Fundamentals Of Nursing NCLEX Exam Questions With 100% Correct And Verified Answers, Exams of Advanced Education

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Fundamentals Of Nursing NCLEX Exam

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A nurse is scheduling hygiene for patients on the unit. What is the priority consideration when planning a patient's personal hygiene? A. When the patient had his or her most recent bath B. The patient's usual hygiene practices and preferences C. Where the bathing fits in the nurse's schedule D. The time that is convenient for the patient care assistant - Correct Answer-b. Bathing practices and cleansing habits and rituals vary widely. The patient's preferences should always be taken into consideration, unless there is a clear threat to health. The patient and nurse should work together to come to a mutually agreeable time and method to accomplish the patient's personal hygiene. The availability of staff to assist may be important, but the patient's preferences are a higher priority. A nurse caring for patients in a critical care unit knows that providing good oral hygiene is an essential part of nursing care. What are some of the benefits of providing this care? Select all that apply. A. It promotes the patient's sense of well-being. B. It prevents deterioration of the oral cavity. C. It contributes to decreased incidence of aspiration pneumonia. D. It eliminates the need for flossing. E. It decreases oropharyngeal secretions. F. It helps to compensate for an inadequate diet. - Correct Answer-a, b, c. Adequate oral hygiene is essential for promoting the patient's sense of well-being and preventing deterioration of the oral cavity. Diligent oral hygiene care can also improve oral health and limit the growth of pathogens in oropharyngeal secretions, decreasing the incidence of aspiration pneumonia and other systemic diseases. Oral care does not eliminate the need for flossing, decrease oropharyngeal secretions, or compensate for poor nutrition. A nurse assisting with a patient bed bath observes that an older female adult has dry skin. The patient states that her skin is always "itchy." Which nursing action would be the nurse's best response? A. Bathe the patient more frequently. B. Use an emollient on the dry skin. C. Massage the skin with alcohol. D. Discourage fluid intake. - Correct Answer-b. An emollient soothes dry skin, whereas frequent bathing increases dryness, as does alcohol. Discouraging fluid intake leads to dehydration and, subsequently, dry skin.

A nurse caring for patients in a skilled nursing facility performs risk assessment on the patients for foot and nail problems. Which patients would be at a higher risk? Select all that apply. A. A patient who is taking antibiotics for chronic bronchitis B. A patient diagnosed with type II diabetes C. A patient who is obese D. A patient who has a nervous habit of biting his nails E. A patient diagnosed with prostate cancer F. A patient whose job involves frequent handwashing - Correct Answer-b, c, d, f. Variables known to cause nail and foot problems include deficient self-care abilities, vascular disease, arthritis, diabetes mellitus, history of biting nails or trimming them improperly, frequent or prolonged exposure to chemicals or water, trauma, ill-fitting shoes, and obesity. Nurses performing skin assessments on patients must pay careful attention to cleanliness, color, texture, temperature, tumor, moisture, sensation, vascularity, and lesions. Which guidelines should nurses follow when performing these assessments? Select all that apply. A. Compare bilateral parts for symmetry B. Proceed in a toe-to-head systematic manner C. Use standard terminology to report and record findings. D. Do not allow data from the nursing history to direct the assessment. E. Document only skin abnormalities on the patient record. F. Perform the appropriate skin assessment when risk factors are identified. - Correct Answer-a, c, f. When performing a skin assessment, the nurse should compare bilateral parts for symmetry, use standard terminology to report and record findings, and perform the appropriate skin assessment when risk factors are identified. The nurse should proceed in a head-to-toe systematic manner, and allow data from the nursing history to direct the assessment. When documenting a physical assessment of the skin, the nurse should describe exactly what is observed or palpated, including appearance, texture, size, location or distribution, and characteristics of any findings. A nurse is caring for an adolescent with sever acne. Which recommendations would be most appropriate to include in the teaching plan for this patient? Select all that apply. A. Wash the skin twice a day with a mild cleanser and warm water. B. Use cosmetics liberally to cover blackheads. C. Use emollients on the area. D. Squeeze blackheads as they appear. E. Keep hair off the face and wash hair daily. F. Avoid sun-tanning booth exposure an use sunscreen - Correct Answer-a, e, f. Washing the skin removes oil and debris, hair should be kept off the face and washed daily to keep oil from the hair off the face, and sunbathing should be avoided when

using acne treatments. Liberal use of cosmetics and emollients can clog the pores. Squeezing blackheads is always discouraged because it may lead to infection. A nurse is performing oral care on a patient who is in traction. The nurse notes that the mouth is extremely dry with crusts remaining after the oral care. What should be the nurse's next action? A. Make a recommendation for the patient to seen an oral surgeon B. Report the condition to the primary care provider C. Gently scrape the oral cavity with a tongue depressor D. Increase the frequency of the oral hygiene and apply mouth moisturizer to oral mucosa. - Correct Answer-d. If the mouth is extremely dry with crusts that remain after oral care provided, the nurse should increase frequency of oral hygiene, apply mouth moisturizer to oral mucosa, and monitor fluid intake and output to ensure adequate intake of fluid. It is not necessary to report this condition prior to providing the interventions mentioned above. The crusts should not be scraped with a tongue depressor A nurse is removing rigid gas-permeable (RGP) contact lenses from the eyes of a patient who is unable to assist with removal. The nurse notices that one of the lenses is not centered over the cornea. What would be the nurse's first action in this procedure? A. Apply gentle pressure on the lower eyelid to center the lens prior to removing it. B. Move the eyelids towards one another to cause the lens to slide out between the eyelids. C. Do not attempt to remove the lens as it should only be removed by an eyecare specialist. D. Have the patient look forward, retract the lower lid, and move the lens down on the sclera. - Correct Answer-a. If the lens is not centered over the cornea, the nurse should apply gentle pressure on the lower eyelid to center the lens, gently pull the outer corner of the eye toward the ear, position the hand below the lens to receive it, and ask the patient to blink. Moving the eyelids toward one another to cause the lens to slide out between the eyelids is a later step in the procedure. Having the patient look forward, retracting the lower lid and moving the lens down on the sclera occurs during removal of soft contact lenses. It is not necessary to call in an eyecare specialist unless there is damage to the eye. A patient has an eye infection with a moderate amount of discharge. Which action is an appropriate step for the nurse to perform when cleaning this patient's eyes? A. Use hydrogen peroxide on a clean washcloth to wipe eyes. B. Wipe the eye from the outer canthus to the inner canthus. C. Position the patient on the opposite side of the eye to be cleansed. D. Cleanse the eye using a different section of the cleaning cloth for each stroke until clean. - Correct Answer-d. When cleaning the eyes, the nurse should wear gloves during the cleaning procedure, use water or normal saline, and a clean washcloth or

compress to clean the eyes. The nurse should dampen a cleaning cloth with the solution of choice and wipe once while moving from the inner canthus to the outer canthus of the eye. This technique minimizes the risk for forcing debris into the area drained by the nasolacrimal duct. The nurse should turn the cleaning cloth and use a different section for each stroke until the eye is clean. A nurse is providing foot care for patients in a lone-term care facility. Which actions are recommended guidelines for this procedure? Select all that apply. A. Bather the feet thoroughly in a mild soap and tepid water solution. B. Soak the feet in warm water and bath oil. C. Dry feet thoroughly, including the area between the toes. D. Use an alcohol rub if feet are dry. E. Use an antifungal foot powder if necessary to prevent fungal infections. F. Cut the toenails at the lateral corners when trimming the nail. - Correct Answer-a, c, e. The following are recommended guidelines for foot care: bathe the feet thoroughly in a mild soap and tepid water solution; dry feet thoroughly, including the area between the toes; and use an antifungal foot powder if necessary to prevent fungal infections. The nurse should avoid soaking the feet, use moisturizer if the feet are dry, and avoid digging into or cutting the toenails at the lateral corners when trimming the nails. A nurse is assisting a patient with demential with bathing. Which guideline is recommended in this procedure? A. Shift the focus of the interaction to the "process of bathing." B. Wash the face and hair at the beginning of the bath. C. Consider using music to soothe anxiety and agitation. D. Do not perform towel baths or alternate forms of bathing with which the patient is unfamiliar. - Correct Answer-c. The nurse should consider the use of music to soothe anxiety and agitation. The nurse should also shift the focus of the interaction from the "task of bathing" to the needs and abilities of the patient, and focus on comfort, safety, autonomy, and self-esteem, in addition to cleanliness. The nurse should wash the face and hair at the end of the bath or at a separate time. Water dripping in the face and having a wet head are often the most upsetting parts of the bathing process for people with dementia. The nurse should also consider other methods for bathing. Showers and tub baths are not the only options in bathing. Towel baths, washing under clothes, and bathing "body sections" one day at a time are other possible options. A nurse is teaching a student nurse how to cleanse the perineal area of both male and female patients. What are accurate guidelines when performing this procedure? A. For male and female patients, wash the groin area with a small amount of soap and water and rinse. B. For a female patient, spread the labia and move the washcloth from the anal area toward the pubic area.

C. For male and female patients, always proceed from the most contaminated area to the least contaminated area. D. For male and female patients, use a clean portion go the washcloth for each stroke. E. For a male patient, clean the tip of the penis first, moving the washcloth in a circular motion from the meatus outward. F. In an uncircumcised male patient, do not retract the foreskin (prepuce) while washing the penis. - Correct Answer-a, d, e. Wash and rinse the groin area (both male and female patients) with a small amount of soap and water, and rinse. For male and female patients, always proceed from the least contaminated area to the most contaminated area and use a clean portion of the washcloth for each stroke. For a male patient, clean the tip of the penis first, moving the washcloth in a circular motion from the meatus outward. For a female patient, spread the labia and move the washcloth from the pubic area toward the anal area. In an uncircumcised male patient (teenage or older), retract the foreskin (prepuce) while washing the penis. A nurse is assisting an older adult with an unsteady gait with a tub bath. Which action is recommended in this procedure? A. Add bath oil to the water to prevent dry skin. B. Allow the patient to lock the door to guarantee privacy. C. Assist the patient in and out of the tub to prevent falling. D. Keep the water temperature very warm because older adults chill easily. - Correct Answer-c. Safe nursing practice requires that the nurse assist a patient with an unsteady gait in and out of the tub. Adding Alpha Keri oil to the bath water is dangerous for this patient because it makes the tub slippery. Although privacy is important, if the patient locks the door, the nurse cannot help if there is an emergency. The water should be comfortably warm at 43° to 46°C. Older adults have an increased susceptibility to burns due to diminished sensitivity. A nurse is about to bathe a female patient who has an intravenous access in place in her forearm. The patient's gown, which does not have snaps on the sleeves, needs to be removed prior to bathing. What is the appropriate nursing action? A. Temporarily disconnect the IV tubing at a point close to the patient and thread it through the gown sleeve. B. Cut the gown with scissors and allow arm movement. C. Thread the bag and tubing through the gown sleeve, keeping the line intact. D. Temporarily disconnect the tubing from the IV container, threading it through the gown. - Correct Answer-c. Threading the bag and tubing through the gown sleeve keep the system intact. Opening an IV line, even temporarily, causes a break in a sterile system and introduces the potential for infection. Cutting a gown is not an alternative except in an emergency. A nurse is caring for a 25-year-old male patient who is comatose following a head injury. The patient has several piercings in his ears and nos. The piercing in his nose appears

to be new and is crusted and slightly inflamed. Which action would be appropriate when caring for this patient's piercings? A. Do not remove or wash the piercings without permission from the patient. B. Rinse the sites with warm water and remove crusts with a cotton swab. C. Wash the sites with alcohol and apply an antibiotic ointment. D. Remove the jewelry and allow the sites to heal over. - Correct Answer-b. When providing care for piercings, the nurse should perform hand hygiene and put on gloves, then cleanse the site of all crusts and debris by rinsing the site with warm water, removing the crusts with a cotton swab. The nurse should then apply a dab of liquid- medicated cleanser to the area, turn the jewelry back and forth to work the cleanser around the opening, rinse well, remove gloves, and perform hand hygiene. The nurse should not use alcohol, peroxide, or ointments at the site or remove the piercings unless it is absolutely necessary (e.g., when an MRI is ordered.) A nurse is preparing for an exercise program for a patient who has COPD. Which instructions would the nurse include in a teaching plan for this patient? Select all that apply. A. Instruct the patient to avoid sudden position changes that may cause dizziness. B. Recommend that they patient restrict fluid until after exercising is finished. C. Instruct the patient to push a little further beyond fatigue each session D. Instruct the patient to avoid exercising in very cold or very hot temperatures E. Encourage the patient to modify exercise if weak or ill F. Recommend that the patient consume a higher-carb, low-protein diet - Correct Answer-a, d. Teaching points for exercising for a patient with COPD include avoiding sudden position changes that may cause dizziness and avoiding extreme temperatures. The nurse should also instruct the patient to provide for adequate hydration, respect fatigue by not pushing to the point of exhaustion, and avoid exercise if weak or ill. Older adults should consume a high-protein, high-calcium, and vitamin D-enriched diet. A nurse is providing range-of-motion exercises for a patient who is recovering from a stroke. During the session, the patient complains that she is "too tired to go on." What would be priority nursing actions for this patient? Select all that apply. A. Stop performing the exercises. B. Decrease the number of reputations performed C. Reevaluate the nursing care plan D. Move the patient's other side to perform exercises E. Encourage the patient to finish the exercises and then rest F. Assess the patient for other symptoms - Correct Answer-a, c, f. When a patient complains of fatigue during range-of-motion exercises, the nurse should stop the activity, reevaluate the nursing care plan, and assess the patient for further symptoms. The exercises could then be scheduled for times of the day when the patient is feeling more rested, or spaced out at different times of the day.

A nurse is ambulating a patient for the first time following surgery for a knee replacement. Shortly after beginning to walk, the patient tells the nurse that she is dizzy and feels like she might fall. Place these nursing actions in the order in which the nurse should perform them to protect the patient: A. Grasp the gait belt B. Stay with the patient and call for help C. Place feet wide apart with one foot in front D. Gently slide patient down to the floor, protecting her head E. Pull the weight of the patient backwards against your body. F. Rock your pelvis out on the side of the patient - Correct Answer-c, f, a, e, d, b. If a patient being ambulated starts to fall, you should place your feet wide apart with one foot in front, rock your pelvis out on the side nearest the patient, grasp the gait belt, support the patient by pulling her weight backward against your body, gently slide her down your body toward the floor while protecting her head, and stay with the patient and call for help. A nurse caring for patients in a pediatrician's office assesses infants and toddlers for physical developmental milestones. Which patient would the nurse refer to a specialist based on failure to achieve these milestones? A. A 4-month-old infant who is unable to roll over B. A 6-month-old infant who is unable to hold his head up himself C. An 11-month-old infant who cannot walk unassisted D. An 18-month-old toddler who cannot jump - Correct Answer-b. By 5 months, head control is usually achieved. An infant usually rolls over by 6 to 9 months. By 15 months, most toddlers can walk unassisted. By 2 years, most toddlers can jump. A nurse is caring for a patient who has been hospitalized for a spinal cord injury following a motor vehicle accident. Which action would the nurse perform when logrolling the patient to reposition him on his side? A. have the patient extend his arms outward and cross his legs on top of a pillow B. Stand at the side of the bed in which the patient will be turned while another nurse gently pushes the patient from the other side. C. Have the patient cross his arms on his Ches and place a pillow between his knees. D. Place a cervical collar on the patient's neck and gently roll him to the other side of the bed. - Correct Answer-c. The procedure for logrolling a patient is: (1) Have the patient cross the arms on the chest and place a pillow between the knees; (2) have two nurses stand on one side of the bed opposite the direction the patient will be turned with the third helper standing on the other side and if necessary, a fourth helper at the head of the bed to stabilize the neck; (3) fanfold or roll the drawsheet tightly against the patient and carefully slide the patient to the side of the bed toward the nurses; (4) have one helper move to the other side of the bed so that two nurses are on the side to which the patient is turning; (5) face the patient and have everyone move on a predetermined

time, holding the drawsheet taut to support the body, and turn the patient as a unit toward the two nurses. A nurse is caring for a patient in a long-term care facility who has two urinary tract infections in the past year related to immobility. Which finding would the nurse expect in this patient? A. Improved renal blood supply to the kidneys B. Urinary stasis C. Decreased urinary calcium D. Acidic urine formation - Correct Answer-b. In a nonerect patient, the kidneys and ureters are level. In this position, urine remains in the renal pelvis for a longer period of time before gravity causes it to move into the ureters and bladder, resulting in urinary stasis. Urinary stasis favors the growth of bacteria that may cause urinary tract infections. Regular exercise, not immobility, improves blood flow to the kidneys. Immobility predisposes the patient to increased levels of urinary calcium and alkaline urine, contributing to renal calculi and urinary tract infection, respectively. A nurse is caring for a patient who is hospitalized with pneumonia and is experiencing some difficulty breathing. The nurse most appropriately assists him into which position to promote maximal breathing in the thoracic cavity? A. Dorsal recumbent position B. Lateral position C. Fowler's position D. Sims' position - Correct Answer-c. Fowler's position promotes maximal breathing space in the thoracic cavity and is the position of choice when someone is having difficulty breathing. Lying flat on the back or side or Sims' position would not facilitate respiration and would be difficult for the patient to maintain. A nurse is assisting a postoperative patient with conditioning exercises to prepare for ambulation. Which instructions from the nurse are appropriate for this patient? Select all that apply. A. Do full-body pushups in bed six to eight times daily. B. Breathe in and out smoothly during quadriceps drills. C. Place the bed in the lowest position or use a footstool for dangling. D. Dangle on the side of the bed for 30 to 60 minutes. E. Allow the nurse to bathe the patient completely to prevent fatigue. F. Perform quadriceps two to three times per hour, four to six times a day. - Correct Answer-b, c, f. Breathing in and out smoothly during quadriceps drills maximizes lung inflation. The patient should perform quadriceps two to three times per hour, four to six times a day, or as ordered. The patient should never hold their breath during exercise drills because this places a strain on the heart. Pushups are usually done three or four times a day and involve only the upper body. Dangling for 30 to 60 minutes is unsafe. The nurse should place the bed in the lowest position or use a footstool for dangling.

The nurse should also encourage the patient to be as independent as possible to prepare for return to normal ambulation and ADLs. A nurse is caring for a patient who is on bed rest following a spinal injury. In which position would the nurse place the patient's feet to prevent footdrop? A. Supination B. Dorsiflexion C. Hyperextension D. Abduction - Correct Answer-b. For a patient who has footdrop, the nurse should support the feet in dorsiflexion and use a footboard or high-top sneakers to further support the foot. Supination involves lying patients on their back or facing a body part upward, and hyperextension is a state of exaggerated extension. Abduction involves lateral movement of a body part away from the midline of the body. These positions would not be used to prevent footdrop. A nurse is instructing a patient who is recovering from a stroke to use a cane. Which steps would the nurse include in the teaching plan for this patient? A. Support weight on stronger leg and cane and advance weaker foot forward B. Hold the cane in the same hand of the leg with the most severe deficit C. Stand with as much weight distributed on the cane as possible D. Do not use the cane to rise from a sitting position, as this is unsafe - Correct Answer- a. The proper procedure for using a cane is to (1) stand with weight distributed evenly between the feet and cane; (2) support weight on the stronger leg and the cane and advance the weaker foot forward, parallel with the cane; (3) support weight on the weaker leg and cane and advance the stronger leg forward ahead of the cane; (4) move the weaker leg forward until even with the stronger leg and advance the cane again as in step 2. The patient should keep the cane within easy reach and use it for support to rise safely from a sitting position. A patient has a fractured left leg, which has been casted. Following teaching from the physical therapist for using crutches, the nurse reinforces which teaching point with the patient? A. Use the axillae to bear body weight B. Keep elbows close to the sides of the body C. When rinsing, extend the uninjured leg to prevent weight bearing D. To climb stairs, place weight on affected leg first - Correct Answer-b. The patient should keep the elbows at the sides, prevent pressure on the axillae to avoid damage to nerves and circulation, extend the injured leg to prevent weight bearing when rising from a chair, and advance the unaffected leg first when climbing stairs. A nurse working in a long-term care facility uses proper patient care ergonomics when handling and transferring patients to avoid back injury. Which action should be the focus of these preventative measures?

A. Carefully assessing the patient care environment B. Using two nurses to lift a patient who cannot assist C. Wearing a back belt to perform routine duties D. Properly documenting the patient lift - Correct Answer-a. Preventive measures should focus on careful assessment of the patient care environment so that patients can be moved safely and effectively. Using lifting teams and assistive patient handling equipment rather than two nurses to lift increases safety. The use of a back belt does not prevent back injury. The methods used for safe patient handling and movement should be documented but are not the primary focus of interventions related to injury prevention. A nurse is assisting a patient who is 2 days postoperative from a cesarean section to sit in a chair. After assisting the patient to the side of the bed and to stand up, the patient's knees buckle and she tells the nurse she feels faint. What is the appropriate nursing action? A. Wait a few minutes and then continue to move to the chair. B. Call for assistance and continue the move with the help of another nurse. C. Lower the patient back to the side of the bed and pivot her back into bed. D. Have the patient sit down on the bed and dangle her feet before moving - Correct Answer-c. If a patient becomes faint and knees buckle when moving from bed to a chair, the nurse should not continue the move to the chair. The nurse should lower the patient back to the side of the bed, pivot her back into bed, cover her, and raise the side rails. Assess the patient's vital signs and for the presence of other symptoms. Another attempt should be made with the assistance of another staff member if vital signs are stable. Instruct the patient to remain in the sitting position on the side of the bed for several minutes to allow the circulatory system to adjust to a change in position, and avoid hypotension related to a sudden change in position. A patient who injured the spine in a motorcycle accident is receiving rehabilitation services in a short-term rehabilitation center. The nurse caring for the patient correctly tells the aide not to place the patent in which position? A. Side-lying B. Fowler's C. Sims' D. Prone - Correct Answer-d. The prone position is contraindicated in patients who have spinal problems because the pull of gravity on the trunk when the patient lies prone produces a marked lordosis or forward curvature of the lumbar spine. A nurse is using the Katz Index of Independence in Activities of Daily Living (ADLs) to assess the mobility of a hospitalized patient. During the patient interview, the nurse documents the following patient data: "Patient bathes self completely but needs help with dressing. Patient toilets independently and is continent. Patient needs help moving

from bed to chair. Patient follows directions and can feed self." Based on this data, which score would the patient receive on the Katz index? A. 2 B. 4 C. 5 D. 6 - Correct Answer-b. The total score for this patient is 4. On the Katz Index of Independence in ADLs, one point is awarded for independence in each of the following activities: bathing, dressing, toileting, transferring, continence, and feeding.