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Nclex questions for Fundamentals of
Nursing with rationale well solved.
Qs What is the leading cause of unintentional death for the entire U.S. population?
- Motor vehicle accidents
- Poisoning
- Choking
- Falls - n Ans✔✔ Answer:
- Motor vehicle accidents Rationale: The leading causes of unintentional death for the total population, in this order, are automobile accidents, poisoning, falls, and drowning. Qs Which change in hygiene practices may be necessary as the patient ages?
- Brushing teeth twice a day
- Bathing every other day
- Decreasing moisturizer use
- Increasing soap use - n Ans✔✔
Answer:
- Bathing every other day Rationale: As a person ages, sebaceous glands become less active, causing skin to dry. Older people may find it necessary to bathe every 2 days, increase the use of moisturizers, and decrease soap use to prevent further drying of skin. Older adults should brush their teeth after every meal and at bedtime to prevent tooth decay. It is recommended that people of all ages brush their teeth at least twice a day, so that option does not represent a change in an older adult's hygiene practices. Qs A woman of Orthodox Jewish faith who underwent a hysterectomy for cancer is being cared for on the surgical floor. Which healthcare team member(s) could be assigned to bathe this patient? Choose all correct answers.
- Male nursing assistant
- Male licensed practical nurse
- Female graduate nurse
- Female registered nurse - n Ans✔✔ Answer:
- Female graduate nurse
- Female registered nurse Rationale: Orthodox Judaism prohibits personal care being provided by a member of the opposite sex. The patient who underwent a hysterectomy is female; therefore, out of respect for her religious beliefs, she should not be bathed by the male licensed practical nurse or nursing assistant.
Rationale: The nurse should document a lesion caused by tissue compression and inadequate perfusion as a pressure ulcer. Abrasion, a rubbing away of the epidermal layer of skin, is commonly caused by shearing forces that occur when a patient moves or is moved in bed. Maceration is a softening of skin from prolonged moisture. Excoriation is a loss of the superficial layers of the skin caused by the digestive enzymes in feces. Qs The charge nurse asks the nursing assistive personnel (NAP) to give a bag bath to a patient with end-stage chronic obstructive pulmonary disease. How should the NAP proceed?
- Bathe the patient's entire body using 8 to 10 washcloths.
- Assist the patient to a chair and provide bathing supplies.
- Saturate a towel and blanket in a plastic bag, and then bathe the patient.
- Assist the patient to the bathtub and provide a bath chair. - n Ans✔✔ Answer:
- Bathe the patient's entire body using 8 to 10 washcloths. Rationale: A towel bath is a modification of the bed bath in which the NAP places a large towel and a bath blanket into a plastic bag, saturates them with a commercially prepared mixture of moisturizer, nonrinse cleaning agent, and water; warms in them in a microwave, and then uses them to bathe the patient. A bag bath is a modification of the towel bath, in which the NAP uses 8 to 10 washcloths instead of a towel or blanket. Each part of the patient's body is bathed with a fresh cloth. A bag bath is not given in a chair or in the tub. Qs For a morbidly obese patient, which intervention should the nurse choose to counteract the pressure created by the skin folds?
- Cover the mattress with a sheepskin.
- Keep the linens wrinkle free.
- Separate the skin folds with towels.
- Apply petrolatum barrier creams. - n Ans✔✔ Answer:
- Keep the linens wrinkle free. Rationale: Separating the skin folds with towels relieves the pressure of skin rubbing on skin. Sheepskins are not recommended for use at all. Petrolatum barrier creams are used to minimize moisture caused by incontinence. Qs A client exhibits all of the following during a physical assessment. Which of these is considered a primary defense against infection?
- Fever
- Intact skin
- Inflammation
- Lethargy - n Ans✔✔ Answer:
- Intact skin Rationale:
- with a stage 3 sacral pressure ulcer.
- admitted with a urinary tract infection. - n Ans✔✔ Answer:
- admitted with unstable diabetes mellitus. Rationale: The client with unstable diabetes mellitus can safely be paired in a client-care assignment because the client is free from infection. Perforation of the bowel exposes the client to infection requiring antibiotic therapy during the postoperative period. Therefore, this client should not be paired with a client in protective isolation. A client in protective isolation should not be paired with a client who has an open wound, such as a stage 3 pressure ulcer, or with a client who has a urinary tract infection. Qs Which action demonstrates a break in sterile technique?
- Remaining 1 foot away from nonsterile areas
- Placing sterile items on the sterile field
- Avoiding the border of the sterile drape
- Reaching 1 foot over the sterile field - n Ans✔✔ Answer:
- Reaching 1 foot over the sterile field Rationale: Reaching over the sterile field while wearing sterile garb breaks sterile technique. While observing sterile technique, healthcare workers should remain 1 foot away from nonsterile areas while wearing sterile garb, place sterile items needed for the procedure
on the sterile drape, and avoid coming in contact with the 1-inch border of the sterile drape. Qs A mother who breastfeeds her child passes on which antibody through breast milk?
- IgA
- IgE
- IgG
- IgM - n Ans✔✔ Answer:
- IgG Rationale: The antibody IgG is passed to the child through the mother's breast milk during breastfeeding. IgA, IgE, and IgM are produced by the child's body after exposure to an antigen. Qs What is the rationale for hand washing? Hand washing is expected to remove:
- transient flora from the skin.
- resident flora from the skin.
- all microorganisms from the skin.
- media for bacterial growth. - n Ans✔✔ Answer:
- transient flora from the skin.
Qs The nurse is orienting a new nurse to the unit and reviews source-oriented charting. Which statement by the nurse best describes source-oriented charting? Source-oriented charting:
- Separates the health record according to discipline
- Organizes documentation around the patient's problems
- Highlights the patient's concerns, problems, and strengths
- Is designed to streamline documentation - n Ans✔✔ Answer:
- Separates the health record according to discipline Rationale: In source-oriented charting, each discipline documents findings in a separately labeled section of the chart. Problem-oriented charting organizes notes around the patient's problems. Focus® charting highlights the patient's concerns, problems, and strengths. Charting by exception is a unique charting system designed to streamline documentation. Qs When the nurse completes the patient's admission nursing database, the patient reports that he does not have any allergies. Which acceptable medical abbreviation can the nurse use to document this finding?
- NA
- NDA
- NKA
- NPO - n
Ans✔✔ Answer:
- NKA Rationale: The nurse can use the medical abbreviation NKA, which means no known allergies, to document this finding. NA is an abbreviation for not applicable. NDA is an abbreviation for no known drug allergies. NPO is an abbreviation that means nothing by mouth. Qs The nurse is working on a unit that uses nursing assessment flow sheets. Which statement best describes this form of charting? Nursing assessment flow sheets:
- Are comprehensive charting forms that integrate assessments and nursing actions
- Contain only graphic information, such as I&O, vital signs, and medication administration
- Are used to record routine aspects of care; they do not contain assessment data
- Contain vital data collected upon admission, which can be compared with newly collected data - n Ans✔✔ Answer:
- Are comprehensive charting forms that integrate assessments and nursing actions Rationale: Nursing assessment flow sheets are organized by body systems. The nurse checks the box corresponding to the current assessment findings. Nursing actions, such as wound care, treatments, or IV fluid administration, are also included. Graphic information, such as vital signs, I&O, and routine care, may be found on the graphic record. The admission form contains baseline information.
Ans✔✔ Answer:
- It improves interdisciplinary collaboration that improves efficiency in procedures. Rationale: The EHR has several benefits for use, including improving interdisciplinary collaboration and making procedures more accurate and efficient. An occurrence report is an organizational record of an unusual occurrence or accident that is not a part of the client's record. Integrated plans of care (IPOC) are a combined charting and care plan format. A medication administration record (MAR) is used to document medications administered and their usage. Qs In the United States, the first programs for training nurses were affiliated with:
- The military
- General hospitals
- Civil service
- Religious orders - n Ans✔✔ Answer:
- Religious orders Rationale: When the Civil War broke out, the Army used nurses who had already been trained in religious orders. Although the Army did provide some training, it occurred later than in the religious orders. Although nurses were trained in hospitals, the training and the hospitals were affiliated with religious orders. Civil service was not mentioned in Chapter 1 and was not a factor in the early 1800s. Nursing started with religious orders. The Hindu
faith was the first to write about nursing. In the United States, all training for nurses was affiliated with religious orders until after the Civil War. Qs Which of the following is/are an example(s) of a health restoration activity? Select all that apply.
- Administering an antibiotic every day
- Teaching the importance of hand washing
- Assessing a client's surgical incision
- Advising a woman to get an annual mammogram after age 50 years - n Ans✔✔ Answer:
- Administering an antibiotic every day
- Assessing a client's surgical incision Rationale: Health restoration activities help an ill client return to health. This would include taking an antibiotic every day and assessing a client's surgical incision. Hand washing and mammograms both involve healthy people who are trying to prevent illness. Qs Which of the following aspects of nursing is essential to defining it as both a profession and a discipline?
- Established standards of care
- Professional organizations
- Practice supported by scientific research
during her entire shift. Private duty nursing is an example of this care model. This medical surgical floor is following the functional nursing model of care, in which care is partitioned and assigned to a staff member with the appropriate skills. For example, the NAP is assigned vital signs, and the LVN is assigned medication administration. When the primary nursing model is utilized, one nurse manages care for a group of patients 24 hours a day, even though others provide care during part of the day. Qs A patient who suffered a stroke has difficulty swallowing. Which healthcare team member should be consulted to assess the patient's risk for aspiration?
- Respiratory therapist
- Occupational therapist
- Dentist
- Speech therapist - n Ans✔✔ Answer:
- Speech therapist Rationale: Respiratory therapists provide care for patients with respiratory disorders. Occupational therapists help patients regain function and independence. Dentists diagnose and treat dental disorders. Speech and language therapists provide assistance to clients experiencing swallowing and speech disturbances. They assess the risk for aspiration and recommend a treatment plan to reduce the risk. Qs Which of the following is/are an example(s) of theoretical knowledge as defined in this chapter? Select all that apply.
- Antibiotics are ineffective in treating viral infections.
- When you take a patient's blood pressure, the patient's arm should be at heart level.
- In Maslow's framework, physical needs are most basic.
- When drawing medication out of a vial, inject air into the vial first. - n Ans✔✔ Answer:
- Antibiotics are ineffective in treating viral infections.
- In Maslow's framework, physical needs are most basic. Rationale: Theoretical knowledge consists of research findings, facts (e.g., "Antibiotics are ineffective.. ." is a fact), principles, and theories (e.g., "In Maslow's framework.. ." is a statement from a theory). Instructions for taking a blood pressure and withdrawing medications are examples of practical knowledge—what to do and how to do it. Qs Critical thinking and the nursing process have which of the following in common? Both:
- Are important to use in nursing practice
- Use an ordered series of steps
- Are patient-specific processes
- Were developed specifically for nursing - n Ans✔✔ Answer:
- Are important to use in nursing practice Rationale:
Rationale: In the assessment phase, the nurse gathers data from many sources for analysis in the diagnosis phase. In the diagnosis phase, the nurse identifies the client's health status. In the planning outcomes phase, the nurse and client decide on goals they want to achieve. In the intervention planning phase, the nurse identifies specific interventions to help achieve the identified goal. During the implementation phase, the nurse carries out the interventions or delegates them to other health care team members. During the evaluation phase, the nurse judges whether her actions have been successful in treating or preventing the identified client health problem. Qs A 73-year-old patient who sustained a right hip fracture in a fall requests pain medication from the nurse. Based on his injury, which type of pain is this patient most likely experiencing?
- Phantom
- Visceral
- Deep somatic
- Referred - n Ans✔✔ Answer:
- Deep somatic Rationale: Deep somatic pain originates in ligaments, tendons, nerves, blood vessels, and bones. Therefore, a hip fracture causes deep somatic pain. Phantom pain is pain that is perceived to originate from a part that was removed during surgery. Visceral pain is caused by deep internal pain receptors and commonly occurs in the abdominal cavity, cranium, and thorax. Referred pain occurs in an area that is distant to the original site. Qs
Which pain management task can the nurse safely delegate to nursing assistive personnel?
- Asking about pain during vital signs
- Evaluating the effectiveness of pain medication
- Developing a plan of care involving nonpharmacologic interventions
- Administering over-the-counter pain medications - n Ans✔✔ Answer:
- Asking about pain during vital signs Rationale: The nurse can delegate the task of asking about pain when nursing assistive personnel (NAP) obtain vital signs. The NAP must be instructed to report findings to the nurse without delay. The nurse should evaluate the effectiveness of pain medications and develop the plan of care. Administering over-the-counter and prescription medications is the responsibility of the registered nurse or licensed practical nurse. Qs Which factor in the patient's past medical history dictates that the nurse exercise caution when administering acetaminophen (Tylenol)?
- Hepatitis B
- Occasional alcohol use
- Allergy to aspirin
- Gastric irritation with bleeding - n Ans✔✔ Answer:
- Hepatitis B
