Fundamentals of Nursing NCLEX Exam Study Guide with Complete Solutions

Fundamentals of Nursing NCLEX Exam Study Guide with Complete Solutions The charge nurse asks the nursing assistive personnel (NAP) to give a bag bath to a patient with end-stage chronic obstructive pulmonary disease. How should the NAP proceed? A. Bathe the patient's entire body using 8 to 10 washcloths. B. Assist the patient to a chair and provide bathing supplies. C. Saturate a towel and blanket in a plastic bag, and then bathe the patient. D. Assist the patient to the bathtub and provide a bath chair. - Answer- A. Bathe the patient's entire body using 8 to 10 washcloths. For a morbidly obese patient, which intervention should the nurse choose to counteract the pressure created by the skin folds? A. Cover the mattress with a sheepskin. B. Keep the linens wrinkle free. C. Separate the skin folds with towels. D. Apply petrolatum barrier creams. - Answer- B. Keep the linens wrinkle free. A client exhibits all of the following during a physical assessment. Which of these is considered a primary defense against infection? A. Fever B. Intact skin C. Inflammation D. Lethargy - Answer- B. Intact skin A client with a stage 2 pressure ulcer has methicillin-resistant Staphylococcus aureus (MRSA) cultured from the wound. Contact precautions are initiated. Which rule must be observed to follow contact precautions? A. A clean gown and gloves must be worn when in contact with the client. B. Everyone who enters the room must wear a N-95 respirator mask. C. All linen and trash must be marked as contaminated and send to biohazard waste. D. Place the client in a room with a client with an upper respiratory infection. - Answer- A. A clean gown and gloves must be worn when in contact with the client. A client requires protective isolation. Which client can be safely paired with this client in a client-care assignment? One: A. admitted with unstable diabetes mellitus. B. who underwent surgical repair of a perforated bowel. C. with a stage 3 sacral pressure ulcer. D. admitted with a urinary tract infection. - Answer- A. admitted with unstable diabetes mellitus. A newly hired at Nurseslabs Medical Center is assigned in the OR Department. Which action demonstrates a break in sterile technique? A. Remaining 1 foot away from nonsterile areas B. Placing sterile items on the sterile field C. Avoiding the border of the sterile drape D. Reaching 1 foot over the sterile field - Answer- D. Reaching 1 foot over the sterile field Nurse Berta is facilitating a monthly mothers' class at a small village. As a knowledgeable nurse, she must know that a mother who breastfeeds her child passes on which antibody through breast milk? A. IgA B. IgE C. IgG D. IgM - Answer- A. IgA The clinical instructor asks her students the rationale for handwashing. The students are correct if they answered that handwashing is expected to remove: A. transient flora from the skin. B. resident flora from the skin. C. all microorganisms from the skin. D. media for bacterial growth. - Answer- A. transient flora from the skin. Which of the following incidents requires the nurse to complete an occurrence report? A. Medication given 30 minutes after scheduled dose time B. Patient's dentures lost after transfer C. Worn electrical cord discovered on an IV infusion pump D. Prescription without the route of administration - Answer- B. Patient's dentures lost after transfer The nurse is orienting a new nurse to the unit and reviews source-oriented charting. Which statement by the nurse best describes source-oriented charting? Source-oriented charting: A. Separates the health record according to discipline B. Organizes documentation around the patient's problems C. Highlights the patient's concerns, problems, and strengths D. Is designed to streamline documentation - Answer- A. Separates the health record according to discipline When the nurse completes the patient's admission nursing database, the patient reports that he does not have any allergies. Which acceptable medical abbreviation can the nurse use to document this finding? A. NA B. NDA C. NKA D. NPO - Answer- C. NKA The nurse is working on a unit that uses nursing assessment flow sheets. Which statement best describes this form of charting? Nursing assessment flow sheets: A. Are comprehensive charting forms that integrate assessments and nursing actions B. Contain only graphic information, such as I&O, vital signs, and medication administration C. Are used to record routine aspects of care; they do not contain assessment data D. Contain vital data collected upon admission, which can be compared with newly collected data - Answer- A. Are comprehensive charting forms that integrate assessments and nursing actions At the end of the shift, the nurse realizes that she forgot to document a dressing change that she performed for a patient. Which action should the nurse take? A. Complete an occurrence report before leaving. B. Do nothing; the next nurse will document it was done. C. Write the note of the dressing change into an earlier note. D. Make a late entry as an addition to the narrative notes. - Answer- D. Make a late entry as an addition to the narrative notes. Patient Z asks Nurse Toni why an electronic health record (EHR) system is being used. Which response by the nurse indicates an understanding of the rationale for an EHR system? A. It includes organizational reports of unusual occurrences that are not part of the client's record. B. This type of system consists of combined documentation and daily care plans. C. It improves interdisciplinary collaboration that improves efficiency in procedures. D. This type of system tracks medication administration and usage over 24 hours. - Answer- C. It improves interdisciplinary collaboration that improves efficiency in procedures.