NCLEX Practice Exam for Fundamentals of Nursing #04 In Text Mode: All questions and answers are given for reading and answering at your own pace.
Question 1. The usual sequence for assessing the bowel is:
A). Rectum, pancreas, stomach and liver.
B). Right lower lobe, right upper lobe, left upper lobe, left lower lobe.
C). Right lower quadrant, right upper quadrant, left upper quadrant. left lower quadrant.
D). Right hypochondriac, left hypochondriac and umbilical regions.
Question 1 Answer: C). Right lower quadrant, right upper quadrant, left upper quadrant. left lower quadrant.
Question 1 Explanation: This sequence follows the anatomy of the bowel. The lobes are parts of the lung. the right and left hypochondriac and the umbilical area are three of the nine regions of the abdomen.
Question 2. A patient states that he has difficulty sleeping in the hospital because of noise. Which of the following would be an appropriate nursing action?
A). Ambulate the patient for 5 minutes before he retires.
B). Give the patient a glass of warm milk before bedtime.
C). Administer a sedative at bedtime, as ordered by the physician.
D). Close the patient’s door from 9pm to 7am.
Question 2 Answer: B). Give the patient a glass of warm milk before bedtime.
Question 2 Explanation: Warm milk will relax the patient because it contains tryptophan, a natural sedative.
Question 3. An appropriate interdependent intervention to prevent thrombophebitis would be:
A). Encourage the patient to sit with his knees crossed.
B). Elevate the knee gatch of the bed.
C). Apply antiembolism stockings to both legs..
D). Massage the legs vigorously.
Question 3 Answer: C). Apply antiembolism stockings to both legs..
Question 3 Explanation: Antiembolism stockings increase venous return to the heart, which helps prevent thromboplebitis.
Question 4. If a patient is injured because a nurse acted in a wrongful manner, which party could be held liable along with the nurse?
A). All of the above.
B). The nursing supervisor.
C). The hospital.
D). The private attending physician.
Question 4 Answer: C). The hospital.
Question 4 Explanation: Under the master servant rule (also known as the doctrine or respondeat superior), when a person is injured by an employee as a result of negligence in the course of the employee’s work, the employer is responsible to the injured person.
Question 5. Mr. Jose is admitted to the hospitalwith a diagnosis of pneumonia and COPD. The physician orders an oxygen therapy for him. The most comfortable method of delivering oxygen to Mr. Jose is by:
A). Nasal catheter.
B). Partial rebreathing mask.
D). Nasal Cannula.
Question 5 Answer: D). Nasal Cannula.
Question 5 Explanation: The nasal cannula is the most comfortable method of delivering oxygen because it allows the patient to talk, eat and drink.
Question 6. Which of the following nursing theorists developed a conceptual model based on the belief that all persons strive to achieve self-care?
A). Florence Nightingale.
B). Martha Rogers.
C). Cister Callista Roy.
D). Dorothea Orem.
Question 6 Answer: D). Dorothea Orem.
Question 6 Explanation: Dorothea Orem’s conceptual model is based on the premise that all persons need to achieve self-care. She also views the goal of nursing as helping the patient to develop self-care practices to maintain maximum wellness.
Question 7. S1 is heard best at the:
A). 5th left intercoastal space along the midclavicular line.
B). Second left intercoastal space at the sternal border.
C). 3rd intercoastal space to the left of the midclavicular line.
D). Second right intercoastal space at the sternal border.
Question 7 Answer: A). 5th left intercoastal space along the midclavicular line.
Question 7 Explanation: The S1 heart sound is best heard at the apex of the heart, at the fifth intercoastal space along the midclavicular line. (An infant’s apex is located at the third or fourth intercoastal space just to the left of the midclavicular line)
Question 8. A sudden redness of the skin is known as:
Question 8 Answer: B). Flush.
Question 8 Explanation: Flush is a sudden redness of the skin. Cyanosis is a slightly bluish, grayish skin discoloration caused by abnormal amounts or reduced hemoglobin in the blood. Jaundice is a yellow discoloration of the skin, mucous membranes and sclerae caused by excessive amounts of bilirubin in the blood. Pallor is an unnatural paleness or absence of color in the skin indicating insufficient oxygen and excessive carbon dioxide in the blood.
Question 9. Which communication skills is most effective in dealing with covert communication?
Question 9 Answer: C). Validation.
Question 9 Explanation: Covert communication reflects inner feelings that a person may be uncomfortable talking about. Such communication may be revealed through body language, silence, withdrawn behavior, or crying. Validation is an attempt to confirm the observer’s perceptions through feedback, interpretation and clarification.
Question 10. The nurse’s main priority when caring for a patient with hemiplegia?
A). Providing a safe environment.
B). Educating the patient.
C). Helping the patient accept the illness.
D). Promoting a positive self-image.
Question 10 Answer: A). Providing a safe environment.
Question 10 Explanation: A patient with hemiplegia (paralysis of one side of the body) has a high risk of injury because of his altered motor and sensory function, so safety is the nurse’s main priority.
Question 11. Constipation is a common problem for immobilized patients because of:
A). An increased defacation reflex.
B). Increased colon motility.
C). Decreased peristalsis and positional discomfort.
D). Decreased tightening of the anal sphincter.
Question 11 Answer: C). Decreased peristalsis and positional discomfort.
Question 11 Explanation: Increased adrenalin production in the immobile patient results in decrease peristalsis and colon motility and more tightly constricted sphincters.
Question 12. Blood pressure measurement is an important part of the patient’s data base. It is considered to be:
A). Subjective data.
B). Objective data.
C). The basis of the nursing diagnosis.
D). An indicator of the patient’s well being.
Question 12 Answer: B). Objective data.
Question 12 Explanation: Objective data are those such as BP, which can be measured or perceived by someone other than the patient. Subjective data are those such as pain, which only the patient can perceive.
Question 13. According to Maslow’s hierarchy of needs, which of the following is a basic physiologic need after oxygen?
A). Self esteem.
Question 13 Answer: D). Activity.
Question 13 Explanation: According to Maslow, activity is one of the man’s most basic physiologic needs, along with oxygen, shelter, food, water, erst, sleep and temperature maintenance.
Question 14. The correct site at which to verify a radial pulse measurement is the:
A). Inguinal site.
B). Brachial artery.
C). Temporal artery.
D). Apex of the heart.
Question 14 Answer: D). Apex of the heart.
Question 14 Explanation: The best site for verifying a pulse rate is the apex of the heart, where the heartbeat is measured directly.
Question 15. If a patient sues a nurse for malpractice, the patient must be able to prove:
A). Error, injury and proximal cause.
B). Error, proximal cause, and lack of concern.
C). Injury, error and assault.
D). Proximal cause, negligence and nurse error.
Question 15 Answer: A). Error, injury and proximal cause.
Question 15 Explanation: Three criteria must be met to establish malpractice: a nursing error, a patient injury, and a connection between the two.
Question 16. The nurse should take a rectal temperature of a patient who has:
A). His arm in a cast.
B). Nasal packing.
C). Gastrostomy feeding tubes.
D). External hemorrhoids.
Question 16 Answer: B). Nasal packing.
Question 16 Explanation: A rectal temperature is usually recommended whenever an oral temperature is contraindicated (e.g. the patient who have undergone oral or nasal surgery, infants and those who have history of seizures, etc). However, a rectal temperature is contraindicated in patients having rectal disease, rectal surgery or diarrhea)
Question 17. Which of the following qualities are relevant in documenting patient care?
A). All of the above.
B). Accuracy and conciseness.
C). Thoroughness and currentness.
Question 17 Answer: A). All of the above.
Question 17 Explanation: Documentation should leave no room for misinterpretation. Thus, the nurse must ensure that all information pertinent to patient care is reworded accurately, concisely and thoroughly. The information must be up-to-date and well organized.
Question 18. Which of the following questions is most appropriate to ask when interviewing a potential candidate for an RN position?
A). What was your last nursing experience?.
B). Do you plan to get pregnant?.
C). Are you willing to do overtime on weekends?.
D). How many children do you have?.
Question 18 Answer: A). What was your last nursing experience?.
Question 18 Explanation: An interviewer’s question should center on the applicant’s qualifications for the position. Questions about the applicant’s personal life are inappropriate and may be illegal.
Question 19. Which of the following nursing theorists is credited with developing a conceptual model specific to nursing, with man as the central focus?
A). Sister Callista Roy.
B). Dorothea Orem.
C). Martha Rogers.
D). Florence Nightingale.
Question 19 Answer: C). Martha Rogers.
Question 19 Explanation: Martha Roger’s life process model views man as an evolving creature interacting with the environment in an open, adaptive manner. According to this model, the purpose of nursing is to help man achieve maximum health in his environment.
Question 20. The term gavage indicates:
A). Administration of a liquid feeding into the stomach.
B). Irrigation of the stomach with a solution.
C). A surgical opening through the abdomen to the stomach.
D). Visual examination of the stomach.
Question 20 Answer: A). Administration of a liquid feeding into the stomach.
Question 20 Explanation: Gavage is the administration of a liquid feeding into the stomach
Question 21. The average daily amount of urine excreted by an adult is:
A). 1,000 to 1,200 ml.
B). 1,500 to 2,000 ml.
C). 800 to 1,400 ml.
D). 500 to 600 ml.
Question 21 Answer: B). 1,500 to 2,000 ml.
Question 21 Explanation: An adult’s average urine output ranges between 1,500 and 2,000 ml/day.
Question 22. Which of the following may be considered a patient’s right?
A). The right to ignore hospital regulations.
B). The right to refuse to pay for what the patient considers to be inferior service..
C). The right to refuse treatment.
D). The right to euthanasia.
Question 22 Answer: C). The right to refuse treatment.
Question 22 Explanation: Under the bill of rights law, the patient has the right to refuse treatment/life – giving measures, to the extent permitted by law, and to be informed of the medical consequences of his action.
Question 23. Postural drainage to relieve respiratory congestion should take place:
A). At the nurse’s convenience.
B). Before meals.
C). At the patient’s convenience.
D). After meals.
Question 23 Answer: B). Before meals.
Question 23 Explanation: Postural drainage is best performed before, rather after meals to avoid tiring the patient or inducing vomiting. The patient’s safety supersedes the convenience in scheduling this procedure.
Question 24. Antiembolism stockings are used primarily to:
A). Prevent dependent edema.
B). Promote venous circulation.
C). Hold foot dressings.
D). Provide external warmth.
Question 24 Answer: B). Promote venous circulation.
Question 24 Explanation: Antiembolism stockings are elastic stockings designed to maintain compression of small veins and capillaries in the legs.
Question 25. To promote correct anatomic alignment in a supine patient, the nurse should:
A). Adduct the patient’s shoulder.
B). Place the patient’s feet in dorsiflexion.
C). Hyperextend the patient’s neck.
D). Place a pillow under the patient’s knees.
Question 25 Answer: B). Place the patient’s feet in dorsiflexion.
Question 25 Explanation: Anatomic alignment prevents strain on body parts, maintains balance, and promotes physiologic functioning. To promote this position, the nurse should place the feet in dorsiflexion (at right angles to the legs)