Fundamentals of Nursing NCLEX
Practice Questions Quiz #2 | 75
Questions
FNDNRS-02-001
Which intervention is an example of primary prevention?
A. Administering digoxin (Lanoxicaps) to a patient with heart failure.
B. Administering measles, mumps, and rubella immunization to an infant.
C. Obtaining a Papanicolaou smear to screen for cervical cancer.
D. Using occupational therapy to help a patient cope with arthritis.
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.
FNDNRS-02-002
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
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.
FNDNRS-02-003
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.
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.
FNDNRS-02-004
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
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.
Practice Questions Quiz #2 | 75
Questions
FNDNRS-02-001
Which intervention is an example of primary prevention?
A. Administering digoxin (Lanoxicaps) to a patient with heart failure.
B. Administering measles, mumps, and rubella immunization to an infant.
C. Obtaining a Papanicolaou smear to screen for cervical cancer.
D. Using occupational therapy to help a patient cope with arthritis.
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.
FNDNRS-02-002
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
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.
FNDNRS-02-003
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.
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.
FNDNRS-02-004
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
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.
