Fundamentals of Nursing NCLEX Practice Questions Quiz Set 6 |
75 Questions
1. 1. Question
The nurse is caring for an elderly woman who has had a fractured hip
repaired. In the first few days following the surgical repair, which of the
following nursing measures will best facilitate the resumption of
activities for this client?
o A. Arranging for the wheelchair
o B. Asking her family to visit
o C. Assisting her to sit out of bed in a chair qid
o D. Encouraging the use of an overhead trapeze
Incorrect
Correct Answer: D. Encouraging the use of an overhead
trapeze.
Exercise is important to keep the joints and muscles functioning and to
prevent secondary complications. Using the overhead trapeze prevents
hazards of immobility by permitting movement in bed and
strengthening of the upper extremities in preparation for ambulation.
Facilitates movement during hygiene or skincare and linen changes;
reduces the discomfort of remaining flat in bed. “Post position”
involves placing the uninjured foot flat on the bed with the knee bent
while grasping the trapeze and lifting the body off the bed.
Option A: Sitting in a wheelchair would require too great hip
flexion initially. Place in supine position periodically if possible,
when traction is used to stabilize lower limb fractures. Reduces
the risk of flexion contracture of the hip.
Option B: Asking her family to visit would not facilitate the
resumption of activities. Provide footboard, wrist splints,
trochanter, or hand rolls as appropriate. Useful in maintaining a
functional position of extremities, hands, and feet, and
preventing complications (contractures, foot drop).
Option C: Sitting in a chair would cause too much hip flexion.
The client initially needs to be in a low Fowler’s position or taking
, a few steps (as ordered) with the aid of a walker. Encourage the
use of isometric exercises starting with the unaffected limb.
Isometrics contract muscles without bending joints or moving
limbs and help maintain muscle strength and mass. Note: These
exercises are contraindicated while acute bleeding and edema
are present.
2. 2. Question
Which of the following is the most important nursing order in a client
with major head trauma who is about to receive bolus enteral feeding?
A. Measure intake and output
B. Check albumin level
C. Monitor glucose levels
D. Increase enteral feeding
Incorrect
Correct Answer: A. Measure intake and output
It is important to measure intake and output, which should be equal.
Water given before feeding will present a hyperosmotic diuresis. I and
O measures assess fluid balance. A urinary catheter is inserted to
assess the adequacy of renal perfusion. The kidney requires 20% to
25% of cardiac output; commonly, it’s the first organ to show the
effects of impaired perfusion or intravascular volume.
Option B: Osmotherapy aims to increase the osmolality of the
intravascular space, which in turn helps mobilize excess fluid
from brain tissue. If ICP increases, mannitol (an osmotic diuretic)
may be given to decrease cerebral edema, transiently increase
intravascular volume, and improve cerebral blood flow.
Option C: Low peripheral oxygen saturation values or low
arterial blood oxygen values (as shown by arterial blood gas
testing) should be avoided. Maintaining adequate brain tissue
oxygenation seems to improve patient outcomes.
Option D: Enteral feedings are hyperosmotic agents pulling fluid
from cells into the vascular bed. Initially, a nasogastric or
orogastric tube is inserted to decompress the stomach and
reduce the aspiration risk. (Typically, the nasal route is avoided
as it can obstruct sinus drainage, leading to sinusitis or VAP).
,3. 3. Question
The pathological process causing esophageal varices is/are:
A. Ascites and edema
B. Systemic hypertension
C. Portal hypertension
D. Dilated veins and varicosities
Incorrect
Correct Answer: C. Portal hypertension
Esophageal varices result from increased portal hypertension. In portal
hypertension, the liver cannot accept all of the fluid from the portal
vein. The excess fluid will backflow to the vessels with lesser pressure,
such as esophageal veins or rectal veins causing esophageal varices or
hemorrhoids.
Option A: Portal hypertension causes portocaval anastomosis to
develop to decompress portal circulation. Normal portal pressure
is between 5-10 mmHg but in the presence of portal obstruction,
the pressure may be as high as 15-20 mmHg. Since the portal
venous system has no valves, resistance at any level between
the splanchnic vessels and the right side of the heart results in
retrograde flow and elevated pressure.
Option B: Esophageal varices are dilated submucosal distal
esophageal veins connecting the portal and systemic circulations.
They form due to portal hypertension, which commonly is a result
of cirrhosis, resistance to portal blood flow, and increased portal
venous blood inflow.
Option D: Intrahepatic vasoconstriction due to decreased nitric
oxide production, and increased release of endothelin-1 (ET-1),
angiotensinogen, and eicosanoids. Increased portal flow is caused
by hyperdynamic circulation due to splanchnic arterial
vasodilation through mediators such as nitric oxide, prostacyclin,
and TNF.
4. 4. Question
Which of the following interventions will help lessen the effect of GERD
(acid reflux)?
, A. Elevate the head of the bed on 4-6 inch blocks.
B. Lie down after eating.
C. Increase fluid intake just before bedtime.
D. Wear a girdle.
Incorrect
Correct Answer: A. Elevate the head of the bed on 4-6 inch
blocks.
Elevation of the head of the bed allows gravity to assist in decreasing
the backflow of acid into the esophagus. The fluid does not flow uphill.
Instruct to remain in an upright position at least 2 hours after meals;
avoiding eating 3 hours before bedtime. Helps control reflux and
causes less irritation from reflux action into the esophagus. The other
three options all increase fluid backflow into the esophagus through
position or increasing abdominal pressure.
Option B: Avoid placing the patient in a supine position, have
the patient sit upright after meals. Supine position after meals
can increase regurgitation of acid. Elevate HOB while in bed. To
prevent aspiration by preventing the gastric acid to flow back into
the esophagus.
Option C: Instruct patient regarding eating small amounts of
bland food followed by a small amount of water. Instruct to
remain in an upright position at least 1–2 hours after meals, and
to avoid eating within 2–4 hours of bedtime. Gravity helps control
reflux and causes less irritation from reflux action into the
esophagus.
Option D: Instruct the patient to avoid bending over, coughing,
straining at defecations, and other activities that increase reflux.
Promotes comfort by the decrease in intra-abdominal pressure,
which reduces the reflux of gastric contents.
5. 5. Question
The main benefit of therapeutic massages is:
A. To help a person with swollen legs to decrease fluid retention.
B. To help a person with duodenal ulcers feel better.
75 Questions
1. 1. Question
The nurse is caring for an elderly woman who has had a fractured hip
repaired. In the first few days following the surgical repair, which of the
following nursing measures will best facilitate the resumption of
activities for this client?
o A. Arranging for the wheelchair
o B. Asking her family to visit
o C. Assisting her to sit out of bed in a chair qid
o D. Encouraging the use of an overhead trapeze
Incorrect
Correct Answer: D. Encouraging the use of an overhead
trapeze.
Exercise is important to keep the joints and muscles functioning and to
prevent secondary complications. Using the overhead trapeze prevents
hazards of immobility by permitting movement in bed and
strengthening of the upper extremities in preparation for ambulation.
Facilitates movement during hygiene or skincare and linen changes;
reduces the discomfort of remaining flat in bed. “Post position”
involves placing the uninjured foot flat on the bed with the knee bent
while grasping the trapeze and lifting the body off the bed.
Option A: Sitting in a wheelchair would require too great hip
flexion initially. Place in supine position periodically if possible,
when traction is used to stabilize lower limb fractures. Reduces
the risk of flexion contracture of the hip.
Option B: Asking her family to visit would not facilitate the
resumption of activities. Provide footboard, wrist splints,
trochanter, or hand rolls as appropriate. Useful in maintaining a
functional position of extremities, hands, and feet, and
preventing complications (contractures, foot drop).
Option C: Sitting in a chair would cause too much hip flexion.
The client initially needs to be in a low Fowler’s position or taking
, a few steps (as ordered) with the aid of a walker. Encourage the
use of isometric exercises starting with the unaffected limb.
Isometrics contract muscles without bending joints or moving
limbs and help maintain muscle strength and mass. Note: These
exercises are contraindicated while acute bleeding and edema
are present.
2. 2. Question
Which of the following is the most important nursing order in a client
with major head trauma who is about to receive bolus enteral feeding?
A. Measure intake and output
B. Check albumin level
C. Monitor glucose levels
D. Increase enteral feeding
Incorrect
Correct Answer: A. Measure intake and output
It is important to measure intake and output, which should be equal.
Water given before feeding will present a hyperosmotic diuresis. I and
O measures assess fluid balance. A urinary catheter is inserted to
assess the adequacy of renal perfusion. The kidney requires 20% to
25% of cardiac output; commonly, it’s the first organ to show the
effects of impaired perfusion or intravascular volume.
Option B: Osmotherapy aims to increase the osmolality of the
intravascular space, which in turn helps mobilize excess fluid
from brain tissue. If ICP increases, mannitol (an osmotic diuretic)
may be given to decrease cerebral edema, transiently increase
intravascular volume, and improve cerebral blood flow.
Option C: Low peripheral oxygen saturation values or low
arterial blood oxygen values (as shown by arterial blood gas
testing) should be avoided. Maintaining adequate brain tissue
oxygenation seems to improve patient outcomes.
Option D: Enteral feedings are hyperosmotic agents pulling fluid
from cells into the vascular bed. Initially, a nasogastric or
orogastric tube is inserted to decompress the stomach and
reduce the aspiration risk. (Typically, the nasal route is avoided
as it can obstruct sinus drainage, leading to sinusitis or VAP).
,3. 3. Question
The pathological process causing esophageal varices is/are:
A. Ascites and edema
B. Systemic hypertension
C. Portal hypertension
D. Dilated veins and varicosities
Incorrect
Correct Answer: C. Portal hypertension
Esophageal varices result from increased portal hypertension. In portal
hypertension, the liver cannot accept all of the fluid from the portal
vein. The excess fluid will backflow to the vessels with lesser pressure,
such as esophageal veins or rectal veins causing esophageal varices or
hemorrhoids.
Option A: Portal hypertension causes portocaval anastomosis to
develop to decompress portal circulation. Normal portal pressure
is between 5-10 mmHg but in the presence of portal obstruction,
the pressure may be as high as 15-20 mmHg. Since the portal
venous system has no valves, resistance at any level between
the splanchnic vessels and the right side of the heart results in
retrograde flow and elevated pressure.
Option B: Esophageal varices are dilated submucosal distal
esophageal veins connecting the portal and systemic circulations.
They form due to portal hypertension, which commonly is a result
of cirrhosis, resistance to portal blood flow, and increased portal
venous blood inflow.
Option D: Intrahepatic vasoconstriction due to decreased nitric
oxide production, and increased release of endothelin-1 (ET-1),
angiotensinogen, and eicosanoids. Increased portal flow is caused
by hyperdynamic circulation due to splanchnic arterial
vasodilation through mediators such as nitric oxide, prostacyclin,
and TNF.
4. 4. Question
Which of the following interventions will help lessen the effect of GERD
(acid reflux)?
, A. Elevate the head of the bed on 4-6 inch blocks.
B. Lie down after eating.
C. Increase fluid intake just before bedtime.
D. Wear a girdle.
Incorrect
Correct Answer: A. Elevate the head of the bed on 4-6 inch
blocks.
Elevation of the head of the bed allows gravity to assist in decreasing
the backflow of acid into the esophagus. The fluid does not flow uphill.
Instruct to remain in an upright position at least 2 hours after meals;
avoiding eating 3 hours before bedtime. Helps control reflux and
causes less irritation from reflux action into the esophagus. The other
three options all increase fluid backflow into the esophagus through
position or increasing abdominal pressure.
Option B: Avoid placing the patient in a supine position, have
the patient sit upright after meals. Supine position after meals
can increase regurgitation of acid. Elevate HOB while in bed. To
prevent aspiration by preventing the gastric acid to flow back into
the esophagus.
Option C: Instruct patient regarding eating small amounts of
bland food followed by a small amount of water. Instruct to
remain in an upright position at least 1–2 hours after meals, and
to avoid eating within 2–4 hours of bedtime. Gravity helps control
reflux and causes less irritation from reflux action into the
esophagus.
Option D: Instruct the patient to avoid bending over, coughing,
straining at defecations, and other activities that increase reflux.
Promotes comfort by the decrease in intra-abdominal pressure,
which reduces the reflux of gastric contents.
5. 5. Question
The main benefit of therapeutic massages is:
A. To help a person with swollen legs to decrease fluid retention.
B. To help a person with duodenal ulcers feel better.
