NCLEX Practice Exam for Fundamentals of Nursing #06 In Text Mode: All questions and answers are given for reading and answering at your own pace.
Question 1. The doctor orders dextrose 5% in water, 1,000 ml to be infused over 8 hours. The I.V. tubing delivers 15 drops per milliliter. The nurse in charge should run the I.V. infusion at a rate of:
A). 15 drop per minute.
B). 32 drop per minute.
C). 21 drop per minute.
D). 125 drops per minute.
Question 1 Answer: B). 32 drop per minute.
Question 1 Explanation: Giving 1,000 ml over 8 hours is the same as giving 125 ml over 1 hour (60 minutes) to find the number of milliliters per minute:
125/60 min = X/1 minute
60X = 125X = 2.1 ml/minute
To find the number of drops/minute:
2.1 ml/X gtts = 1 ml/15 gtts
X = 32 gtts/minute, or 32 drops/minute
Question 2. When examining a patient with abdominal pain the nurse in charge should assess:
A). Any quadrant first.
B). The symptomatic quadrant either second or third.
C). The symptomatic quadrant last.
D). The symptomatic quadrant first.
Question 2 Answer: C). The symptomatic quadrant last.
Question 2 Explanation: The nurse should systematically assess all areas of the abdomen, if time and the patient’s condition permit, concluding with the symptomatic area. Otherwise, the nurse may elicit pain in the symptomatic area, causing the muscles in other areas to tighten. This would interfere with further assessment.
Question 3. The nurse is assessing a postoperative adult patient. Which of the following should the nurse document as subjective data?
A). Electrocardiographic (ECG) waveforms.
B). Vital signs.
C). Patient’s description of pain.
D). Laboratory test result.
Question 3 Answer: C). Patient’s description of pain.
Question 3 Explanation: Subjective data come directly from the patient and usually are recorded as direct quotations that reflect the patient’s opinions or feelings about a situation. Vital signs, laboratory test result, and ECG waveforms are examples of objective data.
Question 4. A patient is in the bathroom when the nurse enters to give a prescribed medication. What should the nurse in charge do?
A). Wait for the patient to return to bed, and then leave the medication at the bedside.
B). Leave the medication at the patient’s bedside.
C). Tell the patient to be sure to take the medication. And then leave it at the bedside.
D). Return shortly to the patient’s room and remain there until the patient takes the medication.
Question 4 Answer: D). Return shortly to the patient’s room and remain there until the patient takes the medication.
Question 4 Explanation: The nurse should return shortly to the patient’s room and remain there until the patient takes the medication to verify that it was taken as directed. The nurse should never leave medication at the patient’s bedside unless specifically requested to do so.
Question 5. To evaluate a patient for hypoxia, the physician is most likely to order which laboratory test?
A). Red blood cell count.
B). Sputum culture.
C). Total hemoglobin.
D). Arterial blood gas (ABG) analysis.
Question 5 Answer: D). Arterial blood gas (ABG) analysis.
Question 5 Explanation: All of these test help evaluate a patient with respiratory problems. However, ABG analysis is the only test evaluates gas exchange in the lungs, providing information about patient’s oxygenation status.
Question 6. A male patient has a soft wrist-safety device. Which assessment finding should the nurse consider abnormal?
A). A palpable ulnar pulse.
B). Pink nail beds.
C). A palpable radial pulse.
D). Cool, pale fingers.
Question 6 Answer: D). Cool, pale fingers.
Question 6 Explanation: A safety device on the wrist may impair circulation and restrict blood supply to body tissues. Therefore, the nurse should assess the patient for signs of impaired circulation, such as cool, pale fingers. A palpable radial or lunar pulse and pink nail beds are normal findings.
Question 7. The nurse in charge measures a patient’s temperature at 102 degrees F. what is the equivalent Centigrade temperature?
A). 40.1 degrees C.
B). 39 degrees C.
C). 38.9 degrees C.
D). 47 degrees C.
Question 7 Answer: C). 38.9 degrees C.
Question 7 Explanation: To convert Fahrenheit degrees to centigrade, use this formula:
C degrees = (F degrees – 32) x 5/9
C degrees = (102 – 32) 5/9
+ 70 x 5/9
38.9 degrees C
Question 8. The nurse in charge is transferring a patient from the bed to a chair. Which action does the nurse take during this patient transfer?
A). Stands behind the patient.
B). Helps the patient dangle the legs.
C). Position the head of the bed flat.
D). Places the chair facing away from the bed.
Question 8 Answer: B). Helps the patient dangle the legs.
Question 8 Explanation: After placing the patient in high Fowler’s position and moving the patient to the side of the bed, the nurse helps the patient sit on the edge of the bed and dangle the legs; the nurse then faces the patient and places the chair next to and facing the head of the bed.
Question 9. An employer establishes a physical exercise area in the workplace and encourages all employees to use it. This is an example of which level of health promotion?
A). Secondary prevention.
B). Primary prevention.
C). Tertiary prevention.
D). Passive prevention.
Question 9 Answer: B). Primary prevention.
Question 9 Explanation: Primary prevention precedes disease and applies to health patients. Secondary prevention focuses on patients who have health problems and are at risk for developing complications. Tertiary prevention enables patients to gain health from others’ activities without doing anything themselves
Question 10. When teaching a female patient how to take a sublingual tablet, the nurse should instruct the patient to place the table on the:
A). Inside of the cheek.
B). Top of the tongue.
C). Roof of the mouth.
D). Floor of the mouth.
Question 10 Answer: D). Floor of the mouth.
Question 10 Explanation: The nurse should instruct the patient to touch the tip of the tongue to the roof of the mouth and then place the sublingual tablet on the floor of the mouth. Sublingual medications are absorbed directly into the bloodstream form the oral mucosa, bypassing the GI and hepatic systems. No drug is administered on top of the tongue or on the roof of the mouth. With the buccal route, the tablet is placed between the gum and the cheek.
Question 11. Which pulse should the nurse palpate during rapid assessment of an unconscious male adult?
Question 11 Answer: C). Carotid.
Question 11 Explanation: During a rapid assessment, the nurse’s first priority is to check the patient’s vital functions by assessing his airway, breathing, and circulation. To check a patient’s circulation, the nurse must assess his heart and vascular network function. This is done by checking his skin color, temperature, mental status and, most importantly, his pulse. The nurse should use the carotid artery to check a patient’s circulation. In a patient with a circulatory problems or a history of compromised circulation, the radial pulse may not be palpable. The brachial pulse is palpated during rapid assessment of an infant.
Question 12. A female patient with a terminal illness is in denial. Indicators of denial include:
B). Preparatory grief.
D). Shock dismay.
Question 12 Answer: D). Shock dismay.
Question 12 Explanation: Shock and dismay are early signs of denial-the first stage of grief. The other options are associated with depression—a later stage of grief.
Question 13. Which human element considered by the nurse in charge during assessment can affect drug administration?
A). The patient’s cognitive abilities.
B). The patient’s occupational hazards.
C). The patient’s socioeconomic status.
D). The patient’s ability to recover.
Question 13 Answer: A). The patient’s cognitive abilities.
Question 13 Explanation: The nurse must consider the patient’s cognitive abilities to understand drug instructions. If not, the nurse must find a family member or significant other to take on the responsibility of administering medications in the home setting. The patient’s ability to recover, occupational hazards, and socioeconomic status do not affect drug administration
Question 14. The physician prescribes 250 mg of a drug. The drug vial reads 500 mg/ml. how much of the drug should the nurse give?
A). 2 ml.
B). ½ ml.
C). ¼ ml.
D). 1 ml.
Question 14 Answer: B). ½ ml.
Question 14 Explanation: The nurse should give ½ ml of the drug. The dosage is calculated as follows:
250 mg/X=500 mg/1 ml
Question 15. A female patient is being discharged after cataract surgery. After providing medication teaching, the nurse asks the patient to repeat the instructions. The nurse is performing which professional role?
B). Patient advocate.
Question 15 Answer: C). Educator.
Question 15 Explanation: When teaching a patient about medications before discharge, the nurse is acting as an educator. The nurse acts as a manager when performing such activities as scheduling and making patient care assignments. The nurse performs the care giving role when providing direct care, including bathing patients and administering medications and prescribed treatments. The nurse acts as a patient advocate when making the patient’s wishes known to the doctor.
Question 16. Before administering the evening dose of a prescribed medication, the nurse on the evening shift finds an unlabeled, filled syringe in the patient’s medication drawer. What should the nurse in charge do?
A). Use the syringe because it looks like it contains the same medication the nurse was prepared to give.
B). Discard the syringe to avoid a medication error.
C). Obtain a label for the syringe from the pharmacy.
D). Call the day nurse to verify the contents of the syringe.
Question 16 Answer: B). Discard the syringe to avoid a medication error.
Question 16 Explanation: As a safety precaution, the nurse should discard an unlabeled syringe that contains medication. The other options are considered unsafe because they promote error.
Question 17. What does the nurse in charge do when making a surgical bed?
A). Rolls the patient to the far side of the bed.
B). Tucks the top sheet and blanket under the bottom of the bed.
C). Leaves the bed in the high position when finished.
D). Places the pillow at the head of the bed.
Question 17 Answer: C). Leaves the bed in the high position when finished.
Question 17 Explanation: When making a surgical bed, the nurse leaves the bed in the high position when finished. After placing the top linens on the bed without pouching them, the nurse fanfolds these linens to the side opposite from where the patient will enter and places the pillow on the bedside chair. All these actions promote transfer of the postoperative patient from the stretcher to the bed. When making an occupied bed or unoccupied bed, the nurse places the pillow at the head of the bed and tucks the top sheet and blanket under the bottom of the bed. When making an occupied bed, the nurse rolls the patient to the far side of the bed.
Question 18. A female patient who speaks a little English has emergency gallbladder surgery, during discharge preparation, which nursing action would best help this patient understand wound care instruction?
A). Demonstrating the procedure and having the patient return the demonstration.
B). Asking frequently if the patient understands the instruction.
C). Asking an interpreter to replay the instructions to the patient..
D). Writing out the instructions and having a family member read them to the patient.
Question 18 Answer: A). Demonstrating the procedure and having the patient return the demonstration.
Question 18 Explanation: Demonstrating by the nurse with a return demonstration by the patient ensures that the patient can perform wound care correctly. Patients may claim to understand discharge instruction when they do not. An interpreter of family member may communicate verbal or written instructions inaccurately.
Question 19. A male patient is to be discharged with a prescription for an analgesic that is a controlled substance. During discharge teaching, the nurse should explain that the patient must fill this prescription how soon after the date on which it was written?
A). Within 12 months.
B). Within 6 months.
C). Within 3 months.
D). Within 1 month.
Question 19 Answer: B). Within 6 months.
Question 19 Explanation: In most cases, an outpatient must fill a prescription for a controlled substance within 6 months of the date on which the prescription was written.
Question 20. Nurse Mackey is monitoring a patient for adverse reactions during barbiturate therapy. What is the major disadvantage of barbiturate use?
A). Poor absorption.
B). Prolonged half-life.
C). Potential for drug dependence.
D). Potential for hepatotoxicity.
Question 20 Answer: C). Potential for drug dependence.
Question 20 Explanation: Patients can become dependent on barbiturates, especially with prolonged use. Because of the rapid distribution of some barbiturates, no correlation exists between duration of action and half-life. Barbiturates are absorbed well and do not cause hepatotoxicity, although existing hepatic damage does require cautions use of the drug because barbiturates are metabolized in the liver.
Question 21. Which nursing action is essential when providing continuous enteral feeding?
A). Hanging a full day’s worth of formula at one time.
B). Warming the formula before administering it.
C). Elevating the head of the bed.
D). Positioning the patient on the left side.
Question 21 Answer: C). Elevating the head of the bed.
Question 21 Explanation: Elevating the head of the bed during enteral feeding minimizes the risk of aspiration and allows the formula to flow in the patient’s intestines. When such elevation is contraindicated, the patient should be positioned on the right side. The nurse should give enteral feeding at room temperature to minimize GI distress. To limit microbial growth, the nurse should hang only the amount of formula that can be infused in 3 hours.
Question 22. A male patient undergoes a total abdominal hysterectomy. When assessing the patient 10 hours later, the nurse identifies which finding as an early sign of shock?
A). Pale, warm, dry skin.
C). Heart rate of 110 beats/minute.
D). Urine output of 30 ml/hour.
Question 22 Answer: B). Restlessness.
Question 22 Explanation: Early in shock, hyperactivity of the sympathetic nervous system causes increased epinephrine secretion, which typically makes the patient restless, anxious, nervous, and irritable. It also decreases tissue perfusion to the skin, causing pale, cool clammy skin. An above-normal heart rate is a late sign of shock. A urine output of 30 ml/hour is within normal limits.
Question 23. The physician orders heparin, 7,500 units, to be administered subcutaneously every 6 hours. The vial reads 10,000 units per milliliter. The nurse should
anticipate giving how much heparin for each dose?
A). ¼ ml.
B). ¾ ml.
C). 1 ¼ ml.
D). ½ ml.
Question 23 Answer: B). ¾ ml.
Question 23 Explanation: The nurse solves the problem as follows:
10,000 units/7,500 units = 1 ml/X
10,000 X = 7,500
X= 7,500/10,000 or ¾ ml
Question 24. When administering drug therapy to a male geriatric patient, the nurse must stay especially alert for adverse effects. Which factor makes geriatric patients to adverse drug effects?
A). Faster drug clearance.
B). Aging-related physiological changes.
C). Enhanced blood flow to the GI tract.
D). Increased amount of neurons.
Question 24 Answer: B). Aging-related physiological changes.
Question 24 Explanation: Aging-related physiological changes account for the increased frequency of adverse drug reactions in geriatric patients. Renal and hepatic changes cause drugs to clear more slowly in these patients. With increasing age, neurons are lost and blood flow to the GI tract decreases.
Question 25. Which of the following planes divides the body longitudinally into anterior and posterior regions?
A). Transverse plane.
B). Frontal plane.
C). Sagittal plane.
D). Midsagittal plane.
Question 25 Answer: B). Frontal plane.
Question 25 Explanation: Frontal or coronal plane runs longitudinally at a right angle to a sagittal plane dividing the body in anterior and posterior regions. A sagittal plane runs longitudinally dividing the body into right and left regions; if exactly midline, it is called a midsagittal plane. A transverse plane runs horizontally at a right angle to the vertical axis, dividing the structure into superior and inferior regions.
Question 26. Which action by the nurse in charge is essential when cleaning the area around a Jackson-Pratt wound drain?
A). Removing the drain before cleaning the skin.
B). Cleaning from the center outward in a circular motion.
C). Cleaning briskly around the site with alcohol.
D). Wearing sterile gloves and a mask.
Question 26 Answer: B). Cleaning from the center outward in a circular motion.
Question 26 Explanation: The nurse always should clean around a wound drain, moving from center outward in ever-larger circles, because the skin near the drain site is more contaminated than the site itself. The nurse should never remove the drain before cleaning the skin. Alcohol should never be used to clean around a drain; it may irritate the skin and has no lasting effect on bacteria because it evaporates. The nurse should wear sterile gloves to prevent contamination, but a mask is not necessary.
Question 27. A female patient exhibits signs of heightened anxiety. Which response by the nurse is most likely to reduce the patient’s anxiety?
A). “Everything will be fine. Don’t worry.”.
B). “Why don’t you listen to the radio?”.
C). “Read this manual and then ask me any questions you may have.”.
D). “Let’s talk about what’s bothering you.”.
Question 27 Answer: D). “Let’s talk about what’s bothering you.”.
Question 27 Explanation: Anxiety may result from feeling of helplessness, isolation, or insecurity. This response helps reduce anxiety by encouraging the patient to express feelings. The nurse should be supportive and develop goals together with the patient to give the patient some control over an anxiety-inducing situation. Because the other options ignore the patient’s feeling and block communication, they would not reduce anxiety.
Question 28. A scrub nurse in the operating room has which responsibility?
A). Positioning the patient.
B). Handling surgical instruments to the surgeon.
C). Assisting with gowning and gloving.
D). Applying surgical drapes.
Question 28 Answer: B). Handling surgical instruments to the surgeon.
Question 28 Explanation: The scrub nurse assist the surgeon by providing appropriate surgical instruments and supplies, maintaining strict surgical asepsis and, with the circulating nurse, accounting for all gauze, sponges, needles, and instruments. The circulating nurse assists the surgeon and scrub nurse, positions the patient, applies appropriate equipment and surgical drapes, assists with gowning and gloving, and provides the surgeon and scrub nurse with supplies.
Question 29. The nurse uses a stethoscope to auscultate a male patient’s chest. Which statement about a stethoscope with a bell and diaphragm is true?
A). The diaphragm detects high-pitched sounds best.
B). The bell detects thrills best.
C). The diaphragm detects low-pitched sounds best.
D). The bell detects high-pitched sounds best.
Question 29 Answer: A). The diaphragm detects high-pitched sounds best.
Question 29 Explanation: The diaphragm of a stethoscope detects high-pitched sound best; the bell detects low pitched sounds best. Palpation detects thrills best.
Question 30. Nurse Brenda is teaching a patient about a newly prescribed drug. What could cause a geriatric patient to have difficulty retaining knowledge about prescribed medications?
A). Lack of family support.
B). Decreased plasma drug levels.
C). Sensory deficits.
D). History of Tourette syndrome.
Question 30 Answer: C). Sensory deficits.
Question 30 Explanation: Sensory deficits could cause a geriatric patient to have difficulty retaining knowledge about prescribed medications. Decreased plasma drug levels do not alter the patient’s knowledge about the drug. A lack of family support may affect compliance, not knowledge retention. Toilette syndrome is unrelated to knowledge retention.