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— Mahatma Gandhi
Topics or concepts included in this exam are:
- Nursing Jurisprudence
- Informed consent
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- Read each question carefully and choose the best answer.
- You are given one minute per question. Spend your time wisely!
- Answers and rationales are given below. Be sure to read them.
- If you need more clarifications, please direct them to the comments section.
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Fundamentals of Nursing NCLEX Practice Quiz 11 (25 Questions)
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Fundamentals of Nursing NCLEX Practice Quiz 11 (25 Questions)
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1. The most appropriate nursing order for a patient who develops dyspnea and shortness of breath would be…
A. Maintain the patient on strict bed rest at all times
B. Maintain the patient in an orthopneic position as needed
C. Administer oxygen by Venturi mask at 24%, as needed
D. Allow a 1 hour rest period between activities
2. The nurse observes that Mr. Adams begins to have increased difficulty breathing. She elevates the head of the bed to the high Fowler position, which decreases his respiratory distress. The nurse documents this breathing as:
3. The physician orders a platelet count to be performed on Mrs. Smith after breakfast. The nurse is responsible for:
A. Instructing the patient about this diagnostic test
B. Writing the order for this test
C. Giving the patient breakfast
D. All of the above
4. Mrs. Mitchell has been given a copy of her diet. The nurse discusses the foods allowed on a 500-mg low sodium diet. These include:
A. A ham and Swiss cheese sandwich on whole wheat bread
B. Mashed potatoes and broiled chicken
C. A tossed salad with oil and vinegar and olives
D. Chicken bouillon
5. The physician orders a maintenance dose of 5,000 units of subcutaneous heparin (an anticoagulant) daily. Nursing responsibilities for Mrs. Mitchell now include:
A. Reviewing daily activated partial thromboplastin time (APTT) and prothrombin time.
B. Reporting an APTT above 45 seconds to the physician
C. Assessing the patient for signs and symptoms of frank and occult bleeding
D. All of the above
6. The four main concepts common to nursing that appear in each of the current conceptual models are:
A. Person, nursing, environment, medicine
B. Person, health, nursing, support systems
C. Person, health, psychology, nursing
D. Person, environment, health, nursing
7. In Maslow’s hierarchy of physiologic needs, the human need of greatest priority is:
8. The family of an accident victim who has been declared brain-dead seems amenable to organ donation. What should the nurse do?
A. Discourage them from making a decision until their grief has eased
B. Listen to their concerns and answer their questions honestly
C. Encourage them to sign the consent form right away
D. Tell them the body will not be available for a wake or funeral
9. A new head nurse on a unit is distressed about the poor staffing on the 11 p.m. to 7 a.m. shift. What should she do?
A. Complain to her fellow nurses
B. Wait until she knows more about the unit
C. Discuss the problem with her supervisor
D. Inform the staff that they must volunteer to rotate
10. Which of the following principles of primary nursing has proven the most satisfying to the patient and nurse?
A. Continuity of patient care promotes efficient, cost-effective nursing care
B. Autonomy and authority for planning are best delegated to a nurse who knows the patient well
C. Accountability is clearest when one nurse is responsible for the overall plan and its implementation.
D. The holistic approach provides for a therapeutic relationship, continuity, and efficient nursing care.
11. If nurse administers an injection to a patient who refuses that injection, she has committed:
A. Assault and battery
D. None of the above
12. If patient asks the nurse her opinion about a particular physicians and the nurse replies that the physician is incompetent, the nurse could be held liable for:
D. Respondent superior
13. A registered nurse reaches to answer the telephone on a busy pediatric unit, momentarily turning away from a 3 month-old infant she has been weighing. The infant falls off the scale, suffering a skull fracture. The nurse could be charged with:
14. Which of the following is an example of nursing malpractice?
A. The nurse administers penicillin to a patient with a documented history of allergy to the drug. The patient experiences an allergic reaction and has cerebral damage resulting from anoxia.
B. The nurse applies a hot water bottle or a heating pad to the abdomen of a patient with abdominal cramping.
C. The nurse assists a patient out of bed with the bed locked in position; the patient slips and fractures his right humerus.
D. The nurse administers the wrong medication to a patient and the patient vomits. This information is documented and reported to the physician and the nursing supervisor.
A. Decreased blood pressure and heart rate and shallow respirations
B. Quiet crying
C. Immobility, diaphoresis, and avoidance of deep breathing or coughing
D. Changing position every 2 hours
16. A patient is admitted to the hospital with complaints of nausea, vomiting, diarrhea, and severe abdominal pain. Which of the following would immediately alert the nurse that the patient has bleeding from the GI tract?
A. Complete blood count
B. Guaiac test
C. Vital signs
C. Abdominal girth
17. The correct sequence for assessing the abdomen is:
A. Tympanic percussion, measurement of abdominal girth, and inspection
B. Assessment for distention, tenderness, and discoloration around the umbilicus.
C. Percussions, palpation, and auscultation
D. Auscultation, percussion, and palpation
18. High-pitched gurgles head over the right lower quadrant are:
A. A sign of increased bowel motility
B. A sign of decreased bowel motility
C. Normal bowel sounds
D. A sign of abdominal cramping
19. A patient about to undergo abdominal inspection is best placed in which of the following positions?
20. For a rectal examination, the patient can be directed to assume which of the following positions?
C. Horizontal recumbent
D. All of the above
21. During a Romberg test, the nurse asks the patient to assume which position?
22. If a patient’s blood pressure is 150/96, his pulse pressure is:
23. A patient is kept off food and fluids for 10 hours before surgery. His oral temperature at 8 a.m. is 99.8 F (37.7 C) This temperature reading probably indicates:
24. Which of the following parameters should be checked when assessing respirations?
D. All of the above
25. A 38-year old patient’s vital signs at 8 a.m. are axillary temperature 99.6 F (37.6 C); pulse rate, 88; respiratory rate, 30. Which findings should be reported?
A. Respiratory rate only
B. Temperature only
C. Pulse rate and temperature
D. Temperature and respiratory rate
Answers and Rationale
The answers and rationale below will give you a better understanding of the exam. Counter-check your answers to those below. If you have any disputes or objects, please direct them to the comments section.
1. Answer: B. Maintain the patient in an orthopneic position as needed
- Option B: When a patient develops dyspnea and shortness of breath, the orthopneic position encourages maximum chest expansion and keeps the abdominal organs from pressing against the diaphragm, thus improving ventilation.
- Options A and C: Bed rest and oxygen by Venturi mask at 24% would improve oxygenation of the tissues and cells but must be ordered by a physician.
- Option D: Allowing for rest periods decreases the possibility of hypoxia.
2. Answer: C. Orthopnea
- Option C: Orthopnea is difficulty of breathing except in the upright position.
- Option A: Tachypnea is rapid respiration characterized by quick, shallow breaths.
- Option B: Eupnea is normal respiration – quiet, rhythmic, and without effort.
3. Answer: C. Giving the patient breakfast
- Option C: A platelet count evaluates the number of platelets in the circulating blood volume. The nurse is responsible for giving the patient breakfast at the scheduled time.
- Options A and B: The physician is responsible for instructing the patient about the test and for writing the order for the test.
4. Answer: B. Mashed potatoes and broiled chicken
- Option B: Mashed potatoes and broiled chicken are low in natural sodium chloride.
- Options A, C, and D: Ham, olives, and chicken bouillon contain large amounts of sodium and are contraindicated on a low sodium diet.
5. Answer: D. All of the above
- Option D: All of the identified nursing responsibilities are pertinent when a patient is receiving heparin. The normal activated partial thromboplastin time is 16 to 25 seconds and the normal prothrombin time is 12 to 15 seconds; these levels must remain within two to two and one half the normal levels. All patients receiving anticoagulant therapy must be observed for signs and symptoms of frank and occult bleeding (including hemorrhage, hypotension, tachycardia, tachypnea, restlessness, pallor, cold and clammy skin, thirst and confusion); blood pressure should be measured every 4 hours and the patient should be instructed to report promptly any bleeding that occurs with tooth brushing, bowel movements, urination or heavy prolonged menstruation.
6. Answer: D. Person, environment, health, nursing
- Option D: The focus concepts that have been accepted by all theorists as the focus of nursing practice from the time of Florence Nightingale include the person receiving nursing care, his environment, his health on the health illness continuum, and the nursing actions necessary to meet his needs.
7. Answer: D. Oxygen
- Option D: Maslow, who defined a need as a satisfaction whose absence causes illness, considered oxygen to be the most important physiologic need; without it, human life could not exist.
- Options A, B, and C: According to this theory, other physiologic needs (including food, water, elimination, shelter, rest and sleep, activity and temperature regulation) must be met before proceeding to the next hierarchical levels on psychosocial needs.
8. Answer: B. Listen to their concerns and answer their questions honestly
- Option B: The brain-dead patient’s family needs support and reassurance in making a decision about organ donation.
- Option A: Because transplants are done within hours of death, decisions about organ donation must be made as soon as possible.
- Option C: However, the family’s concerns must be addressed before members are asked to sign a consent form.
- Option D: The body of an organ donor is available for burial.
9. Answer: C. Discuss the problem with her supervisor
- Option C: Although a new head nurse should initially spend time observing the unit for its strengths and weakness, she should take action if a problem threatens patient safety. In this case, the supervisor is the resource person to approach.
10. Answer: D. The holistic approach provides for a therapeutic relationship, continuity, and efficient nursing care.
- Option D: Studies have shown that patients and nurses both respond well to primary nursing care units. Patients feel less anxious and isolated and more secure because they are allowed to participate in planning their own care. Nurses feel personal satisfaction, much of it related to positive feedback from the patients. They also seem to gain a greater sense of achievement and esprit de corps.
11. Answer: A. Assault and battery
- Option A: Assault is the unjustifiable attempt or threat to touch or injure another person. Battery is the unlawful touching of another person or the carrying out of threatened physical harm. Thus, any act that a nurse performs on the patient against his will is considered assault and battery.
12. Answer: A. Slander
- Option A: Oral communication that injures an individual’s reputation is considered slander.
- Option B: Written communication that does the same is considered libel.
13. Answer: D. Malpractice
- Option D: Malpractice is defined as injurious or unprofessional actions that harm another. It involves professional misconduct, such as omission or commission of an act that a reasonable and prudent nurse would or would not do. In this example, the standard of care was breached; a 3-month-old infant should never be left unattended on a scale.
14. Answer: A. The nurse administers penicillin to a patient with a documented history of allergy to the drug. The patient experiences an allergic reaction and has cerebral damage resulting from anoxia.
- Option A: The three elements necessary to establish a nursing malpractice are nursing error (administering penicillin to a patient with a documented allergy to the drug), injury (cerebral damage), and proximal cause (administering the penicillin caused the cerebral damage).
- Option B: Applying a hot water bottle or heating pad to a patient without a physician’s order does not include the three required components.
- Option C: Assisting a patient out of bed with the bed locked in position is the correct nursing practice; therefore, the fracture was not the result of malpractice.
- Option D: Administering an incorrect medication is a nursing error; however, if such action resulted in a serious illness or chronic problem, the nurse could be sued for malpractice.
15. Answer: C. Immobility, diaphoresis, and avoidance of deep breathing or coughing
- Option C: An Asian patient is likely to hide his pain. Consequently, the nurse must observe for objective signs. In an abdominal surgery patient, these might include immobility, diaphoresis, and avoidance of deep breathing or coughing, as well as increased heart rate, shallow respirations (stemming from pain upon moving the diaphragm and respiratory muscles), and guarding or rigidity of the abdominal wall. Such a patient is unlikely to display emotion, such as crying.
16. Answer: B. Guaiac test
- Option B: To assess for GI tract bleeding when frank blood is absent, the nurse has two options: She can test for occult blood in vomitus, if present, or in stool – through guaiac (Hemoccult) test.
- Option A: A complete blood count does not provide immediate results and does not always immediately reflect blood loss.
- Option C: Changes in vital signs may be caused by factors other than blood loss.
- Option D: Abdominal girth is unrelated to blood loss.
17. Answer: D. Auscultation, percussion, and palpation
- Option D: Because percussion and palpation can affect bowel motility and thus bowel sounds, they should follow auscultation in abdominal assessment.
- Option A: Tympanic percussion, measurement of abdominal girth, and inspection are methods of assessing the abdomen.
- Option B: Assessing for distention, tenderness and discoloration around the umbilicus can indicate various bowel-related conditions, such as cholecystitis, appendicitis and peritonitis.
18. Answer: C. Normal bowel sounds
- Option C: High-pitched gurgles head over the right lower quadrant are normal bowel sounds.
- Option A: Hyperactive sounds indicate increased bowel motility.
- Option B: Two or three sounds per minute indicate decreased bowel motility.
- Option D: Abdominal cramping with hyperactive, high pitched tinkling bowel sounds can indicate a bowel obstruction.
19. Answer: C. Supine
- Option C: The supine position (also called the dorsal position), in which the patient lies on his back with his face upward, allows for easy access to the abdomen.
- Option A: In the prone position, the patient lies on his abdomen with his face turned to the side.
- Option B: In the Trendelenburg position, the head of the bed is tilted downward to 30 to 40 degrees so that the upper body is lower than the legs.
- Option D: In the lateral position, the patient lies on his side.
20. Answer: D. All of the above
- Option D: All of these positions are appropriate for a rectal examination. In the genupectoral (knee-chest) position, the patient kneels and rests his chest on the table, forming a 90-degree angle between the torso and upper legs. In Sims’ position, the patient lies on his left side with the left arm behind the body and his right leg flexed. In the horizontal recumbent position, the patient lies on his back with legs extended and hips rotated outward.
21. Answer: B. Standing
- Option B: During a Romberg test, which evaluates for sensory or cerebellar ataxia, the patient must stand with feet together and arms resting at the sides—first with eyes open, then with eyes closed. The need to move the feet apart to maintain this stance is an abnormal finding.
22. Answer: A. 54
- Option A: The pulse pressure is the difference between the systolic and diastolic blood pressure readings – in this case, 54.
23. Answer: D. Dehydration
- Option D: A slightly elevated temperature in the immediate preoperative or postoperative period may result from the lack of fluids before surgery rather than from infection.
- Option C: Anxiety will not cause an elevated temperature. Hypothermia is an abnormally low body temperature.
24 Answer D. All of the above
- Option D: The quality and efficiency of the respiratory process can be determined by appraising the rate, rhythm, depth, ease, sound, and symmetry of respirations.
25. Answer: D. Temperature and respiratory rate
- Option D: Under normal conditions, a healthy adult breathes in a smooth uninterrupted pattern 12 to 20 times a minute. Thus, a respiratory rate of 30 would be abnormal. A normal adult body temperature, as measured on an oral thermometer, ranges between 97° and 100°F (36.1° and 37.8°C); an axillary temperature is approximately one degree lower and a rectal temperature, one degree higher. Thus, an axillary temperature of 99.6°F (37.6°C) would be considered abnormal. The resting pulse rate in an adult ranges from 60 to 100 beats/minute, so a rate of 88 is normal.
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