Fundamentals of Nursing NCLEX
Practice Questions Quiz #6 | 75
Questions
Questions related to Basic Care and Comfort
FNDNRS-06-001
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?
A. Arranging for the wheelchair
B. Asking her family to visit
C. Assisting her to sit out of bed in a chair qid
D. Encouraging the use of an overhead trapeze
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.
FNDNRS-06-002
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
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).
FNDNRS-06-003
The pathological process causing esophageal varices is/are:
A. Ascites and edema
B. Systemic hypertension
C. Portal hypertension
D. Dilated veins and varicosities
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.
, FNDNRS-06-004
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.
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.
FNDNRS-06-005
The main benefit of therapeutic massages is:
Practice Questions Quiz #6 | 75
Questions
Questions related to Basic Care and Comfort
FNDNRS-06-001
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?
A. Arranging for the wheelchair
B. Asking her family to visit
C. Assisting her to sit out of bed in a chair qid
D. Encouraging the use of an overhead trapeze
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.
FNDNRS-06-002
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
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).
FNDNRS-06-003
The pathological process causing esophageal varices is/are:
A. Ascites and edema
B. Systemic hypertension
C. Portal hypertension
D. Dilated veins and varicosities
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.
, FNDNRS-06-004
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.
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.
FNDNRS-06-005
The main benefit of therapeutic massages is:
