Fundamentals of Nursing Exam - NCLEX

Fundamentals of Nursing Exam - NCLEX Questions, All Answered A nurse is scheduling hygiene for patients on the unit. What is the priority consideration when planning a patient's personal hygiene?

• When the patient had his or her most recent bath
• The patient's usual hygiene practices and preferences
• Where the bathing fits in the nurse's schedule
• The time that is convenient for the patient care assistant

A nurse caring for patients in a critical care unit knows that providing good oral hygiene is an essential part of nursing care. What are some of the benefits of providing this care? Select all that apply.

• It promotes the patient's sense of well-being.
• It prevents deterioration of the oral cavity.
• It contributes to decreased incidence of aspiration pneumonia.
• It eliminates the need for flossing.
• It decreases oropharyngeal secretions.
• It helps to compensate for an inadequate diet.

A nurse assisting with a patient bed bath observes that an older female adult has dry skin. The patient states that her skin is always "itchy". Which nursing action would be the nurse's best response?

• Bathe the patient more frequently.
• Use an emollient on the dry skin.
• Massage the skin with alcohol.
• Discourage fluid intake.

A nurse caring for patients in a skilled nursing facility performs risk assessments on the patients for foot and nail problems. Which patients would be at a higher risk?Select all that apply.

• A patient who is taking antibiotics for chronic bronchitis
• A patient diagnosed with type II diabetes
• A patient who is obese.
• A patient who has a nervous habit of biting his nails.

• A patient diagnosed with prostate cancer.
• A patient whose job involves frequent handwashing.

Nurses performing skin assessments on patients must pay careful attention to cleanliness, color, texture, temperature, turgor, moisture, sensation, vascularity, and lesions. Which guidelines should nurses follow when performing these assessments?Select all that apply.

• Compare bilateral parts for symmetry.
• Proceed in a toe-to-head systematic manner.
• Use standard terminology to report and record findings.
• Do not allow data from the nursing history to direct the assessment.
• Document only skin abnormalities on the patient record.
• Perform the appropriate skin assessment when risk factors are identified.

A nurse is caring for an adolescent with severe acne. Which recommendations would be most appropriate to include in the teaching plan for this patient? Select all that apply.

• Wash the skin twice a day with a mild cleanser and warm water.
• Use cosmetics liberally to cover blackheads.
• Use emollients on the area.
• Squeeze blackheads as they appear.
• Keep hair off the face and wash hair daily.
• Avoid sun-tanning booth exposure and use sunscreen.

A nurse is performing oral care on a patient who is in traction. The nurse notes that the mouth is extremely dry with crusts remaining after oral care. What should be the nurse's next action?

• Make a recommendation for the patient to see an oral surgeon.
• Report the condition to the primary care provider.
• Gently scrape the oral cavity with a tongue depressor.
• Increase the frequency of the oral hygiene and apply mouth moisturizer to oral

mucosa.

A nurse is removing rigid-gas-permeable (RGP) contact lenses from the eyes of a patient who is unable to assist with removal. The nurse notices that one of the lenses is not centered over the cornea. What would be the nurse's first action in this procedure?

• Apply gentle pressure on the lower eyelid to center the lens prior to removing it.
• Move the eyelids toward one another to cause the lens to slide out between the

eyelids.

• Do not attempt to remove the lens as it should only be removed by an eyecare

specialist

• Have the patient look forward, retract the lower lid, and move the lens down on the

sclera.

A patient has an eye infection with a moderate amount of discharge. Which action is an appropriate step for the nurse reform or cleaning this patient eyes?

• Use hydrogen peroxide on a clean washcloth to wipe the eyes
• wipe the eye from the outer canthus to the inner canthus
• position the patient on the opposite side of the eye to be cleansed
• cleanse the eye using a different section of the cleaning cloth for every stroke until

clean

a nurse is providing foot care for patients any long term care facility. Which actions are recommended guidelines for this procedure? Select all that apply.

• Bathe the feet thoroughly in a mild soap and tepid water solution
• soak the feet in warm water and bath oil
• dry Feet thoroughly, including the area between the toes
• use an alcohol rub if the feet are dry
• use an antifungal foot powder if necessary to prevent fungal infections
• cut the toenails at the lateral corners when trimming the nail

a nurse is assisting a patient with dementia with bathing. Which guideline is recommended in this procedure?

• Shift the focus of the interaction to the process of bathing
• wash the face and hair after beginning of the bath
• consider using music to soothe anxiety and agitation
• do not perform towel baths for alternate forms of bathing with which the patient is

unfamiliar

a nurse is teaching a student nurse how to cleanse the perineal area of both male and female patients. What are accurate guidelines when performing this procedure? Select all that apply.

• For male and female patients? Wash the groin area with a small amount of soap and

water and rinse

• for a female patient, Spread the labia and move the washcloth from the anal area

towards the pubic area

• for male and female patients, always proceed from the most contaminated area to the

least contaminated area

• For male and female patients, use a clean portion of the washcloth for each stroke
• for a male patient, clean the tip of the penis first column moving the washcloth in a

circular motion from the meatus outward

• in an uncircumcised male patient, do not retract the foreskin while washing the penis.
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a nurse is assisting an older adult with an unsteady gait with a tub bath. which action is recommended in this procedure?

• Add bath oil to the water to prevent dry skin
• Allow the patient to lock the door to guarantee privacy
• assist the patient in and out of the tub to prevent falling
• keep the water temperature very warm because older adults chill easily

a nurse is about to bathe a female patient who has an intravenous access in place in her forearm. The patient's gown, which does not have snaps on the sleeves, needs to be removed prior to bathing. What is the appropriate nursing action?

• Temporarily disconnect the Ivy tubing at a point close to the patient and thread it

through the ground sleeve

• cut the gown with scissors to allow arm movement
• Thread the bag and tubing through the gown sleeve, keeping the line intact
• temporarily disconnect the tubing from the Ivy container, threading it through the

gown

a nurse is caring for a 25 year old male patient who is comatose following a head injury. The patient has several piercings in his ears and notes. The piercing in his nose appears to be new and is crusted and slightly inflamed. Which action would be appropriate when caring for this patient's piercings?

• Do not remove or wash the piercings without permission from the patient
• rinse the sites with warm water and remove crusts with cotton swab
• wash the sites with alcohol and apply an antibiotic ointment