Fundamentals of Nursing NCLEX RN Exam Practice Questions Q&A Set 2

Fundamentals of Nursing NCLEX RN Exam Practice Questions Q&A 2 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 measurable, tangible data such as vital signs, intake and output, and height and weight. • Option C: During the planning step, the nurse develops strategies to resolve or decrease the patient’s problem. The planning stage is where goals and outcomes are formulated that directly impact patient care based on EDP guidelines. These patient-specific goals and the attainment of such assist in ensuring a positive outcome. • Option D: During the evaluation step, the nurse determines the effectiveness of the plan of care. This final step of the nursing process is vital to a positive patient outcome. Whenever a healthcare provider intervenes or implements care, they must reassess or evaluate to ensure the desired outcome has been met. Reassessment may frequently be needed depending upon overall patient condition. The plan of care may be adapted based on new assessment data. 5. 5. Question A female patient is receiving furosemide (Lasix), 40 mg P.O. b.i.D. in the plan of care, the nurse should emphasize teaching the patient about the importance of consuming: • A. Fresh, green vegetables • B. Bananas and oranges • C. Lean red meat • D. Creamed corn Incorrect Correct Answer: B. Bananas and oranges Because furosemide is a potassium-wasting diuretic, the nurse should plan to teach the patient to increase intake of potassium-rich foods, such as bananas and oranges. Potassium is a mineral in the cells. It helps the nerves and muscles work as they should. The right balance of potassium also keeps the heart beating at a steady rate. Fresh, green vegetables; lean red meat; and creamed corn are not good sources of potassium. • Option A: GLVs are considered as natural caches of nutrients for human beings as they are a rich source of vitamins, such as ascorbic acid, folic acid, tocopherols, ?-carotene, and riboflavin, as well as minerals such as iron, calcium, and phosphorous. • Option C: Lean red meat is an excellent source of high biological value protein, vitamin B12, niacin, vitamin B6, iron, zinc, and phosphorus. It is a source of long?chain omega?3 polyunsaturated fats, riboflavin, pantothenic acid, selenium, and, possibly, also vitamin D. It is also relatively low in fat and sodium. • Option D: Corn has several health benefits. Because of the high fiber content, it can aid with digestion. It also contains valuable B vitamins, which are important to your overall health. Corn also provides our bodies with essential minerals such as zinc, magnesium, copper, iron, and manganese. 6. 6. Question The nurse in charge must monitor a patient receiving chloramphenicol for adverse drug reaction. What is the most toxic reaction to chloramphenicol? • A. Lethal arrhythmias • B. Malignant hypertension • C. Status epilepticus • D. Bone marrow suppression Incorrect Correct Answer: D. Bone marrow suppression The most toxic reaction to chloramphenicol is bone marrow suppression. Chloramphenicol is a synthetically manufactured broad-spectrum antibiotic. It was initially isolated from the bacteria Streptomyces venezuelae in 1948 and was the first bulk produced synthetic antibiotic. However, chloramphenicol is a rarely used drug in the United States because of its known severe adverse effects, such as bone marrow toxicity and grey baby syndrome. Chloramphenicol is not known to cause lethal arrhythmias, malignant hypertension, or status epilepticus. • Option A: Chloramphenicol is associated with severe hematological side effects when administered systemically. Since 1982, chloramphenicol has reportedly caused fatal aplastic anemia, with possible increased risk when taken together with cimetidine. This adverse side effect can occur even with the topical administration of the drug, which is most likely due to the systemic absorption of the drug after topical application. • Option B: Besides causing fatal aplastic anemia and bone marrow suppression, other side effects of chloramphenicol include ototoxicity with the use of topical ear drops, gastrointestinal reactions such as oesophagitis with oral use, neurotoxicity, and severe metabolic acidosis.