NCLEX Exam: Fundamentals of Nursing Questions and Answers

***Download Test Bank Immediately After the Purchase. Just in case you have trouble downloading, kindly message me, and I will send it to you via Google Doc or email. Thank you*** 1. 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. 2. 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. 3. 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 4. 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. 5. 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. 6. 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 7. 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 8. 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. 9. 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 10. 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 11. 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 12. 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 13. 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. 14. 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. 15. In the United States, the first programs for training nurses were affiliated with: A. The military B. General hospitals C. Civil service D. Religious orders 16. Which of the following is/are an example(s) of a health restoration activity? Select all that apply. A. Administering an antibiotic every day B. Teaching the importance of handwashing C. Assessing a client’s surgical incision D. Advising a woman to get an annual mammogram after age 50 years 17. Which of the following aspects of nursing is essential to defining it as both a profession and a discipline? A. Established standards of care B. Professional organizations C. Practice supported by scientific research D. Activities determined by a scope of practice 18. The charge nurse on the medical surgical floor assigns vital signs to the nursing assistive personnel (NAP) and medication administration to the licensed vocational nurse (LVN). Which nursing model of care is this floor following? A. Team nursing B. Case method nursing C. Functional nursing D. Primary nursing 19. Paul Jake suffered a stroke and has difficulty swallowing. Which healthcare team member should be consulted to assess the patient’s risk for aspiration? A. Respiratory therapist B. Occupational therapist C. Dentist D. Speech therapist 20. Which of the following is/are an example(s) of theoretical knowledge? Select all that apply. A. Antibiotics are ineffective in treating viral infections. B. When you take a patient’s blood pressure, the patient’s arm should be at heart level. C. In Maslow’s framework, physical needs are most basic. D. When drawing medication out of a vial, inject air into the vial first. Answers and Rationale 1. Answer: A. Bathe the patient’s entire body using 8 to 10 washcloths. A towel bath is a modification of the bed bath in which the NAP places a large towel and a bath blanket into a plastic bag, saturates them with a commercially prepared mixture of moisturizer, non rinse cleaning agent, and water; warms in them in a microwave, and then uses them to bathe the patient. A bag bath is a modification of the towel bath, in which the NAP uses 8 to 10 washcloths instead of a towel or blanket. Each part of the patient’s body is bathed with a fresh cloth. A bag bath is not given in a chair or in the tub. 2. Answer: B. Keep the linens wrinkle free. Separating the skin folds with towels relieves the pressure of skin rubbing on skin. Sheepskins are not recommended for use at all. Petrolatum barrier creams are used to minimize moisture caused by incontinence. 3 Answer: B. Intact skin Intact skin is considered a primary defense against infection. Fever, the inflammatory response, and phagocytosis (a process of killing pathogens) are considered secondary defenses against infection. 4. Answer: A. A clean gown and gloves must be worn when in contact with the client. A clean gown and gloves must be worn when any contact is anticipated with the client or with contaminated items in the room. A respirator mask is required only with airborne precautions, not contact precautions. All linen must be double-bagged and clearly marked as contaminated. The client should be placed in a private room or in a room with a client with an active infection caused by the same organism and no other infections. 5. Answer: A. admitted with unstable diabetes mellitus. The client with unstable diabetes mellitus can safely be paired in a client-care assignment because the client is free from infection. Perforation of the bowel exposes the client to infection requiring antibiotic therapy during the postoperative period. Therefore, this client should not be paired with a client in protective isolation. A client in protective isolation should not be paired with a client who has an open wound, such as a stage 3 pressure ulcer, or with a client who has a urinary tract infection. 6. Answer: D. Reaching 1 foot over the sterile field Reaching over the sterile field while wearing sterile garb breaks sterile technique. While observing sterile technique, healthcare workers should remain 1 foot away from nonsterile areas while wearing sterile garb, place sterile items needed for the procedure on the sterile drape, and avoid coming in contact with the 1-inch border of the sterile drape. 7. Answer: C. IgG The antibody IgG is passed to the child through the mother’s breast milk during breastfeeding. IgA, IgE, and IgM are produced by the child’s body after exposure to an antigen. 8. Answer: A. transient flora from the skin. There are two types of normal flora: transient and resident. Transient flora are normal flora that a person picks up by coming in contact with objects or another person (e.g., when you touch a soiled dressing). You can remove these with hand washing. Resident flora live deep in skin layers where they live and multiply harmlessly. They are permanent inhabitants of the skin and cannot usually be removed with routine hand washing. Removing all microorganisms from the skin (sterilization) is not possible without damaging the skin tissues. To live and thrive in humans, microbes must be able to use the body’s precise balance of food, moisture, nutrients, electrolytes, pH, temperature, and light. Food, water, and soil that provide these conditions may serve as nonliving reservoirs. Hand washing does little to make the skin uninhabitable for microorganisms, except perhaps briefly when an antiseptic agent is used for cleansing. 9. Answer: B. Patient’s dentures lost after transfer You would need to complete an occurrence report if you suspect your patient’s personal items to be lost or stolen. A medication can be administered within a half-hour of the administration time without an error in administration; therefore, an occurrence report is not necessary. The worn electrical cord should be taken out of use and reported to the biomedical department. The nurse should seek clarification if the provider’s order is missing information; an occurrence report is not necessary. 10. Answer: A. Separates the health record according to discipline In source-oriented charting, each discipline documents findings in a separately labeled section of the chart. Problem-oriented charting organizes notes around the patient’s problems. Focus charting highlights the patient’s concerns, problems, and strengths. Charting by exception is a unique charting system designed to streamline documentation. 11. Answer: C. NKA The nurse can use the medical abbreviation NKA, which means no known allergies, to document this finding. NA is an abbreviation for not applicable. NDA is an abbreviation for no known drug allergies. NPO is an abbreviation that means nothing by mouth. 12. Answer: A. Are comprehensive charting forms that integrate assessments and nursing actions Nursing assessment flow sheets are organized by body systems. The nurse checks the box corresponding to the current assessment findings. Nursing actions, such as wound care, treatments, or IV fluid administration, are also included. Graphic information, such as vital signs, I&O, and routine care, may be found on the graphic record. The admission form contains baseline information. 13. Answer: D. Make a late entry as an addition to the narrative notes. If the nurse fails to make an important entry while charting, she should make a late entry as an addition to the narrative notes. An occurrence report is not necessary in this case. If documentation is omitted, there is no legal verification that the procedure was performed. It is illegal to add to a chart entry that was previously documented. The nurse can only document care directly performed or observed. Therefore, the nurse on the incoming shift would not record the wound change as performed. 14. Answer: C. It improves interdisciplinary collaboration that improves efficiency in procedures. The EHR has several benefits for use, including improving interdisciplinary collaboration and making procedures more accurate and efficient. An occurrence report is an organizational record of an unusual occurrence or accident that is not a part of the client’s record. Integrated plans of care (IPOC) are a combined charting and care plan format. A medication administration record (MAR) is used to document medications administered and their usage. 15. Answer: D. Religious orders When the Civil War broke out, the Army used nurses who had already been trained in religious orders. Although the Army did provide some training, it occurred later than in the religious orders. Although nurses were trained in hospitals, the training and the hospitals were affiliated with religious orders. Civil service was not mentioned in Chapter 1 and was not a factor in the early 1800s. Nursing started with religious orders. The Hindu faith was the first to write about nursing. In the United States, all training for nurses was affiliated with religious orders until after the Civil War. 16. Answer: A, C Health restoration activities help an ill client return to health. This would include taking an antibiotic every day and assessing a client’s surgical incision. Hand washing and mammograms both involve healthy people who are trying to prevent illness. 17. Answer: C. Practice supported by scientific research The American Nurses Association (ANA) has developed standards of care, but they are unrelated to defining nursing as a profession or discipline. Having professional organizations is not included in accepted characteristics of either a profession or a discipline. A profession must have knowledge that is based on technical and scientific knowledge. The theoretical knowledge of a discipline must be based on research, so both are scientifically based. Having a scope of practice is not included in accepted characteristics of either a profession or a discipline. 18. Answer: C. Functional nursing With team nursing, an RN or LVN is paired with a NAP. The pair is then assigned to render care for a group of patients. In case method nursing, one nurse cares for one patient during her entire shift. Private duty nursing is an example of this care model. This medical surgical floor is following the functional nursing model of care, in which care is partitioned and assigned to a staff member with the appropriate skills. For example, the NAP is assigned vital signs, and the LVN is assigned medication administration. When the primary nursing model is utilized, one nurse manages care for a group of patients 24 hours a day, even though others provide care during part of the day. 19. Answer: D. Speech therapist Respiratory therapists provide care for patients with respiratory disorders. Occupational therapists help patients regain function and independence. Dentists diagnose and treat dental disorders. Speech and language therapists provide assistance to clients experiencing swallowing and speech disturbances. They assess the risk for aspiration and recommend a treatment plan to reduce the risk. 20. Answer: A, C Theoretical knowledge consists of research findings, facts (e.g., “Antibiotics are ineffective . . .” is a fact), principles, and theories (e.g., “In Maslow’s framework . . .” is a statement from a theory). Instructions for taking a blood pressure and withdrawing medications are examples of practical knowledge—what to do and how to do it.