NCLEX Practice Exam for Fundamentals of Nursing #07 In Text Mode: All questions and answers are given for reading and answering at your own pace.
Question 1. While examining a client’s leg, the nurse notes an open ulceration with visible granulation tissue in the wound. Until a wound specialist can be contacted, which type of dressings is most appropriate for the nurse in charge to apply?
A). Sterile petroleum gauze.
B). Dry sterile dressing.
C). Povidone-iodine-soaked gauze.
D). Moist, sterile saline gauze.
Question 1 Answer: D). Moist, sterile saline gauze.
Question 1 Explanation: Moist, sterile saline dressings support would heal and are cost-effective. Dry sterile dressings adhere to the wound and debride the tissue when removed. Petroleum supports healing but is expensive. Povidone-iodine can irritate epithelial cells, so it shouldn’t be left on an open wound.
Question 2. A male client is admitted to the hospital with blunt chest trauma after a motor vehicle accident. The first nursing priority for this client would be to:
A). Encourage deep breathing and coughing.
B). Provide pain relief.
C). Assess the client’s airway.
D). Splint the chest wall with a pillow.
Question 2 Answer: C). Assess the client’s airway.
Question 2 Explanation: The first priority is to evaluate airway patency before assessing for signs of obstruction, sternal retraction, stridor, or wheezing. Airway management is always the nurse’s first priority. Pain management and splinting are important for the client’s comfort, but would come after airway assessment. Coughing and deep breathing may be contraindicated if the client has internal bleeding and other injuries.
Question 3. The nurse in charge must monitor a patient receiving chloramphenicol for adverse drug reaction. What is the most toxic reaction to chloramphenicol?
A). Malignant hypertension.
B). Bone marrow suppression.
C). Status epilepticus.
D). Lethal arrhythmias.
Question 3 Answer: B). Bone marrow suppression.
Question 3 Explanation: The most toxic reaction to chloramphenicol is bone marrow suppression. Chloramphenicol is not known to cause lethal arrhythmias, malignant hypertension, or status epilepticus.
Question 4. A newly hired charge nurse assesses the staff nurses as competent individually but ineffective and nonproductive as a team. In addressing her concern, the charge nurse should understand that the usual reason for such a situation is:
A). Failure to incorporate staff in decision making.
B). Unexpected feeling and emotions among the staff.
C). Unhappiness about the charge in leadership.
D). Fatigue from overwork and understaffing.
Question 4 Answer: B). Unexpected feeling and emotions among the staff.
Question 4 Explanation: The usual or most prevalent reason for lack of productivity in a group of competent nurses is inadequate communication or a situation in which the nurses have unexpected feeling and emotions. Although the other options could be contributing to the problematic situation, they’re less likely to be the cause.
Question 5. The nurse in charge is assessing a patient’s abdomen. Which examination technique should the nurse use first?
Question 5 Answer: C). Inspection.
Question 5 Explanation: Inspection always comes first when performing a physical examination. Percussion and palpation of the abdomen may affect bowel motility and therefore should follow auscultation.
Question 6. A male client in a behavioral-health facility receives a 30-minute psychotherapy session, and provider uses a current procedure terminology (CPT) code that bills for a 50-minute session. Under the False Claims Act, such illegal behavior is known as:
Question 6 Answer: D). Upcoding.
Question 6 Explanation: Upcoding is the practice of using a CPT code that’s reimbursed at a higher rate than the code for the service actually provided. Unbundling, overbilling, and misrepresentation aren’t the terms used for this illegal practice.
Question 7. Using Abraham Maslow’s hierarchy of human needs, a nurse assigns highest priority to which client need?
Question 7 Answer: D). Elimination.
Question 7 Explanation: According to Maslow, elimination is a first-level or physiological need, and therefore takes priority over all other needs. Security and safety are second-level needs; belonging is a third-level need. Second- and third-level needs can be met only after a client’s first-level needs have been satisfied.
Question 8. A male client is on prolonged bed rest has developed a pressure ulcer. The wound shows no signs of healing even though the client has received skin care and has been turned every 2 hours. Which factor is most likely responsible for the failure to heal?
A). Inadequate massaging of the affected area.
B). Low calcium level.
C). Inadequate vitamin D intake.
D). Inadequate protein intake.
Question 8 Answer: D). Inadequate protein intake.
Question 8 Explanation: A client on bed rest suffers from a lack of movement and a negative nitrogen balance. Therefore, inadequate protein intake impairs wound healing. Inadequate vitamin D intake and low calcium levels aren’t factors in poor healing for this client. A pressure ulcer should never be massaged.
Question 9. Which intervention is an example of primary prevention?
A). Obtaining a Papanicolaou smear to screen for cervical cancer.
B). Using occupational therapy to help a patient cope with arthritis.
C). Administering digoxin (Lanoxicaps) to a patient with heart failure.
D). Administering a measles, mumps, and rubella immunization to an infant.
Question 9 Answer: D). Administering a measles, mumps, and rubella immunization to an infant.
Question 9 Explanation: Immunizing an infant is an example of primary prevention, which aims to prevent health problems. 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. 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.
Question 10. One aspect of implementation related to drug therapy is:
A). Setting realistic client goals.
B). Documenting drugs given.
C). Establishing outcome criteria.
D). Developing a content outline.
Question 10 Answer: B). Documenting drugs given.
Question 10 Explanation: Although documentation isn’t a step in the nursing process, the nurse is legally required to document activities related to drug therapy, including the time of administration, the quantity, and the client’s reaction. Developing a content outline, establishing outcome criteria, and setting realistic client goals are part of planning rather than implementation.
Question 11. Which document addresses the client’s right to information, informed consent, and treatment refusal?
A). Code for Nurses.
B). Standard of Nursing Practice.
C). Patient’s Bill of Rights.
D). Nurse Practice Act.
Question 11 Answer: C). Patient’s Bill of Rights.
Question 11 Explanation: The Patient’s Bill of Rights addresses the client’s right to information, informed consent, timely responses to requests for services, and treatment refusal. A legal document, it serves as a guideline for the nurse’s decision making. Standards of Nursing Practice, the Nurse Practice Act, and the Code for Nurses contain nursing practice parameters and primarily describe the use of the nursing process in providing care.
Question 12. A male client blood test results are as follows: white blood cell (WBC) count, 100ul; hemoglobin (Hb) level, 14 g/dl; hematocrit (HCT), 40%. Which goal would be most important for this client?
A). Promote rest.
B). Promote fluid balance.
C). Prevent infection.
D). Prevent injury.
Question 12 Answer: C). Prevent infection.
Question 12 Explanation: The client is at risk for infection because WBC count is dangerously low. Hb level and HCT are within normal limits; therefore, fluid balance, rest, and prevention of injury are inappropriate.
Question 13. Nurse Danny has been teaching a client about a high-protein diet. The teaching is successful if the client identifies which meal as high in protein?
A). Baked beans, hamburger, and milk.
B). Bouillon, spinach, and soda.
C). Spaghetti with cream sauce, broccoli, and tea.
D). Chicken cutlet, spinach, and soda.
Question 13 Answer: A). Baked beans, hamburger, and milk.
Question 13 Explanation: Baked beans, hamburger, and milk are all excellent sources of protein. The spaghetti-broccoli-tea choice is high in carbohydrates. The bouillon-spinach-soda choice provides liquid and sodium as well as some iron, vitamins, and carbohydrates. Chicken provides protein but the chicken-spinach-soda combination provides less protein than the baked beans-hamburger-milk selection.
Question 14. Nurse Berri inspects a client’s pupil size and determines that it’s 2 mm in the left eye and 3 mm in the right eye. Unequal pupils are known as:
Question 14 Answer: B). Anisocoria.
Question 14 Explanation: Unequal pupils are called anisocoria. Ataxia is uncoordinated actions of involuntary muscle use. A cataract is an opacity of the eye’s lens. Diplopia is double vision.
Question 15. When positioned properly, the tip of a central venous catheter should lie in the:
A). Jugular vein.
B). Superior vena cava.
C). Subclavian vein.
D). Basilica vein.
Question 15 Answer: B). Superior vena cava.
Question 15 Explanation: When the central venous catheter is positioned correctly, its tip lies in the superior vena cava, inferior vena cava, or the right atrium—that is, in central venous circulation. Blood flows unimpeded around the tip, allowing the rapid infusion of large amounts of fluid directly into circulation. The basilica, jugular, and subclavian veins are common insertion sites for central venous catheters.
Question 16. A female patient is receiving furosemide (Lasix), 40 mg P.O. b.i.d. in the plan of care, the nurse should emphasize teaching the patient about the importance of consuming:
A). Fresh, green vegetables.
B). Creamed corn.
C). Bananas and oranges.
D). Lean red meat.
Question 16 Answer: C). Bananas and oranges.
Question 16 Explanation: Because furosemide is a potassium-wasting diuretic, the nurse should plan to teach the patient to increase intake of potassium-rich foods, such as bananas and oranges. Fresh, green vegetables; lean red meat; and creamed corn are not good sources of potassium.
Question 17. Following a tonsillectomy, a female client returns to the medical-surgical unit. The client is lethargic and reports having a sore throat. Which position would be most therapeutic for this client?
Question 17 Answer: D). Side-lying.
Question 17 Explanation: Because of lethargy, the post tonsillectomy client is at risk for aspirating blood from the surgical wound. Therefore, placing the client in the side-lying position until he awake is best. The semi-Fowler’s, supine, and high-Fowler’s position don’t allow for adequate oral drainage in a lethargic post tonsillectomy client, and increase the risk of blood aspiration.
Question 18. A female client who received general anesthesia returns from surgery. Postoperatively, which nursing diagnosis takes highest priority for this client?
A). Acute pain related to surgery.
B). Risk for aspiration related to anesthesia.
C). Deficient fluid volume related to blood and fluid loss from surgery.
D). Impaired physical mobility related to surgery.
Question 18 Answer: B). Risk for aspiration related to anesthesia.
Question 18 Explanation: Risk for aspiration related to anesthesia takes priority for thins client because general anesthesia may impair the gag and swallowing reflexes, possibly leading to aspiration. The other options, although important, are secondary.
Question 19. A female client is readmitted to the facility with a warm, tender, reddened area on her right calf. Which contributing factor would the nurse recognize as most important?
A). A history of increased aspirin use.
B). A history of diabetes.
C). An active daily walking program.
D). Recent pelvic surgery.
Question 19 Answer: D). Recent pelvic surgery.
Question 19 Explanation: The client shows signs of deep vein thrombosis (DVT). The pelvic area is rich in blood supply, and thrombophlebitis of the deep vein is associated with pelvic surgery. Aspirin, an antiplatelet agent, and an active walking program help decrease the client’s risk of DVT. In general, diabetes is a contributing factor associated with peripheral vascular disease.
Question 20. Nurse Margareth is revising a client’s care plan. During which step of the nursing process does such revision take place?
Question 20 Answer: D). Evaluation.
Question 20 Explanation: During the evaluation step of the nursing process the nurse determines whether the goals established in the care plan have been achieved, and evaluates the success of the plan. If a goal is unmet or partially met the nurse reexamines the data and revises the plan. Assessment involves data collection. Planning involves setting priorities, establishing goals, and selecting appropriate interventions.
Question 21. A 65-year-old female who has diabetes mellitus and has sustained a large laceration on her left wrist asks the nurse, “How long will it take for my scars to disappear?” which statement would be the nurse’s best response?
A). “If you don’t develop an infection, the wound should heal any time between 1 and 3 years from now.”.
B). “With your history and the type of location of the injury, it’s hard to say.”.
C). “Wound healing is very individual but within 4 months the scar should fade.”.
D). “The contraction phase of wound healing can take 2 to 3 years.”.
Question 21 Answer: B). “With your history and the type of location of the injury, it’s hard to say.”.
Question 21 Explanation: Wound healing in a client with diabetes will be delayed. Providing the client with a time frame could give the client false information.
Question 22. If a blood pressure cuff is too small for a client, blood pressure readings taken with such a cuff may do which of the following?
A). Produce a false-low measurement.
B). Produce a false-high measurement.
C). Cause sciatic nerve damage.
D). Fail to show changes in blood pressure.
Question 22 Answer: B). Produce a false-high measurement.
Question 22 Explanation: Using an undersized blood pressure cuff produces a falsely elevated blood pressure because the cuff can’t record brachial artery measurements unless it’s excessively inflated. The sciatic nerve wouldn’t be damaged by hyperinflation of the blood pressure cuff because the sciatic nerve is located in the lower extremity.
Question 23. The nurse in charge identifies a patient’s responses to actual or potential health problems during which step of the nursing process?
C). Nursing diagnosis.
Question 23 Answer: C). Nursing diagnosis.
Question 23 Explanation: The nurse identifies human responses to actual or potential health problems during the nursing diagnosis step of the nursing process. During the assessment step, the nurse systematically collects data about the patient or family. During the planning step, the nurse develops strategies to resolve or decrease the patient’s problem. During the evaluation step, the nurse determines the effectiveness of the plan of care.
Question 24. 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 base.
C). S1 is loudest at the apex, and S2 is loudest at the base.
D). S1 and S2 sound fainter at the apex.
Question 24 Answer: C). S1 is loudest at the apex, and S2 is loudest at the base.
Question 24 Explanation: 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
Question 25. The nurse in charge is caring for an Italian client. He’s complaining of pain, but he falls asleep right after his complaint and before the nurse can assess his pain. The nurse concludes that:
A). He may have a low threshold for pain.
B). He was faking pain.
C). The pain went away.
D). Someone else gave him medication.
Question 25 Answer: A). He may have a low threshold for pain.
Question 25 Explanation: People of Italian heritage tend to verbalize discomfort and pain. The pain was real to the client, and he may need medication when he wakes up.
Question 26. Which intervention should the nurse in charge try first for a client that exhibits signs of sleep disturbance?
A). Provide the client with normal sleep aids, such as pillows, back rubs, and snacks.
B). Teach the client relaxation techniques, such as guided imagery, medication, and progressive muscle relaxation.
C). Ask the client each morning to describe the quantity of sleep during the previous night.
D). Administer sleeping medication before bedtime.
Question 26 Answer: A). Provide the client with normal sleep aids, such as pillows, back rubs, and snacks.
Question 26 Explanation: The nurse should begin with the simplest interventions, such as pillows or snacks, before interventions that require greater skill such as relaxation techniques. Sleep medication should be avoided whenever possible. At some point, the nurse should do a thorough sleep assessment, especially if common sense interventions fail
Question 27. A female patient is diagnosed with deep-vein thrombosis. Which nursing diagnosis should receive highest priority at this time?
A). Altered peripheral tissue perfusion related to venous congestion.
B). Fluid volume excess related to peripheral vascular disease.
C). Risk for injury related to edema.
D). Impaired gas exchanges related to increased blood flow.
Question 27 Answer: A). Altered peripheral tissue perfusion related to venous congestion.
Question 27 Explanation: Altered peripheral tissue perfusion related to venous congestion” takes highest priority because venous inflammation and clot formation impede blood flow in a patient with deep-vein thrombosis. Impaired gas exchange is related to decreased, not increased, blood flow. No evidence suggest that this patient has a fluid volume excess. Risk for injury related to edema may be warranted but is secondary to altered tissue perfusion.
Question 28. A nurse assigned to care for a postoperative male client who has diabetes mellitus. During the assessment interview, the client reports that he’s impotent and says that he’s concerned about its effect on his marriage. In planning this client’s care, the most appropriate intervention would be to:
A). Encourage the client to ask questions about personal sexuality.
B). Provide time for privacy.
C). Suggest referral to a sex counselor or other appropriate professional.
D). Provide support for the spouse or significant other.
Question 28 Answer: C). Suggest referral to a sex counselor or other appropriate professional.
Question 28 Explanation: The nurse should refer this client to a sex counselor or other professional. Making appropriate referrals is a valid part of planning the client’s care. The nurse doesn’t normally provide sex counseling. Therefore, providing time for privacy and providing support for the spouse or significant other are important, but not as important as referring the client to a sex counselor.
Question 29. A female client is admitted to the emergency department with complaints of chest pain shortness of breath. The nurse’s assessment reveals jugular vein
distention. The nurse knows that when a client has jugular vein distension, it’s typically due to:
A). A neck tumor.
B). Fluid overload.
C). An electrolyte imbalance.
Question 29 Answer: B). Fluid overload.
Question 29 Explanation: Fluid overload causes the volume of blood within the vascular system to increase. This increase causes the vein to distend, which can be seen most obviously in the neck veins. A neck tumor doesn’t typically cause jugular vein distention. An electrolyte imbalance may result in fluid overload, but it doesn’t directly contribute to jugular vein distention.
Question 30. Nurse Cay inspects a client’s back and notices small hemorrhagic spots. The nurse documents that the client has:
Question 30 Answer: A). Petechiae.
Question 30 Explanation: Petechiae are small hemorrhagic spots. Extravasation is the leakage of fluid in the interstitial space. Osteomalacia is the softening of bone tissue. Uremia is an excess of urea and other nitrogen products in the blood.