Fundamentals of Nursing NCLEX Questions

Fundamentals of Nursing NCLEX Questions ScienceMedicineNursing agee_t Save Nclex questions for Fundamentals o...71 terms Maggie84_Preview Nursing 101 Fundamentals of Nursin...49 terms grace_ramirez Preview Fundamentals of Nursing Teacher 204 terms lesliertarangoPreview Fundam 53 terms elli 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
• Bathing practices and cleansing habits and rituals vary widely. The patient's preferences should always be taken into consideration, unless

there is a clear threat to health. The patient and nurse should work together to come to a mutually agreeable time and method to accomplish the patient's personal hygiene. The availability of staff to assist may be important, but the patient's preferences are a higher priority.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, b, c. Adequate oral hygiene is essential for promoting the patient's sense of well-being and preventing deterioration of the oral cavity. Diligent oral hygiene care can also improve oral health and limit the growth of pathogens in oropharyngeal secretions, decreasing the incidence of aspiration pneumonia and other systemic diseases. Oral care does not eliminate the need for flossing, decrease oropharyngeal secretions, or compensate for poor nutrition.

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.
• An emollient soothes dry skin, whereas frequent bathing increases dryness, as does alcohol. Discouraging fluid intake leads to dehydration

and, subsequently, dry skin.A nurse caring for patients in a skilled nursing facility performs risk assessment 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

b, c, d, f. Variables known to cause nail and foot problems include deficient self-care abilities, vascular disease, arthritis, diabetes mellitus, history of biting nails or trimming them improperly, frequent or prolonged exposure to chemicals or water, trauma, ill-fitting shoes, and obesity.Nurses performing skin assessments on patients must pay careful attention to cleanliness, color, texture, temperature, tumor, 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, c, f. When performing a skin assessment, the nurse should compare bilateral parts for symmetry, use standard terminology to report and record findings, and perform the appropriate skin assessment when risk factors are identified. The nurse should proceed in a head-to-toe systematic manner, and allow data from the nursing history to direct the assessment. When documenting a physical assessment of the skin, the nurse should describe exactly what is observed or palpated, including appearance, texture, size, location or distribution, and characteristics of any findings.A nurse is caring for an adolescent with sever 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 an use sunscreen

a, e, f. Washing the skin removes oil and debris, hair should be kept off the face and washed daily to keep oil from the hair off the face, and sunbathing should be avoided when using acne treatments. Liberal use of cosmetics and emollients can clog the pores. Squeezing blackheads is always discouraged because it may lead to infection.

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 the oral care. What should be the nurse's next action?

• Make a recommendation for the patient to seen 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.
• If the mouth is extremely dry with crusts that remain after oral care provided, the nurse should increase frequency of oral hygiene, apply

mouth moisturizer to oral mucosa, and monitor fluid intake and output to ensure adequate intake of fluid. It is not necessary to report this condition prior to providing the interventions mentioned above. The crusts should not be scraped with a tongue depressor 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 towards 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.
• If the lens is not centered over the cornea, the nurse should apply gentle pressure on the lower eyelid to center the lens, gently pull the outer

corner of the eye toward the ear, position the hand below the lens to receive it, and ask the patient to blink. Moving the eyelids toward one another to cause the lens to slide out between the eyelids is a later step in the procedure. Having the patient look forward, retracting the lower lid and moving the lens down on the sclera occurs during removal of soft contact lenses. It is not necessary to call in an eyecare specialist unless there is damage to the eye.A patient has an eye infection with a moderate amount of discharge. Which action is an appropriate step for the nurse to perform when cleaning this patient's eyes?

• Use hydrogen peroxide on a clean washcloth to wipe 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 each stroke until clean.
• When cleaning the eyes, the nurse should wear gloves during the cleaning procedure, use water or normal saline, and a clean washcloth or

compress to clean the eyes. The nurse should dampen a cleaning cloth with the solution of choice and wipe once while moving from the inner canthus to the outer canthus of the eye. This technique minimizes the risk for forcing debris into the area drained by the nasolacrimal duct. The nurse should turn the cleaning cloth and use a different section for each stroke until the eye is clean.A nurse is providing foot care for patients in a lone-term care facility. Which actions are recommended guidelines for this procedure? Select all that apply.

• Bather 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 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, c, e. The following are recommended guidelines for foot care: bathe the feet thoroughly in a mild soap and tepid water solution; dry feet thoroughly, including the area between the toes; and use an antifungal foot powder if necessary to prevent fungal infections. The nurse should avoid soaking the feet, use moisturizer if the feet are dry, and avoid digging into or cutting the toenails at the lateral corners when trimming the nails.

A nurse is assisting a patient with demential 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 at the beginning of the bath.
• Consider using music to soothe anxiety and agitation.
• Do not perform towel baths or alternate forms of bathing with which the patient is unfamiliar.
• The nurse should consider the use of music to soothe anxiety and agitation. The nurse should also shift the focus of the interaction from the

"task of bathing" to the needs and abilities of the patient, and focus on comfort, safety, autonomy, and self-esteem, in addition to cleanliness. The nurse should wash the face and hair at the end of the bath or at a separate time. Water dripping in the face and having a wet head are often the most upsetting parts of the bathing process for people with dementia. The nurse should also consider other methods for bathing. Showers and tub baths are not the only options in bathing. Towel baths, washing under clothes, and bathing "body sections" one day at a time are other possible options.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?

• 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 toward 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 go the washcloth for each stroke.
• For a male patient, clean the tip of the penis first, moving the washcloth in a circular motion from the meatus outward.
• In an uncircumcised male patient, do not retract the foreskin (prepuce) while washing the penis.

a, d, e. Wash and rinse the groin area (both male and female patients) with a small amount of soap and water, and rinse. For male and female patients, always proceed from the least contaminated area to the most contaminated area and use a clean portion of the washcloth for each stroke. For a male patient, clean the tip of the penis first, moving the washcloth in a circular motion from the meatus outward. For a female patient, spread the labia and move the washcloth from the pubic area toward the anal area. In an uncircumcised male patient (teenage or older), retract the foreskin (prepuce) while washing the penis.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.
• Safe nursing practice requires that the nurse assist a patient with an unsteady gait in and out of the tub. Adding Alpha Keri oil to the bath water

is dangerous for this patient because it makes the tub slippery. Although privacy is important, if the patient locks the door, the nurse cannot help if there is an emergency. The water should be comfortably warm at 43° to 46°C. Older adults have an increased susceptibility to burns due to diminished sensitivity.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 IV tubing at a point close to the patient and thread it through the gown sleeve.
• Cut the gown with scissors and allow arm movement.
• Thread the bag and tubing through the gown sleeve, keeping the line intact.
• Temporarily disconnect the tubing from the IV container, threading it through the gown.
• Threading the bag and tubing through the gown sleeve keep the system intact. Opening an IV line, even temporarily, causes a break in a

sterile system and introduces the potential for infection. Cutting a gown is not an alternative except in an emergency.