Fundamentals of Nursing NCLEX Challenge Exam (Quiz #1: 75 Questions)

A 72-year-old female patient with a history of type 2 diabetes and hypertension was admitted to the medical-surgical unit due to a minor stroke. On assessment, the nurse noted generalized skin dryness, particularly on the arms, legs, and face. The nurse understands the importance of skin integrity, especially considering the patient’s age and comorbidities. Which of the following nursing interventions should the nurse consider when addressing the patient’s skin dryness? Select all that apply. 

A 68-year-old male patient was admitted to the cardiac unit following a recent myocardial infarction. The patient has a history of chronic venous insufficiency in both lower extremities. The nurse is preparing to provide a bed bath to the patient. The charge nurse advises the nurse to use long, firm strokes from the distal to the proximal areas when washing the patient’s extremities. The primary reason for this technique is to:

Vivid dreaming occurs in which stage of sleep?

The natural sedative in meat and milk products (especially warm milk) that can help induce sleep is:

Nursing interventions that can help the patient to relax and sleep restfully include all of the following except:

Restraints can be used for all of the following purposes except to:

Which of the following is the nurse’s legal responsibility when applying restraints?

Kubler-Ross’s five successive stages of death and dying are:

A terminally ill patient usually experiences all of the following feelings during the anger stage except:

Nurses and other healthcare providers often have difficulty helping a terminally ill patient through the necessary stages leading to acceptance of death. Which of the following strategies is most helpful to the nurse in achieving this goal?

Which of the following symptoms is the best indicator of imminent death?

A nurse caring for a patient with an infectious disease who requires isolation should refers to guidelines published by the:

To institute appropriate isolation precautions, the nurse must first know the:

Which is the correct procedure for collecting a sputum specimen for culture and sensitivity testing?

An autoclave is used to sterilize hospital supplies because:

The best way to decrease the risk of transferring pathogens to a patient when removing contaminated gloves is to:

After having an I.V. line in place for 72 hours, a patient complains of tenderness, burning, and swelling. Assessment of the I.V. site reveals that it is warm and erythematous. This usually indicates:

To ensure homogenization when diluting powdered medication in a vial, the nurse should:

The nurse is teaching a patient to prepare a syringe with 40 units of U-100 NPH insulin for self-injection. The patient’s first priority concerning self-injection in this situation is to:

The physician’s order reads “Administer 1 g cefazolin sodium (Ancef) in 150 ml of normal saline solution in 60 minutes.” What is the flow rate if the drop factor is 10 gtt = 1 ml?

A patient must receive 50 units of Humulin regular insulin. The label reads 100 units = 1 ml. How many milliliters should the nurse administer?

How should the nurse prepare an injection for a patient who takes both regular and NPH insulin?

A patient has just received 30 mg of codeine by mouth for pain. Five minutes later he vomits. What should the nurse do first?

A patient is catheterized with a #16 indwelling urinary (Foley) catheter to determine if:

A staff nurse who is promoted to assistant nurse manager may feel uncomfortable initially when supervising her former peers. She can best decrease this discomfort by:

Nurse Clarisse is teaching a patient about a newly prescribed drug. What could cause a geriatric patient to have difficulty retaining knowledge about prescribed medications?

When examining a patient with abdominal pain the nurse in charge should assess:

The nurse is assessing a postoperative adult patient. Which of the following should the nurse document as subjective data?

A male patient has a soft wrist-safety device. Which assessment finding should the nurse consider abnormal?

Which of the following planes divides the body longitudinally into anterior and posterior regions?

A female patient with a terminal illness is in denial. Indicators of denial include:

The nurse in charge is transferring a patient from the bed to a chair. Which action does the nurse take during this patient transfer?

A female patient who speaks a little English has emergency gallbladder surgery, during discharge preparation, which nursing action would best help this patient understand wound care instruction?

Before administering the evening dose of a prescribed medication, the nurse on the evening shift finds an unlabeled, filled syringe in the patient’s medication drawer. What should the nurse in charge do?

When administering drug therapy to a male geriatric patient, the nurse must stay especially alert for adverse effects. Which factor makes geriatric patients have adverse drug effects?

A female patient is being discharged after cataract surgery. After providing medication teaching, the nurse asks the patient to repeat the instructions. The nurse is performing which professional role?

A female patient exhibits signs of heightened anxiety. Which response by the nurse is most likely to reduce the patient’s anxiety?

A scrub nurse in the operating room has which responsibility?

A patient is in the bathroom when the nurse enters to give a prescribed medication. What should the nurse in charge do?

The physician orders heparin, 7,500 units, to be administered subcutaneously every 6 hours. The vial reads 10,000 units per milliliter. The nurse should anticipate giving how much heparin for each dose?

The nurse in charge measures a patient’s temperature at 102 degrees F. what is the equivalent Centigrade temperature?

To evaluate a patient for hypoxia, the physician is most likely to order which laboratory test?

The nurse uses a stethoscope to auscultate a male patient’s chest. Which statement about a stethoscope with a bell and diaphragm is true?

A male patient is to be discharged with a prescription for an analgesic that is a controlled substance. During discharge teaching, the nurse should explain that the patient must fill this prescription how soon after the date on which it was written?

Which human element considered by the nurse in charge during assessment can affect drug administration?

An employer establishes a physical exercise area in the workplace and encourages all employees to use it. This is an example of which level of health promotion?

What does the nurse in charge do when making a surgical bed?

The physician prescribes 250 mg of a drug. The drug vial reads 500 mg/ml. How much of the drug should the nurse give?

Nurse Mackey is monitoring a patient for adverse reactions during barbiturate therapy. What is the major disadvantage of barbiturate use?

Which nursing action is essential when providing continuous enteral feeding?

When teaching a female patient how to take a sublingual tablet, the nurse should instruct the patient to place the table on the:

Which action by the nurse in charge is essential when cleaning the area around a Jackson-Pratt wound drain?

The doctor orders dextrose 5% in water, 1,000 ml to be infused over 8 hours. The I.V. tubing delivers 15 drops per milliliter. The nurse in charge should run the I.V. infusion at a rate of:

A female patient undergoes a total abdominal hysterectomy. When assessing the patient 10 hours later, the nurse identifies which finding as an early sign of shock?

Which pulse should the nurse palpate during rapid assessment of an unconscious male adult?

Clients should be taught that repeatedly ignoring the sensation of needing to defecate could result in which of the following?

Which statement provides evidence that an older adult who is prone to constipation is in need of further teaching?

A client is scheduled for a colonoscopy. The nurse will provide information to the client about which type of enema?

The nurse is most likely to report which finding to the primary care provider for a client who has an established colostomy?

Which goal is the most appropriate for clients with diarrhea related to ingestion of an antibiotic for an upper respiratory infection?

A client with a new stoma who has not had a bowel movement since surgery last week reports feeling nauseous. What is the appropriate nursing action?

The nurse assesses a client’s abdomen several days after abdominal surgery. It is firm, distended, and painful to palpate. The client reports feeling “bloated” . The nurse consults with the surgeon, who orders an enema. The nurse prepares to give what kind of enema?

Which of the following is most likely to validate that a client is experiencing intestinal bleeding?

Which nursing diagnosis is/are most applicable to a client with fecal incontinence? Select all that apply.

A nurse determines that a fracture bedpan should be used for the patient who:

A patient with the diagnosis of diverticulosis is advised to eat a diet high in fiber. What should the nurse recommend that the patient eat to best increase the bulk and fecal material?

Which statement by a patient with an ileostomy alerts the nurse to the need for further education?

A practitioner orders a return flow enema (Harris flush drip) for an adult patient with flatulence. When preparing to administer this enema the nurse compares the steps of a return flow enema with cleansing enemas. What should the nurse do that is unique to a return flow enema?

A nurse discourages a patient from straining excessively when attempting to have a bowel movement. What physiological response primarily may be prevented by avoiding straining on defecation?

A nurse is caring for a client who will perform fecal occult blood testing at home. Which of the following information should the nurse include when explaining the procedure to the client?

A nurse is talking with a client who reports constipation. When the nurse discusses dietary changes that can help prevent constipation, which of the following foods should the nurse recommend?

A nurse is caring for a client who has diarrhea for the past four days. When assessing a client, the nurse should expect which of the following findings? Select all that apply.

A nurse is preparing to administer a cleansing enema to an adult client in preparation for a diagnostic procedure. Which of the following are appropriate steps for the nurse to take? Select all that apply.

While a nurse is administering a cleansing enema, the client reports abdominal cramping. Which of the following is the appropriate intervention?

A client with chronic pulmonary disease has a bluish tinge around the lips. The nurse charts which term to most accurately describe the client’s condition?