Fundamentals NCLEX Questions And Correct Answers

Fundamentals NCLEX Questions And Correct Answers A nurse is preparing to insert an IV catheter into a client's arm prior to initiating IV fluid therapy. Which of the following interventions should the nurse implement to prevent infection? a) Thread the IV catheter so that the hub rests at the insertion site b) Shave excess hair from around the insertion site c) Cleanse the site with hydrogen peroxide before IV catheter insertion d) Palpate the site carefully just before inserting the IV catheter A Inserting the catheter up to the hub reduces the risk of contaminating along the length of the catheter A nurse is caring for a postoperative adult client who refuses to use an incentive spirometer following major abdominal surgery. Which of the following is the nurse's priority action? a) Request that a respiratory therapist discuss the technique for incentive spirometry b) Administer a pain medication to the client c) Chart the client's refusal to participate in health restorative activities d) Determine the reasons why the client is refusing the use the incentive spirometer D A nurse is preparing to administer meperidine (Demerol) 80 mg IM from a 100 mg prefilled syringe. After the injection, which of the following is an appropriate action by the nurse? a) Return the unused portion to the pharmacy b) Have another nurse witness the disposal of the excess medication c) Place the syringe with the unused portion in a locked medication drawer d)Discard the unused medication in the sharps container meperidine is a controlled substance B A charge nurse is discussing the responsibility of nurses carig for clients who have C. difficile. Which of the following information should the nurse include in the teaching? a) Assign the client to a room with a negative air-flow system b) Use alcohol-based hand sanitizer when leaving the clients room c) clean contaminated surfaces in the clients room with a phenol solution d) have family members wear a gown and gloves when visiting D A nurse is providing teaching to a client about techniques to promote sleep. Which of the following instructions should the nurse include in the teaching? a) Consume a light snack of carbohydrates at bedtime b) Drink warm tea at bedtime c) watch TV in bed util drowsy d) exercise 1 hr before bedtime A A nurse is caring for a client receiving IV fluids. During a routine check, the nurse determines that the client has developed phlebitis and removes the IV catheter. Which of the following actions should the nurse take next? a) place a warm compress over the IV site b) record the findings in the client's chart c) notify the client's primary care provider d) prepare to insert a new IV catheter A The greatest risk to the client is further injury. The next action should take is to apply a warm compress over the IV site to decrease edema and client discomfort. A nurse is caring for a client who has dementia. Which of the following interventions should the nurse take to minimize the risk for injury for this client? a) use a bed exit alarm system b) raise 4 side rails while client is in bed c) apply one soft wrist restraint d) dim the lights in the client's room A A nurse is implementing a plan of care for a client who is at risk for falls. Which of the following is an appropriate nursing action? a) implement a regular toileting schedule b) encourage the client to wear athletic socks when ambulating c) place all 4 bed rails in the upright position c) require a family member to remain at the bedside A The nurse should toilet every 1 to 3 hours to reduce the risk of falls due to the client ambulating to the bathroom without assistance A nurse is completing an admission assessment of an older adult client. Which of the following f indings is a potential indication of abuse? a) loss of skin turgor on the back of the hands b) varicosities on lower extremities c) thickened discolored nail with ridges d) presence of bruises on the arm in various stages of healing D A nurse is educating a family member of a client who is immobile about how to prevent back injury associated with moving the client up in bed. Which of the following statements by the family member should indicate to the nurse that he understands the teaching? a) "I will relax my abdominal muscles when preparing to move her" b) "I will keep my knees straight and my feet together" c) I will move back from the bed and bend at the waist" d) I will leverage my weight against my wife and shift as I move her" D A nurse on an oncology unit is caring for a client who has tears in his eyes and states "The doctor just told me that I don't have long to live." Which of the following is an appropriate response of the nurse? a) "I'm sure that you will feel better soon" b) "Chemotherapy is almost always effective" c) "Tell me more about how you're feeling" d) "We will do our best to keep you as comfortable as possible" C Which of the following techniques should the nurse use when performing nasotracheal suctioning for a client? a) insert the suction catheter while the client is swallowing b) apply intermittent suction when withdrawing the catheter c) place the catheter in a location that is clean and dry for later use d) hold the suction catheter with the clean, non-dominant hand B A nurse is assisting a client with range of motion exercise of the neck. Which of the following should the nurse suggest to promote neck rotation? a) move her neck backwards b) touch her chin to chest c) touch her ear to shoulder d) move her head from side to side D