Fundamentals of nursing highlights ethics in nursing, role and responsibilities of a nurse. This exam tackles the significance of the fundamental needs of humans and competence in fundamental skills as prerequisites to providing extensive nursing care. Take this 20-item NCLEX-style exam and soar high your actual NCLEX!
The journey of a thousand miles starts with a single step.
~ Chinese Proverb
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- Various questions about Fundamentals of Nursing
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Fundamentals of Nursing NCLEX Practice Quiz 8 (20 Items)
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Fundamentals of Nursing NCLEX Practice Quiz 8 (20 Items)
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1. To prevent postoperative complications, Nurse Kim assists the client with coughing and deep breathing exercises. This is best accomplished by implementing which of the following?
1. Coughing exercises one hour before meals and deep breathing one hour after meals.
2. Forceful coughing as many times as tolerated.
3. Huff coughing every two hours or as needed.
4. Diaphragmatic and pursed lip breathing 5 to 10 times, four times a day
2. Nurse Trixie is preparing to perform tracheostomy care. Prior to beginning the procedure the nurse performs which action?
1. Tells the client to raise two fingers to indicate pain or distress.
2. Changes twill tape holding the tracheostomy and place.
3. Cleans the incision site.
4. Checks the tightness of the ties and knot
3. Which action by the nurse represents proper nasopharyngeal/nasotracheal suctioning technique?
1. Lubricate the suction catheter with petroleum jelly before and between insertion.
2. Apply suction intermittently while inserting the suction catheter.
3. Rotate the catheter while applying suction.
4. Hyper oxygenate with 100% oxygen for 30 minutes before and after suctioning
4. Which client statement informs the nurse that his teaching about the proper use of an incentive spirometer was effective?
1. “I should breathe out as fast and as hard as possible into the device.”
2. “I should inhale slowly and steadily to keep the balls up.”
3. “I should use the device three times a day, after meals.”
4. “the entire device should be washed thoroughly in sudsy water once a week.”
5. While a client with chest tubes is ambulating, the connection between the tube and the water seal dislodges. Which action by Nurse Flora is most appropriate?
1. Assist the client to ambulate back to bed.
2. Reconnect to the tube to the water seal.
3. Assess the clients lung sounds with a stethoscope.
4. Have the client cough forcibly several times.
6. Nurse Peter makes the assessment that which client has the greatest risk for a problem with the transport of oxygen from the lungs to the tissues? A client who has:
7. Which term does the nurse document to best describe a client experiencing shortness of breath while lying down who must assume an upright or sitting position to breathe more comfortably and effectively?
8. A client with emphysema is prescribed corticosteroid therapy on a short-term basis for acute bronchitis. The client asks the nurse how the steroids will help him. The nurse respond by saying that the corticosteroids will do which of the following?
1. Promote bronchodilation.
2. Help the client to cough.
3. Prevent respiratory infection.
4. Decrease inflammation in the airways.
9. Nurse Aleli is planning to perform percussion and postural drainage. Which is an important aspect of planning the clients care?
1. Percussion and postural drainage should be done before lunch.
2. The order should be coughing, percussion, positioning, and then suctioning.
3. A good time to perform percussion and postural drainage is in the morning after breakfast when the client is well rested.
4. Percussion and postural drainage should always be preceded by three minutes of 100% oxygen.
10. Nurse Winona teaches a patient how to use an incentive spirometer. What patient outcome will support the conclusion that the use of the incentives spirometer was effective?
1. Supplemental oxygen use will be reduced.
2. Inspiratory volume will be increased.
3. Sputum will be expectorated.
4. Coughing will be stimulated.
11. Nurse AJ is applying a warm compress. What should the nurse explain to the patient is the primary reason why heat is used instead of cold?
1. Minimizes muscle spasms
2. Prevents hemorrhage
3. Increases circulation
4. Reduces discomfort
12. A practitioner orders chest physiotherapy with percussion and vibration for a newly admitted patient. Which information obtained by the nurse during the health history should alert the nurse to question the practitioners order?
13. Nurse Sue teaches a patient about pursed lip breathing. The nurse identifies that the teaching is affected when the patient says its purpose is to:
1. precipitate coughing.
2. help maintain open airways.
3. decrease intrathoracic pressure.
4. facilitate expectoration of mucus
14. What should Nurse Mavie do first if a patient is choking on food?
1. Apply sharp for thrusts over the patient’s xiphoid process.
2. Determine if the patient can make any verbal sounds.
3. Hit the middle of the patients back firmly.
4. Sweep the patient’s mouth with a finger
15. Nurse Stephanie is assessing a client who has an acute respiratory infection that puts her at risk for hypoxemia. Which of the following findings are early indications that should alert the nurse that the client is developing hypoxemia? Select all that apply.
16. Nurse CJ is caring for a client who is having difficulty breathing. The client is lying in bed and is already receiving oxygen therapy via nasal cannula. Which of the following interventions is the nurses priority?
1. Increase the oxygen flow.
2. Assist the client to Fowlers position.
3. Promote removal of pulmonary secretions.
4. Attain a specimen for arterial blood gases.
17. Nurse Aldrin is preparing to perform endotracheal suctioning for a client. Which of the following are appropriate guidelines for the nurse to follow? Select all that apply.
1. Apply suction while withdrawing the catheter.
2. Perform suctioning on a routine basis, every 2 to 3 hours.
3. Maintain medical asepsis during suctioning.
4. Use a new catheter for each suctioning attempt.
5. Limit suctioning to 2 to 3 attempts.
18. A nurses caring for a client who has a tracheostomy. Which of the following actions should the nurse take each time he provides a tracheostomy care? Select all that apply.
1. Apply the oxygen source loosely if the SPO2 increases during the procedure.
2. Use surgical asepsis to remove and clean the inner cannula.
3. Clean the outer surfaces in a circular motion from the stoma site outward.
4. Replace the tracheostomy ties with new ties.
5. Cut a slit in gauze squares to place beneath the tube holder.
19. An elderly nursing home resident has refused to eat or drink for several days and is admitted to the hospital. The nurse should expect which assessment finding?
1. Increase blood pressure.
2. Weak, rapid pulse.
3. Moist mucous membranes.
4. Jugular vein distention.
20. A man brings his elderly wife to the emergency department. He states that she has been vomiting and has had diarrhea for the past two days. She appears lethargic and is complaining of leg cramps. What should the nurse do first?
Answers and Rationale
1. Answer: 3. Huff coughing every two hours or as needed.
Huff coughing helps keep the airways open and secretions mobilized. Huff coughing is an alternative for clients who are unable to perform a normal forceful cough (such as postoperatively) deep breathing and coughing should be performed at the same time. Only at mealtimes is not sufficient (option 1). Extended forceful coughing fatigues the client, especially postoperatively (option 2). Diaphragmatic and pursed lip breathing are techniques used for clients with obstructive airway disease (option 4).
2. Answer: 1. Tells the client to raise two fingers to indicate pain or distress.
Prior to starting the procedure, it is important to develop a means of communication by which the client can express pain or discomfort. The twill tape is not changed until after performing tracheostomy care (option 2). Cleaning the incision should be done after cleaning the inner cannula (option 3). Checking the tightness of the ties and knot is done after apply new twill tape (option 4).
3. Answer: 3. Rotate the catheter while applying suction.
Rotating the catheter prevents pulling of tissue into the opening on the catheter tip and the side. Suction catheters may only be lubricated with water or water-soluble lubricant and petroleum jelly such as Vaseline has an oil base (option one). no suction should ever be applied while the catheters being inserted because this can traumatize tissues (option two). The client should be hyper-oxygenated for only a few minutes before and after suctioning and this is generally limited to clients who are intubated or have a tracheostomy (option four).
4. Answer: 2. “I should inhale slowly and steadily to keep the balls up.”
Proper use of an SMI requires the client to take slow, steady inhalations, every hour or two, 5 to 10 reps each time. Only the mouthpiece can be successfully rinsed or wiped clean. The device should not be submerged in water (option 4).
5. Answer: 2. Reconnect to the tube to the water seal.
The tube should be reconnected to the water seal as quickly as possible. Assisting the client back to bed (option 1) and assessing the clients lung (option 3) are possible actions after the system is reconnected.
6. Answer: 1. anemia.
Anemia is a condition of decreased red blood cells and decreased hemoglobin. Hemoglobin is how the oxygen molecules are transported to the tissues. Option 2 would depend on where the infection is located. Option 3: A fractured rib would interrupt transport of oxygen from the atmosphere to the airways. Option 4: Damage to the medulla would interfere with neural stimulation of the respiratory system.
7. Answer: 3. Orthopneaespiratory difficulty related to a reclining position without other physical alterations is defined as orthopnea
Respiratory difficulty related to a reclining position without other physical alterations is defined as orthopnea.
8. Answer: 4. Decrease inflammation in the airways
Glucocorticoids are prescribed because of their anti-inflammatory effect. Options 1, 2, and 4 are not achieved with glucocorticoids.The nurse is planning to perform percussion and postural drainage. Which is an important aspect of planning the clients care? 1.Percussion and postural drainage should be done before lunch.
9. Answer: 1. Percussion and postural drainage should be done before lunch.
Postural drainage result in expectoration of large amounts of mucus. Client sometimes ingest part of the secretions. The secretions may also produce an unpleasant taste in the oral cavity, which could result in nausea/vomiting. This procedure should be done on an empty stomach to decrease client discomfort.
10. Answer: 2. Inspiratory volume will be increased.
An incentive spirometry or provides a visual goal for and measurement of inspiration. It encourages the patient to execute and maintain a sustained inspiration. A sustained inspiration opens airways, increases the inspiratory volume, and reduces the risk of atelectasis. Patients who use an incentive spirometer may or may not be receiving oxygen (option1). Although sputum may be expectorated after the use of an incentive Iran mature, this is not the primary reason for its use (option 3). Although the deep breathing associated with the use of an incentive barometer may stimulate coughing, this is not the primary reason for its use (option 4).
11. Answer: 3. Increases circulation.
Heat increases the skin surface temperature, promoting vasodilation, which increases blood flow to the area. Cold has the opposite effect: it promotes vasoconstriction, which decreases blood flow to the area. Both heat and cold relax muscles and thus minimize muscle spasms. There is no advantage to using heat over cold. (option 1). Heat does not prevent hemorrhage; heat causes vasodilation, which promotes hemorrhage (option 2). Both heat and cold can reduce discomfort. Cold reduces discomfort by numbing the area, slowing the transmission of pain impulses, and increasing the pain threshold. Heat reduces the discomfort by relaxing the muscles (option 4).
12. Answer: 2. Osteoporosis.
Implementing the practitioners order may compromise patient safety because percussion and vibration in the presence of osteoporosis may cause fractures. Osteoporosis is an abnormal loss of bone mass and strength. Option 1: These are appropriate interventions for a patient with emphysema. Emphysema is a chronic pulmonary disease characterized by an abnormal increase in the size of air spaces distal to the terminal bronchioles with destructive changes in their walls. Option 3: These are appropriate interventions for a patient with cystic fibrosis cystic fibrosis causes widespread dysfunction of the exocrine glands. It is characterized by thick, tenacious secretions in the respiratory system that block the bronchioles, creating breathing difficulties. Option 4: These are appropriate interventions for a patient with chronic bronchitis. Bronchitis is an inflammation of the mucous membranes of the bronchial airways.
13. Answer: 2. help maintain open airways.
Pursed-lip breathing involves deep inspiration and prolonged expiration against slightly closed lips. The pursed lips create a resistance to the air flowing out of the lungs, which prolongs exhalation and maintains positive airway pressure, thereby maintaining an open airway and preventing airway collapse. Deep breathing and huff coughing, not pursed lip breathing, stimulate effective coughing (option 1). Pursed lip breathing increases, not decreases intrathoracic pressure (option 3). The huff coughing stimulates the natural cough reflex and is effective for clearing the central air ways of sputum. Saying the word huff with short forceful exhalations keeps the glottis open, mobilizes sputum, and stimulates a cough (option 4).
14. Answer: 2. Determine if the patient can make any verbal sounds.
When a person is choking on food, the first intervention is to determine if the person can speak because the next intervention will depend on if it is a partial or total airway obstruction. With a partial airway obstruction, the person will be able to make sounds because some air can pass from the lungs through the vocal chords. In this situation the person’s own efforts open parentheses gagging and coughing) should be allowed to clear the airway. With a total airway obstruction, the person will not be able to make a sound because the airway is blocked and the nurse should immediately initiate the abdominal thrust maneuver (Heimlich maneuver). Thrusts to the xiphoid process may cause a fracture that may result in a pneumothorax (option 1).
15. Answer: 1, 2, and 5
Restlessness, tachypnea, and pallor are early manifestations of hypoxemia, along with tachycardia, elevated blood pressure, use of accessory muscles, nasal flaring, tracheal tugging, and adventitious lung sounds. Bradycardia and confusion are late manifestations of hypoxemia, along with stupor, cyanotic skin and mucous membranes, bradypnea, hypotension, and cardiac dysrhythmias.
16. Answer: 2. Assist the client to Fowlers position.
The priority action the nurse should take when using the airway, breathing, circulation approach to care delivery is to relieve the clients dyspnea. Fowler’s position facilitates maximal long expansion and thus optimizing breathing. With the client in this position, the nurse can better assess and determine the cause of the clients dyspnea. Option 1: The client may need more oxygen, as hypoxemia may be the cause of his difficulty breathing. However, administering oxygen and adjusting the fraction of inspired oxygen requires the providers prescription after a careful assessment of the clients oxygenation status, there is a higher priority given the nature of the client’s distress. Option 3: The client may need suction or expectoration, as pulmonary secretions may be the cause of his difficulty breathing. However, there is a higher priority given the nature of the client’s distress. Option 4: It is important to check the clients oxygenation status, and in many nursing situations, assessment precedes action, but there is a higher priority given the nature of the client’s distress.
17. Answers: 1, 4, and 5
The nurse should apply suction pressure only while withdrawing the catheter, not while inserting it. The nurse should not reuse the suction catheter unless an in-line suctioning system is in place. To prevent hypoxemia, the nurse should limit each section in session to 2 to 3 attempts and allow at least one minute between passes for ventilation and oxygenation. The nurse should not suction routinely because suctioning is not without risk. It can cause mucosal damage, bleeding, and bronchospasm. Endotracheal suctioning requires surgical asepsis.
18. Answer: 1, 2, and 3
The nurse must be prepared to provide supplemental oxygen in response to any decline in oxygenation saturation while performing tracheostomy care. The nurse should use a sterile disposable tracheostomy cleaning kit or sterile supplies and maintain surgical asepsis throughout this part of the procedure. Option 3 helps move mucus and contaminated material away from the stoma for easy removal. Option 4: To help keep the skin clean and dry, the nurse should replace the tracheostomy ties if they are wet or soiled. There is a risk of two dislodgment with replacing the ties, so he should not replace them routinely. Option 5: The nurse should use a commercially prepared tracheostomy dressing with a slit in it. Cutting gauze squares can loosen lint or cause fibers the client could aspirate.
19. Answer: 2. Week, rapid pulse.
20. Answer: 2. Review the results of serum electrolytes.
Further assessment is needed to determine appropriate action. While the nurse may perform some of the interventions in options one, three, and four, assessment is needed initially.
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