: All of the identified nursing responsibilities are pertinent when a patient is receiving heparin. The normal activated partial thromboplastin time is 16 to 25 seconds and the normal prothrombin time is 12 to 15 seconds; these levels must remain within two to two and one half the normal levels. All patients receiving anticoagulant therapy must be observed for signs and symptoms of frank and occult bleeding (including hemorrhage, hypotension, tachycardia, tachypnea, restlessness, pallor, cold and clammy skin, thirst and confusion); blood pressure should be measured every 4 hours and the patient should be instructed to report promptly any bleeding that occurs with tooth brushing, bowel movements, urination or heavy prolonged menstruation.
Question 33. The most common injury among elderly persons is:
A). Urinary Tract Infection.
B). Hip fracture.
C). Increased incidence of gallbladder disease.
D). Atheroscleotic changes in the blood vessels.
Question 33 Answer: B). Hip fracture.
Question 33 Explanation: Hip fracture, the most common injury among elderly persons, usually results from osteoporosis. The other answers are diseases that can occur in the elderly from physiologic changes.
Question 34. A patient is admitted to the hospital with complaints of nausea, vomiting, diarrhea, and severe abdominal pain. Which of the following would immediately alert the nurse that the patient has bleeding from the GI tract?
A). Complete blood count.
B). Guaiac test.
C). Abdominal girth.
D). Vital signs.
Question 34 Answer: B). Guaiac test.
Question 34 Explanation: To assess for GI tract bleeding when frank blood is absent, the nurse has two options: She can test for occult blood in vomitus, if present, or in stool – through guaiac (Hemoccult) test. A complete blood count does not provide immediate results and does not always immediately reflect blood loss. Changes in vital signs may be cause by factors other than blood loss. Abdominal girth is unrelated to blood loss.
Question 35. Examples of patients suffering from impaired awareness include all of the following except:
A). A disoriented or confused patient.
B). A semiconscious or over fatigued patient.
C). A patient who cannot care for himself at home.
D). A patient demonstrating symptoms of drugs or alcohol withdrawal.
Question 35 Answer: C). A patient who cannot care for himself at home.
Question 35 Explanation: A patient who cannot care for himself at home does not necessarily have impaired awareness; he may simply have some degree of immobility.
Question 36. Palpating the midclavicular line is the correct technique for assessing
A). Systolic blood pressure.
B). Baseline vital signs.
C). Respiratory rate.
D). Apical pulse.
Question 36 Answer: D). Apical pulse.
Question 36 Explanation: 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. Base line vital signs include pulse rate, temperature, respiratory rate, and blood pressure. Blood pressure is typically assessed at the antecubital fossa, and respiratory rate is assessed best by observing chest movement with each inspiration and expiration.
Question 37. The most common psychogenic disorder among elderly person is:
A). Sleep disturbances (such as bizarre dreams).
B). Decreased appetite.
D). Inability to concentrate.
Question 37 Answer: C). Depression.
Question 37 Explanation: Sleep disturbances, inability to concentrate and decreased appetite are symptoms of depression, the most common psychogenic disorder among elderly persons. Other symptoms include diminished memory, apathy, disinterest in appearance, withdrawal, and irritability. Depression typically begins before the onset of old age and usually is caused by psychosocial, genetic, or biochemical factors
Question 38. After 1 week of hospitalization, Mr. Gray develops hypokalemia. Which of the following is the most significant symptom of his disorder?
B). Muscle irritability.
C). Increased pulse rate and blood pressure.
D). Muscle weakness.
Question 38 Answer: D). Muscle weakness.
Question 38 Explanation: Presenting symptoms of hypokalemia ( a serum potassium level below 3.5 mEq/liter) include muscle weakness, chronic fatigue, and cardiac dysrhythmias. The combined effects of inadequate food intake and prolonged diarrhea can deplete the potassium stores of a patient with GI problems.
Question 39. All of the following can cause tachycardia except:
A). Sympathetic nervous system stimulation.
C). Parasympathetic nervous system stimulation.
Question 39 Answer: C). Parasympathetic nervous system stimulation.
Question 39 Explanation: 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.
Question 40. Which of the following principles of primary nursing has proven the most satisfying to the patient and nurse?
A). Autonomy and authority for planning are best delegated to a nurse who knows the patient well.
B). The holistic approach provides for a therapeutic relationship, continuity, and efficient nursing care..
C). Accountability is clearest when one nurse is responsible for the overall plan and its implementation..
D). Continuity of patient care promotes efficient, cost-effective nursing care.
Question 40 Answer: B). The holistic approach provides for a therapeutic relationship, continuity, and efficient nursing care..
Question 40 Explanation: Studies have shown that patients and nurses both respond well to primary nursing care units. Patients feel less anxious and isolated and more secure because they are allowed to participate in planning their own care. Nurses feel personal satisfaction, much of it related to positive feedback from the patients. They also seem to gain a greater sense of achievement and esprit de corps.
Question 41. Mrs. Mitchell has been given a copy of her diet. The nurse discusses the foods allowed on a 500-mg low sodium diet. These include:
A). A ham and Swiss cheese sandwich on whole wheat bread.
B). Mashed potatoes and broiled chicken.
C). A tossed salad with oil and vinegar and olives.
D). Chicken bouillon.
Question 41 Answer: B). Mashed potatoes and broiled chicken.
Question 41 Explanation: Mashed potatoes and broiled chicken are low in natural sodium chloride. Ham, olives, and chicken bouillon contain large amounts of sodium and are contraindicated on a low sodium diet.
Question 42. A patient has exacerbation of chronic obstructive pulmonary disease (COPD) manifested by shortness of breath; orthopnea: thick, tenacious secretions; and a dry hacking cough. An appropriate nursing diagnosis would be:
A). Pain related to immobilization of affected leg..
B). Ineffective airway clearance related to dry, hacking cough..
C). Ineffective airway clearance related to thick, tenacious secretions..
D). Ineffective individual coping to COPD..
Question 42 Answer: C). Ineffective airway clearance related to thick, tenacious secretions..
Question 42 Explanation: Thick, tenacious secretions, a dry, hacking cough, orthopnea, and shortness of breath are signs of ineffective airway clearance. Ineffective airway clearance related to dry, hacking cough is incorrect because the cough is not the reason for the ineffective airway clearance. Ineffective individual coping related to COPD is wrong because the etiology for a nursing diagnosis should not be a medical diagnosis (COPD) and because no data indicate that the patient is coping ineffectively. Pain related to immobilization of affected leg would be an appropriate nursing diagnosis for a patient with a leg fracture.
Question 43. During a Romberg test, the nurse asks the patient to assume which position?
Question 43 Answer: B). Standing.
Question 43 Explanation: During a Romberg test, which evaluates for sensory or cerebellar ataxia, the patient must stand with feet together and arms resting at the sides—first with eyes open, then with eyes closed. The need to move the feet apart to maintain this stance is an abnormal finding.
Question 44. Before rigor mortis occurs, the nurse is responsible for:
A). Allowing the body to relax normally.
B). Removing the body’s clothing and wrapping the body in a shroud.
C). Providing a complete bath and dressing change.
D). Placing one pillow under the body’s head and shoulders.
Question 44 Answer: D). Placing one pillow under the body’s head and shoulders.
Question 44 Explanation: The nurse must place a pillow under the decreased person’s head and shoulders to prevent blood from settling in the face and discoloring it. She is required to bathe only soiled areas of the body since the mortician will wash the entire body. Before wrapping the body in a shroud, the nurse places a clean gown on the body and closes the eyes and mouth.
Question 45. Which of the following nursing interventions promotes patient safety?
A). Asses the patient’s ability to ambulate and transfer from a bed to a chair.
B). Demonstrate the signal system to the patient.
C). All of the above.
D). Check to see that the patient is wearing his identification band.
Question 45 Answer: C). All of the above.
Question 45 Explanation: Assisting a patient with ambulation and transfer from a bed to a chair allows the nurse to evaluate the patient’s ability to carry out these functions safely. Demonstrating the signal system and providing an opportunity for a return demonstration ensures that the patient knows how to operate the equipment and encourages him to call for assistance when needed. Checking the patient’s identification band verifies the patient’s identity and prevents identification mistakes in drug administration.
Question 46. If patient asks the nurse her opinion about a particular physicians and the nurse replies that the physician is incompetent, the nurse could be held liable for:
C). Respondent superior.
Question 46 Answer: B). Slander.
Question 46 Explanation: Oral communication that injures an individual’s reputation is considered slander. Written communication that does the same is considered libel.
Question 47. The physician orders a platelet count to be performed on Mrs. Smith after breakfast. The nurse is responsible for:
A). Instructing the patient about this diagnostic test.
B). Giving the patient breakfast.
C). All of the above.
D). Writing the order for this test.
Question 47 Answer: B). Giving the patient breakfast.
Question 47 Explanation: A platelet count evaluates the number of platelets in the circulating blood volume. The nurse is responsible for giving the patient breakfast at the scheduled time. The physician is responsible for instructing the patient about the test and for writing the order for the test.
Question 48. The nurse observes that Mr. Adams begins to have increased difficulty breathing. She elevates the head of the bed to the high Fowler position, which decreases his respiratory distress. The nurse documents this breathing as:
Question 48 Answer: D). Orthopnea.
Question 48 Explanation: Orthopnea is difficulty of breathing except in the upright position. Tachypnea is rapid respiration characterized by quick, shallow breaths. Eupnea is normal respiration – quiet, rhythmic, and without effort.
Question 49. The most common deficiency seen in alcoholics is:
B). Pantothenic acid.
Question 49 Answer: C). Thiamine.
Question 49 Explanation: Chronic alcoholism commonly results in thiamine deficiency and other symptoms of malnutrition.
Question 50. A new head nurse on a unit is distressed about the poor staffing on the 11 p.m. to 7 a.m. shift. What should she do?
A). Complain to her fellow nurses.
B). Wait until she knows more about the unit.
C). Discuss the problem with her supervisor.
D). Inform the staff that they must volunteer to rotate.
Question 50 Answer: C). Discuss the problem with her supervisor.
Question 50 Explanation: Although a new head nurse should initially spend time observing the unit for its strengths and weakness, she should take action if a problem threatens patient safety. In this case, the supervisor is the resource person to approach.