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- Various questions about Fundamentals of Nursing
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Fundamentals of Nursing NCLEX Practice Quiz 14 (25 Questions)
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Fundamentals of Nursing NCLEX Practice Quiz 14 (25 Questions)
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1. Parenteral penicillin can be administered as an:
A. IM injection or an IV solution
B. IV or an intradermal injection
C. Intradermal or subcutaneous injection
D. IM or a subcutaneous injection
2. The physician orders gr 10 of aspirin for a patient. The equivalent dose in milligrams is:
A. 0.6 mg
B. 10 mg
C. 60 mg
D. 600 mg
3. The physician orders an IV solution of dextrose 5% in water at 100ml/hour. What would the flow rate be if the drop factor is 15 gtt = 1 ml?
A. 5 gtt/minute
B. 13 gtt/minute
C. 25 gtt/minute
D. 50 gtt/minute
4. Which of the following is a sign or symptom of a hemolytic reaction to blood transfusion?
B. Chest pain
D. Distended neck veins
5. Which of the following conditions may require fluid restriction?
6. All of the following are common signs and symptoms of phlebitis except:
A. Ask the patient if he/she has used ear drops before
B. Have the patient repeat the nurse’s instructions using her own words
C. Demonstrate the procedure to the patient and encourage to ask questions
D. Ask the patient to demonstrate the procedure
8. Which of the following types of medications can be administered via gastrostomy tube?
A. Any oral medications
B. Capsules whole contents are dissolved in water
C. Enteric-coated tablets that are thoroughly dissolved in water
D. Most tablets designed for oral use, except for extended-duration compounds
9. A patient who develops hives after receiving an antibiotic is exhibiting drug:
10. A patient has returned to his room after femoral arteriography. All of the following are appropriate nursing interventions except:
A. Assess femoral, popliteal, and pedal pulses every 15 minutes for 2 hours
B. Check the pressure dressing for sanguineous drainage
C. Assess vital signs every 15 minutes for 2 hours
D. Order a hemoglobin and hematocrit count 1 hour after the arteriography
11. The nurse explains to a patient that a cough:
A. Is a protective response to clear the respiratory tract of irritants
B. Is primarily a voluntary action
C. Is induced by the administration of an antitussive drug
D. Can be inhibited by “splinting” the abdomen
12. An infected patient has chills and begins shivering. The best nursing intervention is to:
A. Apply iced alcohol sponges
B. Provide increased cool liquids
C. Provide additional bedclothes
D. Provide increased ventilation
13. A clinical nurse specialist is a nurse who has:
A. Been certified by the National League for Nursing
B. Received credentials from the American Nurses’ Association
C. Graduated from an associate degree program and is a registered professional nurse
D. Completed a master’s degree in the prescribed clinical area and is a registered professional nurse.
14. The purpose of increasing urine acidity through dietary means is to:
A. Decrease burning sensations
B. Change the urine’s color
C. Change the urine’s concentration
D. Inhibit the growth of microorganisms
15. Clay-colored stools indicate:
16. In which step of the nursing process would the nurse ask a patient if the medication she administered relieved his pain?
17. All of the following are good sources of vitamin A except:
A. White potatoes
D. Egg yolks
18. Which of the following is a primary nursing intervention necessary for all patients with a Foley Catheter in place?
A. Maintain the drainage tubing and collection bag level with the patient’s bladder
B. Irrigate the patient with 1% Neosporin solution three times a daily
C. Clamp the catheter for 1 hour every 4 hours to maintain the bladder’s elasticity
D. Maintain the drainage tubing and collection bag below bladder level to facilitate drainage by gravity
19. The ELISA test is used to:
20. The two blood vessels most commonly used for TPN infusion are the:
A. Subclavian and jugular veins
B. Brachial and subclavian veins
C. Femoral and subclavian veins
D. Brachial and femoral veins
21. Effective skin disinfection before a surgical procedure includes which of the following methods?
A. Shaving the site on the day before surgery
B. Applying a topical antiseptic to the skin on the evening before surgery
C. Having the patient take a tub bath on the morning of surgery
D. Having the patient shower with an antiseptic soap on the evening before and the morning of surgery
22. When transferring a patient from a bed to a chair, the nurse should use which muscles to avoid back injury?
A. Abdominal muscles
B. Back muscles
C. Leg muscles
D. Upper arm muscles
23. Thrombophlebitis typically develops in patients with which of the following conditions?
A. Increases partial thromboplastin time
B. Acute pulsus paradoxus
C. An impaired or traumatized blood vessel wall
D. Chronic Obstructive Pulmonary Disease (COPD)
24. In a recumbent, immobilized patient, lung ventilation can become altered, leading to such respiratory complications as:
A. Respiratory acidosis, atelectasis, and hypostatic pneumonia
B. Apneustic breathing, atypical pneumonia and respiratory alkalosis
C. Cheyne-Stokes respirations and spontaneous pneumothorax
D. Kussmaul’s respirations and hypoventilation
25. Immobility impairs bladder elimination, resulting in such disorders as
A. Increased urine acidity and relaxation of the perineal muscles, causing incontinence
B. Urine retention, bladder distention, and infection
C. Diuresis, natriuresis, and decreased urine specific gravity
D. Decreased calcium and phosphate levels in the urine
Answers and Rationale
Gauge your performance by counter checking your answers to the answers below. Learn more about the question by reading the rationale. If you have any disputes or questions, please direct them to the comments section.
1. Answer: A. IM injection or an IV solution
- Option A: Parenteral penicillin can be administered I.M. or added to a solution and given I.V. It cannot be administered subcutaneously or intradermally.
2. Answer: D. 600 mg
- Option D: gr 10 x 60 mg/gr 1 = 600 mg
3. Answer: C. 25 gtt/minute
- Option C: 100ml/60 min X 15 gtt/ 1 ml = 25 gtt/minute
4. Answer: A. Hemoglobinuria
- Option A: Hemoglobinuria, the abnormal presence of hemoglobin in the urine, indicates a hemolytic reaction (incompatibility of the donor’s and recipient’s blood). In this reaction, antibodies in the recipient’s plasma combine rapidly with donor RBC’s; the cells are hemolyzed in either circulatory or reticuloendothelial system. Hemolysis occurs more rapidly in ABO incompatibilities than in Rh incompatibilities.
- Options B and C: Chest pain and urticaria may be symptoms of impending anaphylaxis.
- Option D: Distended neck veins are an indication of hypervolemia.
5. Answer: C. Renal Failure
- Option C: In renal failure, the kidney loses their ability to effectively eliminate wastes and fluids. Because of this, limiting the patient’s intake of oral and I.V. fluids may be necessary.
- Options A, B, and D: Fever, chronic obstructive pulmonary disease, and dehydration are conditions for which fluids should be encouraged.
6. Answer: D. Frank bleeding at the insertion site
- Option D: Phlebitis, the inflammation of a vein, can be caused by chemical irritants (I.V. solutions or medications), mechanical irritants (the needle or catheter used during venipuncture or cannulation), or a localized allergic reaction to the needle or catheter.
- Options A, B, and C: Signs and symptoms of phlebitis include pain or discomfort, edema and heat at the I.V. insertion site, and a red streak going up the arm or leg from the I.V. insertion site.
7. Answer: D. Ask the patient to demonstrate the procedure
- Option D: Return demonstration provides the most certain evidence for evaluating the effectiveness of patient teaching.
8. Answer: D. Most tablets designed for oral use, except for extended-duration compounds
- Option D: Most tablets designed for oral use, except for extended-duration compounds can be administered via gastrostomy tube.
- Options A, B, and C: Capsules, enteric-coated tablets, and most extended duration or sustained release products should not be dissolved for use in a gastrostomy tube. They are pharmaceutically manufactured in these forms for valid reasons, and altering them destroys their purpose. The nurse should seek an alternate physician’s order when an ordered medication is inappropriate for delivery by tube.
9. Answer: D. Allergy
- Option D: A drug-allergy is an adverse reaction resulting from an immunologic response following a previous sensitizing exposure to the drug. The reaction can range from a rash or hives to anaphylactic shock.
- Option A: Tolerance to a drug means that the patient experiences a decreasing physiologic response to repeated administration of the drug in the same dosage.
- Option B: Idiosyncrasy is an individual’s unique hypersensitivity to a drug, food, or other substance; it appears to be genetically determined.
- Option C: Synergism, is a drug interaction in which the sum of the drug’s combined effects is greater than that of their separate effects.
10. Answer: D. Order a hemoglobin and hematocrit count 1 hour after the arteriography
- Option D: A hemoglobin and hematocrit count would be ordered by the physician if bleeding were suspected.
- Options A, B, and C: The other answers are appropriate nursing interventions for a patient who has undergone femoral arteriography.
11. Answer: A. Is a protective response to clear the respiratory tract of irritants
- Option A: Coughing, a protective response that clears the respiratory tract of irritants, usually is involuntary.
- Option B: However, it can be voluntary as when a patient is taught to perform coughing exercises.
- Option C: An antitussive drug inhibits coughing.
- Option D: Splinting the abdomen supports the abdominal muscles when a patient coughs.
12. Answer: C. Provide additional bedclothes
- Option C: In an infected patient, shivering results from the body’s attempt to increase heat production and the production of neutrophils and phagocytic action through increased skeletal muscle tension and contractions. Initial vasoconstriction may cause skin to feel cold to the touch. Applying additional bed clothes helps to equalize the body temperature and stop the chills. Attempts to cool the body result in further shivering, increased metabolism, and thus increased heat production.
13. Answer: D. Completed a master’s degree in the prescribed clinical area and is a registered professional nurse.
- Option D: A clinical nurse specialist must have completed a master’s degree in a clinical specialty and be a registered professional nurse.
- Option A: The National League of Nursing accredits educational programs in nursing and provides a testing service to evaluate student nursing competence but it does not certify nurses.
- Option B: The American Nurses Association identifies requirements for certification and offers examinations for certification in many areas of nursing, such as medical-surgical nursing. This certification (credentialing) demonstrates that the nurse has the knowledge and the ability to provide high-quality nursing care in the area of her certification.
- Option C: A graduate of an associate degree program is not a clinical nurse specialist: however, she is prepared to provide bedside nursing with a high degree of knowledge and skill. She must successfully complete the licensing examination to become a registered professional nurse.
14. Answer: D. Inhibit the growth of microorganisms
- Option D: Microorganisms usually do not grow in an acidic environment.
15. Answer: D. Bile obstruction
- Option D: Bile colors the stool brown. Any inflammation or obstruction that impairs bile flow will affect the stool pigment, yielding light, clay-colored stool.
- Option A: Upper GI bleeding results in black or tarry stool.
- Option B: Constipation is characterized by small, hard masses.
- Option C: Many medications and foods will discolor stool – for example, drugs containing iron turn stool black.; beets turn stool red.
16. Answer: D. Evaluation
- Option D: In the evaluation step of the nursing process, the nurse must decide whether the patient has achieved the expected outcome that was identified in the planning phase.
17. Answer: A. White potatoes
- Option A: The main sources of vitamin A are yellow and green vegetables (such as carrots, sweet potatoes, squash, spinach, collard greens, broccoli, and cabbage) and yellow fruits (such as apricots, and cantaloupe). Animal sources include liver, kidneys, cream, butter, and egg yolks.
18. Answer: D. Maintain the drainage tubing and collection bag below bladder level to facilitate drainage by gravity
- Option D: Maintaining the drainage tubing and collection bag level with the patient’s bladder could result in reflux of urine into the kidney. Irrigating the bladder with Neosporin and clamping the catheter for 1 hour every 4 hours must be prescribed by a physician.
19. Answer: D. All of the above
- Option D: The ELISA test of venous blood is used to assess blood and potential blood donors to human immunodeficiency virus (HIV). A positive ELISA test combined with various signs and symptoms helps to diagnose acquired immunodeficiency syndrome (AIDS)
20. Answer: A. Subclavian and jugular veins
- Option A: Total Parenteral Nutrition (TPN) requires the use of a large vessel, such as the subclavian or jugular vein, to ensure rapid dilution of the solution and thereby prevent complications, such as hyperglycemia. The brachial and femoral veins usually are contraindicated because they pose an increased risk of thrombophlebitis.
21. Answer: D. Having the patient shower with an antiseptic soap on the evening before and the morning of surgery
- Option D: Studies have shown that showering with an antiseptic soap before surgery is the most effective method of removing microorganisms from the skin.
- Option A: Shaving the site of the intended surgery might cause breaks in the skin, thereby increasing the risk of infection; however, if indicated, shaving, should be done immediately before surgery, not the day before.
- Option B: A topical antiseptic would not remove microorganisms and would be beneficial only after proper cleaning and rinsing.
- Option C: Tub bathing might transfer organisms to another body site rather than rinse them away.
22. Answer: C. Leg muscles
- Option C: The leg muscles are the strongest muscles in the body and should bear the greatest stress when lifting. Muscles of the abdomen, back, and upper arms may be easily injured.
23. Answer: C. An impaired or traumatized blood vessel wall
- Option C: The factors, known as Virchow’s triad, collectively predispose a patient to thrombophlebitis; impaired venous return to the heart, blood hypercoagulability, and injury to a blood vessel wall.
- Option A: Increased partial thromboplastin time indicates a prolonged bleeding time during fibrin clot formation, commonly the result of anticoagulant (heparin) therapy.
- Options B and D: Arterial blood disorders (such as pulsus paradoxus) and lung diseases (such as COPD) do not necessarily impede venous return of injured vessel walls.
24. Answer: A. Respiratory acidosis, atelectasis, and hypostatic pneumonia
- Option A: Because of restricted respiratory movement, a recumbent, immobilize patient is at particular risk for respiratory acidosis from poor gas exchange; atelectasis from reduced surfactant and accumulated mucus in the bronchioles, and hypostatic pneumonia from bacterial growth caused by stasis of mucus secretions.
25. Answer: B. Urine retention, bladder distention, and infection
- Option B: The immobilized patient commonly suffers from urine retention caused by decreased muscle tone in the perineum. This leads to bladder distention and urine stagnation, which provide an excellent medium for bacterial growth leading to infection.
- Options A, C, and D: Immobility also results in more alkaline urine with excessive amounts of calcium, sodium and phosphate, a gradual decrease in urine production, and an increased specific gravity.
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