NCLEX Fundamentals of Nursing Exam Questions With ELABORATED 100% Correct COMPLETE SOLUTIONS Guaranteed Pass

NCLEX Fundamentals of Nursing Exam Questions With ELABORATED 100% Correct COMPLETE SOLUTIONS Guaranteed Pass Body Mechanics - Answer- the proper use of the body to facilitate lifting and moving and prevent injury The nurse should move close to the object and use the large muscles of the arms and legs to lift the object Advance Directive Requirements - Answer- It is signed by the client There are 2 signatures on the form There is a durable POA on the form Incident Report - Answer- A report documenting an incident and the response to the incident; also known as an occurrence report or event report. Kept seperate from the medical record Rectal Temperature - Answer- 98.6-100.6 Never take on a cardiac patient - risk of stimulating the vagal nerve, leading to vasodilation and bradycardia 5 Stages of Grief - Answer- 1. Denial 2. Anger 3. Bargaining 4. Depression 5. Acceptance Kosher Diet - Answer- no shellfish, no meat and milk together, only fish with fins and scales, no pork Heating Pads - Answer- Used in chronic pain Never put on an active bleeding site - heat increases blood flow Hyphema - Answer- Blood in anterior chamber of the eye, as seen during the fundoscopic exam Patient should be placed in a semi - folwers position Mobilizing Secretions - Answer- postural drainage, percussion, and vibration Patient should be turned every 2 hours to prevent pooling of secretions Normal I&O - Answer- Urine output should be at least 500 mL in 24 hours (20 mL/h) Cultural Imposition - Answer- When one person imposes his or her beliefs, values, and practices on another because he or she believe his or her ideals are superior Cultural assimilation - Answer- the process by which racial or ethnic groups are absorbed into the dominant group by adopting the dominant group's culture Cholecystectomy - Answer- surgical removal of the gallbladder Sputum Sample Collection - Answer- 1. Fowler's position 2. Instruct the client to cough 3. Obtain the sample 4. Perform oral hygiene 5. Remove gloves & wash hands 6. Label and send to lab DO NOT PERFORM ORAL HYGIENE BEFORE THE SAMPLE Albumin - Answer- protein in blood; maintains the proper amount of water in the blood 3.5 - 5 g/dL Low levels indicate risk for skin breakdown WBC count - Answer- Indicator of immune function 5,000-10,000 Low: body can't fight infection. Seen in cancers and low bone marrow function High: patient has an infection currently Oral Anticoagulant Education - Answer- Avoid foods high in vitamin K - vitamin K can interfere with anticoagulation The client should use an electric razor — not a straight razor. Aspirin may increase the risk of bleeding; the client should use acetaminophen for pain relief. Foods high in vitamin K - Answer- - Leafy green vegetables - Broccoli - Brussel Sprouts - Cabbage - Canola Oil - Liver Infant Breastfeeding Times per day - Answer- Infants should breastfeed a minimum of 8 to 12 times per day for every 2 to 3 hours. A minimum acceptable urine output for an infant is 1 to 3 mL/kg/hr. Breastfed infants should have 2 to 3 seedy, yellow stools per day. Skin Vesicles - Answer- elevated, round, blister-like lesions filled with clear fluid Seen in chickenpox (varicella) and shingles (herpes zoster) Skin Pustle - Answer- raised spot on the skin containing pus Seen in acne and impetigo Skin Plaque - Answer- circumscribed, solid, elevated lesion that's more than 3/8″, in diameter Seen in psoriasis Skin Papule - Answer- a firm, inflammatory, raised lesion that's as long as 1/4″ in diameter and that may be pigmented or the same color as the client's skin Seen in acne papule and lichen planus. Stoma Appearance - Answer- appear dark pink to red in color and should have no drainage or scant crusty drainage around the feeding tube Post Colostomy Education - Answer- The surgical site remains fresh for up to 1 week after a colostomy and touching the stoma normally causes slight bleeding Tonsil Ratings - Answer- 1+ Tonsils barely visible outside the tonsillar pillar 2+ Tonsils between the tonsillar pillar & the uvula 3+ Tonsils that touch the uvula 4+ Tonsils that touch each other Abdominal Assessment - Answer- inspection, auscultation, percussion, palpation The nurse should assess the symptomatic quadrant last to prevent enticing pain and tightening muscle Aortic Valve Stenosis Assessment - Answer- The murmur of aortic stenosis is low-pitched, rough, and rasping. It is heard best in the second intercostal space, to the right of the sternum. Bowel Obstruction Assessment - Answer- Abdominal cramping causes hyperactive, high-pitched tinkling bowel sounds and may indicate a bowel obstruction. Tardive dyskinesia (TD) - Answer- potentially disabling motor disorder that may occur following regular use of antipsychotic drugs Abbreviations in Nursing - Answer- Do not use - they can be misinterpreted Maslow's Hierarchy of Needs - Answer- 1: Physiological Needs 2: Safety and Security 3: Relationships, Love and Affection 4: Self Esteem, 5: Self Actualization Recovery Position - Answer- A side-lying position used to maintain a clear airway in unconscious patients without injuries who are breathing adequately. - used in seizure patients What do you do if a patient can not read or write but needs to sign an informed consent document? - Answer- Have the patient draw an X on the line SOAP Charting - Answer- subjective - patient says objective - nurse observes assessment plan Central Venous Pressure (CVP) - Answer- 3 - 7 mmHg