Transcript NCLEX MCQs On Fundamentals of Nursing 1

NCLEX MCQs On
Fundamentals of Nursing 1
1. The most important nursing intervention to correct skin dryness is:
A. Avoid bathing the patient until the condition is remedied, and notify the physician
B. Ask the physician to refer the patient to a dermatologist, and suggest that the
patient wear home-laundered sleepwear
C. Consult the dietitian about increasing the patient’s fat intake, and take necessary
measures to prevent infection
D. Encourage the patient to increase his fluid intake, use non-irritating soap when
bathing the patient, and apply lotion to the involved areas
1. Answer: D. Encourage the patient to increase his fluid intake, use non-irritating soap
when bathing the patient, and apply lotion to the involved areas
Dry skin will eventually crack, leading to infection. To prevent this, the nurse should
provide adequate hydration through fluid intake, use nonirritating soaps or no soap
when bathing the patient, and lubricate the patient’s skin with lotion. Bathing may be
limited but need not be avoided entirely.
2. When bathing a patient’s extremities, the nurse should use long, firm strokes from the distal to
the proximal areas. This technique:
A. Provides an opportunity for skin assessment
B. Avoids undue strain on the nurse
C. Increases venous blood return
D. Causes vasoconstriction and increases circulation
2. Answer: C. Increases venous blood return
Washing from distal to proximal areas stimulates venous blood flow, thereby preventing
venous stasis. It improves circulation but does not result in vasoconstriction. The nurse
can assess the patient’s condition throughout the bath, regardless of washing technique,
and should feel no strain while bathing the patient.
3. Vivid dreaming occurs in which stage of sleep?
A. Stage I non-REM
B. Rapid eye movement (REM) stage
C. Stage II non-REM
D. Delta stage
3. Answer: B. Rapid eye movement (REM) stage
Other characteristics of rapid eye movement (REM) sleep are deep sleep (the patient cannot
be awakened easily), depressed muscle tone, and possibly irregular heart and
respiratory rates. Non-REM sleep is a deep, restful sleep without dreaming. Delta stage,
or slow-wave sleep, occurs during non-REM Stages III and IV and is often equated with
quiet sleep.
4. The natural sedative in meat and milk products (especially warm milk) that can help induce
sleep is:
A. Flurazepam
B. Temazepam
C. Tryptophan
D. Methotrimeprazine
4. Answer: C. Tryptophan
Tryptophan is a natural sedative; flurazepam (Dalmane), temazepam (Restoril), and
methotrimeprazine (Levoprome) are hypnotic sedatives.
5. Nursing interventions that can help the patient to relax and sleep restfully include all of the
following except:
A. Have the patient take a 30- to 60-minute nap in the afternoon
B. Turn on the television in the patient’s room
C. Provide quiet music and interesting reading material
D. Massage the patient’s back with long strokes
5. Answer: A. Have the patient take a 30- to 60-minute nap in the afternoon
Napping in the afternoon is not conductive to nighttime sleeping. Quiet music, watching
television, reading, and massage usually will relax the patient, helping him to fall
asleep.
6. Restraints can be used for all of the following purposes except to:
A. Prevent a confused patient from removing tubes, such as feeding tubes, I.V. lines,
and urinary catheters
B. Prevent a patient from falling out of bed or a chair
C. Discourage a patient from attempting to ambulate alone when he requires
assistance for his safety
D. Prevent a patient from becoming confused or disoriented
6. Answer: D. Prevent a patient from becoming confused or disoriented
By restricting a patient’s movements, restraints may increase stress and lead to confusion,
rather than prevent it. The other choices are valid reasons for using restraints.
7. Which of the following is the nurse’s legal responsibility when applying restraints?
A. Document the patient’s behavior
B. Document the type of restraint used
C. Obtain a written order from the physician except in an emergency, when the
patient must be protected from injury to himself or others
D. All of the above
7. Answer: D. All of the above
When applying restraints, the nurse must document the type of behavior that prompted
her to use them, document the type of restraints used, and obtain a physician’s written
order for the restraints.
8. Kubler-Ross’s five successive stages of death and dying are:
A. Anger, bargaining, denial, depression, acceptance
B. Denial, anger, depression, bargaining, acceptance
C. Denial, anger, bargaining, depression acceptance
D. Bargaining, denial, anger, depression, acceptance
8. Answer: C. Denial, anger, bargaining, depression acceptance
Kubler-Ross’s five successive stages of death and dying are denial, anger, bargaining,
depression, and acceptance. The patient may move back and forth through the different
stages as he and his family members react to the process of dying, but he usually goes
through all of these stages to reach acceptance.
9. A terminally ill patient usually experiences all of the following feelings during the anger stage
except:
A. Rage
B. Envy
C. Numbness
D. Resentment
9. Answer: C. Numbness
Numbness is typical of the depression stage, when the patient feels a great sense of loss.
The anger stage includes such feelings as rage, envy, resentment, and the patient’s
questioning “Why me?”
10. Nurses and other health care provides often have difficulty helping a terminally ill patient through the
necessary stages leading to acceptance of death. Which of the following strategies is most helpful to the
nurse in achieving this goal?
A. Taking psychology courses related to gerontology
B. Reading books and other literature on the subject of thanatology
C. Reflecting on the significance of death
D. Reviewing varying cultural beliefs and practices related to death
10. Answer: C. Reflecting on the significance of death
According to thanatologists, reflecting on the significance of death helps to reduce the fear
of death and enables the health care provider to better understand the terminally ill
patient’s feelings. It also helps to overcome the belief that medical and nursing measures
have failed, when a patient cannot be cured.
11. Which of the following symptoms is the best indicator of imminent death?
A. A weak, slow pulse
B. Increased muscle tone
C. Fixed, dilated pupils
D. Slow, shallow respirations
11. Answer: C. Fixed, dilated pupils
Fixed, dilated pupils are sign of imminent death. Pulse becomes weak but rapid, muscles
become weak and atonic, and periods of apnea occur during respiration.
12. A nurse caring for a patient with an infectious disease who requires isolation should refer to
guidelines published by the:
A. National League for Nursing (NLN)
B. Centers for Disease Control (CDC)
C. American Medical Association (AMA)
D. American Nurses Association (ANA)
12. Answer: B. Centers for Disease Control (CDC)
The Center of Disease Control (CDC) publishes and frequently updates guidelines on
caring for patients who require isolation. The National League of Nursing’s (NLN’s)
major function is accrediting nursing education programs in the United States. The
American Medical Association (AMA) is a national organization of physicians. The
American Nurses’ Association (ANA) is a national organization of registered nurses.
13. To institute appropriate isolation precautions, the nurse must first know the:
A. Organism’s mode of transmission
B. Organism’s Gram-staining characteristics
C. Organism’s susceptibility to antibiotics
D. Patient’s susceptibility to the organism
13. Answer: A. Organism’s mode of transmission
The nurse must first determine the organism’s mode of transmission. For example, an organism
transmitted through nasal secretions requires that the patient be kept in respiratory isolation,
which involves keeping the patient in a private room with the door closed and wearing a mask, a
gown, and gloves when coming in direct contact with the patient. The organism’s Gram-straining
characteristics reveal whether the organism is gram-negative or gram-positive, an important
criterion in the physician’s choice for drug therapy and the nurse’s development of an effective
plan of care. The nurse also needs to know whether the organism is susceptible to antibiotics, but
this could take several days to determine; if she waits for the results before instituting isolation
precautions, the organism could be transmitted in the meantime. The patient’s susceptibility to the
14. Which is the correct procedure for collecting a sputum specimen for culture and sensitivity
testing?
A. Have the patient place the specimen in a container and enclose the container in a
plastic bag
B. Have the patient expectorate the sputum while the nurse holds the container
C. Have the patient expectorate the sputum into a sterile container
D. Offer the patient an antiseptic mouthwash just before he expectorate the sputum
14. Answer: C. Have the patient expectorate the sputum into a sterile container
Placing the specimen in a sterile container ensures that it will not become contaminated.
The other answers are incorrect because they do not mention sterility and because
antiseptic mouthwash could destroy the organism to be cultured (before sputum
collection, the patient may use only tap water for nursing the mouth).
15. An autoclave is used to sterilize hospital supplies because:
A. More articles can be sterilized at a time
B. Steam causes less damage to the materials
C. A lower temperature can be obtained
D. Pressurized steam penetrates the supplies better
15. Answer: D. Pressurized steam penetrates the supplies better
An autoclave, an apparatus that sterilizes equipment by means of high-temperature
pressurized steam, is used because it can destroy all forms of microorganisms, including
spores.
16. The best way to decrease the risk of transferring pathogens to a patient when removing
contaminated gloves is to:
A. Wash the gloves before removing them
B. Gently pull on the fingers of the gloves when removing them
C. Gently pull just below the cuff and invert the gloves when removing them
D. Remove the gloves and then turn them inside out
16. Answer: C. Gently pull just below the cuff and invert the gloves when removing
them
Turning the gloves inside out while removing them keeps all contaminants inside the
gloves. They should then be placed in a plastic bag with soiled dressings and discarded
in a soiled utility room garbage pail (double bagged). The other choices can spread
pathogens within the environment.
17. After having an I.V. line in place for 72 hours, a patient complains of tenderness, burning, and
swelling. Assessment of the I.V. site reveals that it is warm and erythematous. This usually
indicates:
A. Infection
B. Infiltration
C. Phlebitis
D. Bleeding
17. Answer: C. Phlebitis
Tenderness, warmth, swelling, and, in some instances, a burning sensation are signs and
symptoms of phlebitis. Infection is less likely because no drainage or fever is present.
Infiltration would result in swelling and pallor, not erythema, near the insertion site.
The patient has no evidence of bleeding.
18. To ensure homogenization when diluting powdered medication in a vial, the nurse should:
A. Shake the vial vigorously
B. Roll the vial gently between the palms
C. Invert the vial and let it stand for 1 minute
D. Do nothing after adding the solution to the via
18. Answer: B. Roll the vial gently between the palms
Gently rolling a sealed vial between the palms produces sufficient heat to enhance
dissolution of a powdered medication. Shaking the vial vigorously can break down the
medication and alter its pharmacologic action. Inverting the vial or leaving it alone does
not ensure thorough homogenization of the powder and the solvent.
19. The nurse is teaching a patient to prepare a syringe with 40 units of U-100 NPH insulin for
self-injection. The patient’s first priority concerning self-injection in this situation is to:
A. Assess the injection site
B. Select the appropriate injection site
C. Check the syringe to verify that the nurse has removed the prescribed insulin dose
D. Clean the injection site in a circular manner with alcohol sponge
19. Answer: C. Check the syringe to verify that the nurse has removed the prescribed
insulin dose
When the nurse teaches the patient to prepare an insulin injection, the patient’s first
priority is to validate the dose accuracy. The next steps are to select the site, assess the
site, and clean the site with alcohol before injecting the insulin.
20. The physician’s order reads “Administer 1 g cefazolin sodium (Ancef) in 150 ml of normal
saline solution in 60 minutes.” What is the flow rate if the drop factor is 10 gtt = 1 ml?
A. 25 gtt/minute
B. 37 gtt/minute
C. 50 gtt/minute
D. 60 gtt/minute
20. Answer: A. 25 gtt/minute
21. A patient must receive 50 units of Humulin regular insulin. The label reads 100 units = 1 ml.
How many milliliters should the nurse administer?
A. 0.5 ml
B. 0.75 ml
C. 1 ml
D. 2 ml
21. Answer: A. 0.5 ml
22. How should the nurse prepare an injection for a patient who takes both regular and NPH
insulin?
A. Draw up the NPH insulin, then the regular insulin, in the same syringe
B. Draw up the regular insulin, then the NPH insulin, in the same syringe
C. Use two separate syringe
D. Check with the physician
22. Answer: B. Draw up the regular insulin, then the NPH insulin, in the same syringe
Drugs that are compatible may be mixed together in one syringe. In the case of insulin, the
shorter-acting, clear insulin (regular) should be drawn up before the longer-acting,
cloudy insulin (NPH) to ensure accurate measurements.
23. A patient has just received 30 mg of codeine by mouth for pain. Five minutes later he vomits.
What should the nurse do first?
A. Call the physician
B. Remedicate the patient
C. Observe the emesis
D. Explain to the patient that she can do nothing to help him
23. Answer: C. Observe the emesis
After a patient has vomited, the nurse must inspect the emesis to document color,
consistency, and amount. In this situation, the patient recently ingested medication, so
the nurse needs to check for remnants of the medication to help determine whether the
patient retained enough of it to be effective. The nurse must then notify the physician,
who will decide whether to repeat the dose or prescribe an antiemetic.
24. A patient is catheterized with a #16 indwelling urinary (Foley) catheter to determine if:
A. Trauma has occurred
B. His 24-hour output is adequate
C. He has a urinary tract infection
D. Residual urine remains in the bladder after voiding
24. Answer: B. His 24-hour output is adequate
A 24-hour urine output of less than 500 ml in an adult is considered inadequate and may
indicate kidney failure. This must be corrected while the patient is in the acute state so
that appropriate fluids, electrolytes, and medications can be administered and excreted.
Indwelling catheterization is not needed to diagnose trauma, urinary tract infection, or
residual urine.
25. A staff nurse who is promoted to assistant nurse manager may feel uncomfortable initially
when supervising her former peers. She can best decrease this discomfort by:
A. Writing down all assignments
B. Making changes after evaluating the situation and having discussions with the
staff.
C. Telling the staff nurses that she is making changes to benefit their performance
D. Evaluating the clinical performance of each staff nurse in a private conference
25. Answer: B. Making changes after evaluating the situation and having discussions
with the staff.
A new assistant nurse manager should not make changes until she has had a chance to
evaluate staff members, patients, and physicians. Changes must be planned thoroughly
and should be based on a need to improve conditions, not just for the sake of change.
Written assignments allow all staff members to know their own and others
responsibilities and serve as a checklist for the manager, enabling her to gauge whether
the unit is being run effectively and whether patients are receiving appropriate care.
Telling the staff nurses that she is making changes to benefit their performance should
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