Fundamentals of Nursing NCLEX Practice Questions Quiz Set 2 |
75 Questions
1. 1. Question
Which intervention is an example of primary prevention?
o A. Administering digoxin (Lanoxicaps) to a patient with heart
failure.
o B. Administering measles, mumps, and rubella
immunization to an infant.
o C. Obtaining a Papanicolaou smear to screen for cervical cancer.
o D. Using occupational therapy to help a patient cope with arthritis.
Incorrect
Correct Answer: B. Administering measles, mumps, and rubella
immunization to an infant.
Immunizing an infant is an example of primary prevention, which aims
to prevent health problems. Primary prevention includes those
preventive measures that come before the onset of illness or injury
and before the disease process begins. Examples include immunization
and taking regular exercise to prevent health problems developing in
the future.
Option A: Administering digoxin to treat heart failure and
obtaining a smear for a screening test are examples for
secondary prevention, which promotes early detection and
treatment of disease. Those preventive measures that lead to
early diagnosis and prompt treatment of a disease, illness, or
injury to prevent more severe problems developing. Here health
educators such as Health Extension Practitioners can help
individuals acquire the skills of detecting diseases in their early
stages.
Option C: Obtaining a Papanicolau smear is a secondary
prevention. Secondary prevention includes those preventive
measures that lead to early diagnosis and prompt treatment of a
disease, illness, or injury. This should limit disability, impairment,
, or dependency and prevent more severe health problems
developing in the future.
Option D: Using occupational therapy to help a patient cope with
arthritis is an example of tertiary prevention, which aims to help
a patient deal with the residual consequences of a problem or to
prevent the problem from recurring. Tertiary prevention includes
those preventive measures aimed at rehabilitation following
significant illness. At this level, health educators work to retrain,
re-educate and rehabilitate the individual who has already had an
impairment or disability.
2. 2. Question
The nurse in charge is assessing a patient’s abdomen. Which
examination technique should the nurse use first?
A. Auscultation
B. Inspection
C. Percussion
D. Palpation
Incorrect
Correct Answer: B. Inspection
Inspection always comes first when performing a physical examination.
It is important to begin with the general examination of the abdomen
with the patient in a completely supine position. The presence of any
of the following signs may indicate specific disorders. Percussion and
palpation of the abdomen may affect bowel motility and therefore
should follow auscultation.
Option A: The last step of the abdominal examination is
auscultation with a stethoscope. The diaphragm of the
stethoscope should be placed on the right side of the umbilicus to
listen to the bowel sounds, and their rate should be calculated
after listening for at least two minutes. Normal bowel sounds are
low-pitched and gurgling, and the rate is normally 2-5/min.
Absent bowel sounds may indicate paralytic ileus and hyperactive
rushes (borborygmi) are usually present in small bowel
obstruction and sometimes may be auscultated in lactose
intolerance.
, Option C: A proper technique of percussion is necessary to gain
maximum information regarding the abdominal pathology. While
percussing, it is important to appreciate tympany over air-filled
structures such as the stomach and dullness to percussion which
may be present due to an underlying mass or organomegaly (for
example, hepatomegaly or splenomegaly).
Option D: The ideal position for abdominal examination is to sit
or kneel on the right side of the patient with the hand and
forearm in the same horizontal plane as the patient’s abdomen.
There are three stages of palpation that include the superficial or
light palpation, deep palpation, and organ palpation and should
be performed in the same order. Maneuvers specific to certain
diseases are also a part of abdominal palpation.
3. 3. Question
Which statement regarding heart sounds is correct?
A. S1 and S2 sound equally loud over the entire cardiac area.
B. S1 and S2 sound fainter at the apex.
C. S1 and S2 sound fainter at the base.
D. S1 is loudest at the apex, and S2 is loudest at the base.
Incorrect
Correct Answer: D. S1 is loudest at the apex, and S2 is loudest
at the base.
The S1 sound—the “lub” sound—is loudest at the apex of the heart. It
sounds longer, lower, and louder there than the S2 sounds. The S2—
the “dub” sound—is loudest at the base. It sounds shorter, sharper,
higher, and louder there than S1. Heart sounds are created from blood
flowing through the heart chambers as the cardiac valves open and
close during the cardiac cycle. Vibrations of these structures from the
blood flow create audible sounds — the more turbulent the blood flow,
the more vibrations that get created.
Option A: The S1 heart sound is produced as the mitral and
tricuspid valves close in systole. This structural and
hemodynamic change creates vibrations that are audible at the
chest wall. The mitral valve closing is the louder component of
S1. It also occurs sooner because of the left ventricle contracts
earlier in systole.
, Option B: Changes in the intensity of S1 are more attributable to
forces acting on the mitral valve. Such causes include a change
in left ventricular contractility, mitral structure, or the PR interval.
However, under normal resting conditions, the mitral and
tricuspid sounds occur close enough together not to be
discernible. The most common reasons for a split S1 are things
that delay right ventricular contraction, like a right bundle branch
block.
Option C: The S2 heart sound is produced with the closing of the
aortic and pulmonic valves in diastole. The aortic valve closes
sooner than the pulmonic valve, and it is the louder component of
S2; this occurs because the pressures in the aorta are higher than
the pulmonary artery.
4. 4. Question
The nurse in charge identifies a patient’s responses to actual or
potential health problems during which step of the nursing process?
A. Assessment
B. Nursing diagnosis
C. Planning
D. Evaluation
Incorrect
Correct Answer: B. Nursing diagnosis
The nurse identifies human responses to actual or potential health
problems during the nursing diagnosis step of the nursing process. The
formulation of a nursing diagnosis by employing clinical judgment
assists in the planning and implementation of patient care. The North
American Nursing Diagnosis Association (NANDA) provides nurses with
an up to date list of nursing diagnoses. A nursing diagnosis, according
to NANDA, is defined as a clinical judgment about responses to actual
or potential health problems on the part of the patient, family or
community.
Option A: During the assessment step, the nurse systematically
collects data about the patient or family. Assessment is the first
step and involves critical thinking skills and data collection;
subjective and objective. Subjective data involves verbal
statements from the patient or caregiver. Objective data is
75 Questions
1. 1. Question
Which intervention is an example of primary prevention?
o A. Administering digoxin (Lanoxicaps) to a patient with heart
failure.
o B. Administering measles, mumps, and rubella
immunization to an infant.
o C. Obtaining a Papanicolaou smear to screen for cervical cancer.
o D. Using occupational therapy to help a patient cope with arthritis.
Incorrect
Correct Answer: B. Administering measles, mumps, and rubella
immunization to an infant.
Immunizing an infant is an example of primary prevention, which aims
to prevent health problems. Primary prevention includes those
preventive measures that come before the onset of illness or injury
and before the disease process begins. Examples include immunization
and taking regular exercise to prevent health problems developing in
the future.
Option A: Administering digoxin to treat heart failure and
obtaining a smear for a screening test are examples for
secondary prevention, which promotes early detection and
treatment of disease. Those preventive measures that lead to
early diagnosis and prompt treatment of a disease, illness, or
injury to prevent more severe problems developing. Here health
educators such as Health Extension Practitioners can help
individuals acquire the skills of detecting diseases in their early
stages.
Option C: Obtaining a Papanicolau smear is a secondary
prevention. Secondary prevention includes those preventive
measures that lead to early diagnosis and prompt treatment of a
disease, illness, or injury. This should limit disability, impairment,
, or dependency and prevent more severe health problems
developing in the future.
Option D: Using occupational therapy to help a patient cope with
arthritis is an example of tertiary prevention, which aims to help
a patient deal with the residual consequences of a problem or to
prevent the problem from recurring. Tertiary prevention includes
those preventive measures aimed at rehabilitation following
significant illness. At this level, health educators work to retrain,
re-educate and rehabilitate the individual who has already had an
impairment or disability.
2. 2. Question
The nurse in charge is assessing a patient’s abdomen. Which
examination technique should the nurse use first?
A. Auscultation
B. Inspection
C. Percussion
D. Palpation
Incorrect
Correct Answer: B. Inspection
Inspection always comes first when performing a physical examination.
It is important to begin with the general examination of the abdomen
with the patient in a completely supine position. The presence of any
of the following signs may indicate specific disorders. Percussion and
palpation of the abdomen may affect bowel motility and therefore
should follow auscultation.
Option A: The last step of the abdominal examination is
auscultation with a stethoscope. The diaphragm of the
stethoscope should be placed on the right side of the umbilicus to
listen to the bowel sounds, and their rate should be calculated
after listening for at least two minutes. Normal bowel sounds are
low-pitched and gurgling, and the rate is normally 2-5/min.
Absent bowel sounds may indicate paralytic ileus and hyperactive
rushes (borborygmi) are usually present in small bowel
obstruction and sometimes may be auscultated in lactose
intolerance.
, Option C: A proper technique of percussion is necessary to gain
maximum information regarding the abdominal pathology. While
percussing, it is important to appreciate tympany over air-filled
structures such as the stomach and dullness to percussion which
may be present due to an underlying mass or organomegaly (for
example, hepatomegaly or splenomegaly).
Option D: The ideal position for abdominal examination is to sit
or kneel on the right side of the patient with the hand and
forearm in the same horizontal plane as the patient’s abdomen.
There are three stages of palpation that include the superficial or
light palpation, deep palpation, and organ palpation and should
be performed in the same order. Maneuvers specific to certain
diseases are also a part of abdominal palpation.
3. 3. Question
Which statement regarding heart sounds is correct?
A. S1 and S2 sound equally loud over the entire cardiac area.
B. S1 and S2 sound fainter at the apex.
C. S1 and S2 sound fainter at the base.
D. S1 is loudest at the apex, and S2 is loudest at the base.
Incorrect
Correct Answer: D. S1 is loudest at the apex, and S2 is loudest
at the base.
The S1 sound—the “lub” sound—is loudest at the apex of the heart. It
sounds longer, lower, and louder there than the S2 sounds. The S2—
the “dub” sound—is loudest at the base. It sounds shorter, sharper,
higher, and louder there than S1. Heart sounds are created from blood
flowing through the heart chambers as the cardiac valves open and
close during the cardiac cycle. Vibrations of these structures from the
blood flow create audible sounds — the more turbulent the blood flow,
the more vibrations that get created.
Option A: The S1 heart sound is produced as the mitral and
tricuspid valves close in systole. This structural and
hemodynamic change creates vibrations that are audible at the
chest wall. The mitral valve closing is the louder component of
S1. It also occurs sooner because of the left ventricle contracts
earlier in systole.
, Option B: Changes in the intensity of S1 are more attributable to
forces acting on the mitral valve. Such causes include a change
in left ventricular contractility, mitral structure, or the PR interval.
However, under normal resting conditions, the mitral and
tricuspid sounds occur close enough together not to be
discernible. The most common reasons for a split S1 are things
that delay right ventricular contraction, like a right bundle branch
block.
Option C: The S2 heart sound is produced with the closing of the
aortic and pulmonic valves in diastole. The aortic valve closes
sooner than the pulmonic valve, and it is the louder component of
S2; this occurs because the pressures in the aorta are higher than
the pulmonary artery.
4. 4. Question
The nurse in charge identifies a patient’s responses to actual or
potential health problems during which step of the nursing process?
A. Assessment
B. Nursing diagnosis
C. Planning
D. Evaluation
Incorrect
Correct Answer: B. Nursing diagnosis
The nurse identifies human responses to actual or potential health
problems during the nursing diagnosis step of the nursing process. The
formulation of a nursing diagnosis by employing clinical judgment
assists in the planning and implementation of patient care. The North
American Nursing Diagnosis Association (NANDA) provides nurses with
an up to date list of nursing diagnoses. A nursing diagnosis, according
to NANDA, is defined as a clinical judgment about responses to actual
or potential health problems on the part of the patient, family or
community.
Option A: During the assessment step, the nurse systematically
collects data about the patient or family. Assessment is the first
step and involves critical thinking skills and data collection;
subjective and objective. Subjective data involves verbal
statements from the patient or caregiver. Objective data is
