NCLEX Questions - Fundamentals #1

NCLEX Questions - Fundamentals #1 4.5 (2 reviews) Students also studied Terms in this set (41) Science MedicineNursing Save Nursing 101 Fundamentals of Nursin...49 terms grace_ramirez Preview Nclex questions for Fundamentals o...71 terms Maggie84_Preview Fundamentals of Nursing NCLEX Qu...30 terms agee_tPreview Dosage 20 terms jenj A nurse is a preceptor for a nurse who just graduated from nursing school. When caring for a patient, the new graduate nurse begins to explain to the patient the purpose of completing a physical assessment. Which of the following statements made by the new graduate nurse requires the preceptor to intervene?

• "I will use the information from my assessment to figure

out if your antihypertensive medication is working effectively."

• "Nursing assessment data are used only to provide

information about the effectiveness of your medical care."

• "Nurses use data from their patient's physical

assessment to determine a patient's educational needs."

• "Information gained from physical assessment helps

nurses better understand their patients' emotional needs."

ANS: B

Nursing assessment data are used to evaluate the effectiveness of all aspects of a patient's care, not just the patient's medical care. Assessment data help to evaluate the effectiveness of medications and to determine a patient's health care needs, including the need for patient education. Nurses also use assessment data to identify patients' psychosocial and cultural needs.Having misplaced his stethoscope, a nurse borrows a colleague's stethoscope. He next enters the patient's room and identifies himself, washes his hands with soap, and states the purpose of his visit. He performs proper identification of the patient before he auscultates her lungs. Which critical health assessment step was not performed?

• Running warm water over stethoscope for patient

comfort

• Cleaning stethoscope with Betadine
• Using alcohol-based hand disinfectant
• Cleaning stethoscope with alcohol

ANS: D

Bacteria and viruses can be transferred from patient to patient when a stethoscope that is not clean is used. The stethoscope should be cleaned before use on each patient. Running water over the stethoscope does not kill bacteria.Betadine is an inappropriate cleaning solution and may damage the equipment.Hand sanitizer is not an approved cleaning product.

Which is the best examination position for a complete geriatric physical examination on a weak patient with bilateral basilar pneumonia?

• Prone position
• Sims' position
• Supine position
• Lateral recumbent

ANS: C

This is the most normally relaxed position. It will not compromise the patient's breathing because it is likely compromised with pneumonia. If the patient becomes short of breath easily, raise the head of the bed. This position would be easiest for an elderly weak person to get into position for an examination. Lateral recumbent and prone positions cause respiratory difficulty for any patient with respiratory difficulties. Sims' position is used for assessment of the rectum and the vagina.During an annual gynecological examination, a college student discusses her upcoming college break at a tropical location. After the student receives an oral contraceptive prescription, the nurse identifies the importance of skin cancer prevention education by discussing which evidence-based prevention health topic?

• Applying water-based sunscreen only before

swimming

• Using tanning bed daily for 7 days before college

break trip

• Applying broad-spectrum sunscreen of SPF 5
• Taking extra precautions in the sun secondary to the

prescription

ANS: D

Oral contraceptives can make the skin more sensitive to the sun. For this reason, the patient should be educated about the need for sun protection such as wide- brimmed hats, use of broad-spectrum sunscreen of SPF 15 or greater, not tanning during midday, and not using tanning beds. Broad-spectrum sunscreens should be applied 15 minutes before going into the sun and after swimming or perspiring.Tanning parlors, sunlamps, etc., should be avoided. Sunscreens with SPF of 15 or greater should be used.A head and neck physical examination is completed on a 50-year-old female patient. All physical findings are normal except for fine brittle hair. Based on the physical findings, which of the following laboratory tests would the nurse expect to be ordered?

• Liver function test
• Lead level
• Thyroid-stimulating hormone test
• Complete blood count

ANS: C

Thyroid disease can make hair thin and brittle. Liver function testing is indicated for a patient who has jaundice. Lead levels and a CBC are not indicated for the presence of brittle hair.A febrile preschool-aged child presents to the after- hours clinic. Varicella is diagnosed on the basis of the illness history and the presence of small, circumscribed skin lesions filled with serous fluid. The nurse documents the varicellar lesions as which type of skin lesion?

• Vesicle
• Wheal
• Papule
• Pustule

ANS: A

Vesicles are circumscribed, elevated skin lesions filled with serous fluid that measure less than 1 cm. Wheals are irregularly shaped, elevated areas of superficial localized edema that vary in size. They are common with bug bits and hives. Papules are palpable, circumscribed, solid elevations in the skin that are smaller than 1 cm. Pustules are elevations of skin similar to vesicles, but they are filled with pus.

A school nurse recognizes a belt buckle-shaped ecchymosis on a 7-year-old student. When privately asked about how the injury occurred, the student described falling on the playground. Upon suspecting abuse, the school nurse's best next action is which of the following?

• Interviewing the patient in the presence of his/her

teacher

• Ignoring the findings because child abuse is a

declining problem

• Realizing that abuse victims usually report abusive

situations

• Contacting Social Services and reporting suspected

abuse

ANS: D

Most states mandate a report to a social service center if nurses suspect abuse or neglect. When abuse is suspected, the nurse interviews the patient in private.Abuse of children, women, and older adults is a growing health problem. It is difficult to detect abuse because victims often will not complain or report that they are in an abusive situation.A nurse identifies Pediculosis humananus capitis.Considering the possible complications of treatment, the nurse knows to not use which of the following treatment products?

• Fine-toothed comb
• Pediculicide
• Lindane-based shampoo
• Vinegar hair rinse

ANS: C

Products containing lindane, a toxic ingredient, often cause adverse reactions.Instruct patients who have head lice to shampoo thoroughly with pediculicide (shampoo available at drugstores) in cold water, comb thoroughly with a fine- toothed comb, and discard the comb. A dilute solution of vinegar and water helps loosen nits.A parent calls the school nurse with questions regarding the recent school vision screening. Snellen chart examination revealed 20/60 for both eyes. Considering the visual acuity results, the nurse informs the parent that the child

• Should have an optometric examination.
• Is suffering from strabismus.
• May have presbyopia.
• Has vision issues most likely due to cataracts.

ANS: A

Normal vision is 20/20. The larger the denominator, the poorer the patient's visual acuity. For example, a value of 20/60 means that the patient, when standing 20 feet away, can read a line that a person with normal vision can read from 60 feet away. Strabismus is a (congenital) condition in which both eyes do not focus on an

object simultaneously: These eyes appear crossed. Acuity may not be affected.

Presbyopia is impaired near vision that occurs in middle-aged and older adults and is caused by loss of elasticity of the lens. Cataracts develop slowly and progressively after age 35 or suddenly after trauma.During a routine pediatric history and physical, the parents report that their child was a premature infant and was so small that he had to stay in the neonatal intensive care unit longer than usual. They state that the infant was yellow when born, and that he developed an infection that required "every antibiotic under the sun" to cure him.Considering the neonatal history, the nurse determines that it is especially important to perform a focused _____ examination.

• Cardiac
• Respiratory
• Ophthalmic
• Hearing acuity

ANS: D

Risk factors for hearing problems include low birth weight, nonbacterial intrauterine infection, and excessively high bilirubin levels. Hearing loss due to ototoxicity (injury to auditory nerves) can result from high maintenance doses of antibiotics. Cardiac, respiratory, and eye examinations are important assessments but are not relevant to this child's condition.

During a sexually transmitted illness presentation to high school students, the nurse recommends the HPV vaccine series to prevent

• Cervical cancer.
• Genital lesions.
• Vaginal discharge.
• Swollen perianal tissues.

ANS: A

Human papillomavirus (HPV) infection increases the person's risk for cervical cancer. HPV vaccine is recommended by the American Cancer Society for females aged 9 to 26 years. Vaginal discharge, painful or swollen perianal tissues, and genital lesions are signs and symptoms that may indicate a sexually transmitted infection.A male student comes to the college health clinic. He hesitantly describes that his testis has lumps. The nurse recognizes this as a potential sign of which of the following?

• Inguinal hernia
• Sexually transmitted infection
• Testicular cancer
• Diuretic use

ANS: C

Irregular lumps of the testes may indicate testicular cancer. Testicular cancer is cancer that begins in the testicles. Testicular cancer is the most common form of cancer in men between the ages of 15 and 35 years. A hernia presents with bulging in the scrotum. Sexually transmitted infections often present with genital lesions. Use of diuretics, sedatives, or antihypertensives can cause difficulty in achieving erection or ejaculation but does not usually cause lumps.The nurse is urgently called to the gymnasium regarding an injured student. The student is crying in severe pain with a malformed fractured lower leg. The proper sequence for the nurse's initial assessment is

• Deep palpation, light palpation, inspection.
• Light palpation, deep palpation, inspection.
• Inspection, light palpation.
• Auscultation, deep palpation, light palpation.

ANS: C

Inspection is the use of vision and hearing to distinguish normal from abnormal findings. Light palpation determines areas of tenderness and skin temperature, moisture, and texture. Deep palpation is used to examine the condition of organs, such as those in the abdomen. Caution is the rule with deep palpation. Deep palpation is done after light palpation. Auscultation is used to evaluate sound.The nurse is caring for a female victim of rape. To perform the proper evaluation, the nurse should place the patient in which of the following positions?

• Sitting
• Dorsal recumbent
• Lithotomy
• Knee-chest

ANS: C

Lithotomy is the position for examination of female genitalia. The lithotomy position provides for the maximum exposure of genitalia and allows the insertion of a vaginal speculum. Sitting does not allow adequate access for speculum insertion and is better used to visualize upper body parts. Dorsal recumbent is used to examine the head and neck, anterior thorax and lungs, breasts, axillae, heart, and abdomen. Knee-chest provides maximal exposure of the rectal area but is embarrassing and uncomfortable.On admission, a patient weighs 250 pounds. The weight is recorded as 256 pounds on the second inpatient day. The nurse should evaluate the patient for

• Fluid retention.
• Fluid loss.
• Decreased nutritional reserves.
• Anorexia.

ANS: A

This patient has gained 6 pounds in a 24-hour period. A weight gain of 5 pounds (2.3 kg) or more in a day indicates fluid retention problems. A downward trend may indicate a reduction in nutritional reserves that may be caused by decreased intake such as anorexia or by fluid loss.The patient is a 50-year-old African American male who has come in for his routine annual physical. Which of the following preventive screenings does the nurse recommend?

• Digital rectal examination of the prostate (DRE)

annually

• Ca125 blood test once a year
• Complete eye examination every year
• Colonoscopy every 3 years

ANS: A

Men need to have a digital rectal examination of the prostate every year beginning at 50 years of age. Ca125 blood tests are indicated for women at high risk for ovarian cancer. Because this patient is a man, Ca125 is not needed. Patients over the age of 65 need to have complete eye examinations yearly. Colonoscopy every 10 years is recommended in patients 50 years of age and older.