Nclex questions with answers |Fundamentals of Nursing with rationale 100% correct and veri, Exams of Nursing

Download Nclex questions with answers |Fundamentals of Nursing with rationale 100% correct and veri and more Exams Nursing in PDF only on Docsity! Nclex questions with answers |Fundamentals of Nursing with rationale 100% correct and verified 1. A 73-year-old patient who sustained a right hip fracture in a fall requests pain medication from the nurse. Based on his injury, which type of pain is this patient most likely experiencing? 1. Phantom 2.Visceral 3.deep somatic 4.Referred Answer: Deep somatic Rationale: Deep somatic pain originates in ligaments, tendons, nerves, blood vessels, and bones. Therefore, a hip fracture causes deep somatic pain. Phantom pain is pain that is perceived to originate from a part that was removed during surgery. Visceral pain is caused by deep internal pain receptors and commonly occurs in the abdominal cavity, cranium, and thorax. Referred pain occurs in an area that is distant to the original site. 2. Which pain management task can the nurse safely delegate to nursing assistive personnel? Nclex questions with answers |Fundamentals of Nursing with rationale 100% correct and verified Nclex questions with answers |Fundamentals of Nursing with rationale 100% correct and verified 1) Asking about pain during vital signs 2) Evaluating the effectiveness of pain medication 3) Developing a plan of care involving nonpharmacologic interventions 4) Administering over-the-counter pain medications Answer: a. Asking about pain during vital signs Rationale: The nurse can delegate the task of asking about pain when nursing assistive personnel (NAP) obtain vital signs. The NAP must be instructed to report findings to the nurse without delay. The nurse should evaluate the effectiveness of pain medications and develop the plan of care. Administering over-the-counter and prescription medications is the responsibility of the registered nurse or licensed practical nurse.  Nclex questions with answers |Fundamentals of Nursing with rationale 100% correct and verified Nclex questions with answers |Fundamentals of Nursing with rationale 100% correct and verified 3) Instruct the patient to administer a dose only when experiencing pain. 4)Provide clear, simple instructions for dosing if the patient is cognitively impaired. Answer: 2) Ask another nurse to double-check the setup before patient use. Rationale: As a safeguard to reduce the risk for dosing errors, the nurse should request another nurse to double-check the setup before patient use. The nurse should reassure the patient that the pump has a lockout feature that prevents him from overdosing even if he continues to push the dose administration button. The nurse should also instruct the patient to administer a dose before potentially painful activities, such as walking. Patient-controlled analgesia is contraindicated for those who are cognitively impaired.  The nurse administers codeine sulfate 30 mg orally to a patient who underwent craniotomy 3 days ago for a brain tumor. How soon after administration should the nurse reassess the patient's pain? 1) Immediately 2) In 10 minutes 3) In 15 minutes 4) In 60 minutes Nclex questions with answers |Fundamentals of Nursing with rationale 100% correct and verified Nclex questions with answers |Fundamentals of Nursing with rationale 100% correct and verified Answer: 4) In 60 minutes Rationale: Codeine administered by the oral route reaches peak concentration in 60 minutes; therefore, the nurse should reassess the patient's pain 60 minutes after administration. The nurse should reassess pain after 10 minutes when administering codeine by the intramuscular or subcutaneous routes. Drugs administered by the intravenous (IV) route are effective almost immediately; however, codeine is not recommended for IV administration.  Which nonsteroidal anti-inflammatory drug might be administered to inhibit platelet aggregation in a patient at risk for thrombophlebitis? 1) Ibuprofen (Motrin) 2)Celecoxib (Celebrex) 3)Aspirin (Ecotrin) 4) Indomethacin (Indocin) Answer: 3) Aspirin (Ecotrin) Nclex questions with answers |Fundamentals of Nursing with rationale 100% correct and verified Nclex questions with answers |Fundamentals of Nursing with rationale 100% correct and verified Rationale: Aspirin is a unique NSAID that inhibits platelet aggregation. Low-dose aspirin therapy is commonly administered to decrease the risk of thrombophlebitis, myocardial infarction, and stroke. Ibuprofen, celecoxib, and indomethacin are NSAIDs, but they do not inhibit platelet aggregation.  A client who is receiving epidural analgesia complains of nausea and loss of motor function in his legs. The nurse obtains his blood pressure and notes a drop in his blood pressure from the previous reading. Which complication is the patient most likely experiencing? 1) Infection at the catheter insertion site 2)Side effect of the epidural analgesic 3)Epidural catheter migration 4)Spinal cord damage Answer: 3) Epidural catheter migration Rationale: The patient is exhibiting signs of epidural catheter migration, which include nausea, a decrease in blood pressure, and loss of motor function without an identifiable cause. Signs of infection at the catheter site include redness, swelling, and drainage. Loss of motor function is not a typical side Nclex questions with answers |Fundamentals of Nursing with rationale 100% correct and verified Nclex questions with answers |Fundamentals of Nursing with rationale 100% correct and verified on this assessment finding, it would be important for the nurse to also assess the: 1)Pulse deficit 2)Blood pressure 3)Apical pulse 4)Pulse pressure Answer: 2) Blood pressure Rationale: If the leg pulses are weak, the nurse should assess the blood pressure in order to further explore the reason for the low pulse volume. If the blood pressure is low, then a low pulse volume would be expected. The pulse deficit is the difference between the apical and radial pulse. The apical pulse would not be helpful to assess peripheral circulation. The pulse pressure is the difference between the systolic and diastolic pressures.  Which of the following clients has indications of orthostatic hypotension? A client whose blood pressure is: Nclex questions with answers |Fundamentals of Nursing with rationale 100% correct and verified Nclex questions with answers |Fundamentals of Nursing with rationale 100% correct and verified 1)118/68 when standing and 110/72 when lying down 2)140/80, HR 82 bpm when sitting and 136/76, HR 98 bpm when standing 3)126/72 lying down and 133/80 when sitting, and reports shortness of breath 4)146/88 when lying down and 130/78 when standing, and reports feeling dizzy Answer: 4) 146/88 when lying down and 130/78 when standing, and reports feeling dizzy Rationale: Orthostatic hypotension is a drop of 10 mm Hg or more in blood pressure upon moving to a standing position, with complaints of feeling dizzy and/or faint.  A client who has experienced prolonged exposure to the cold is admitted to the hospital. Which method of taking a temperature would be most appropriate for this client? 1)Axillary with an electronic thermometer 2)Oral with a glass thermometer 3)Rectal with an electronic thermometer 4)Tympanic with an infrared thermometer Answer: Nclex questions with answers |Fundamentals of Nursing with rationale 100% correct and verified Nclex questions with answers |Fundamentals of Nursing with rationale 100% correct and verified 3) Rectal with an electronic thermometer Rationale: The rectal route is the most accurate for assessing core temperature, especially when it is critical to get an accurate temperature. Therefore, in this situation it is preferred. Temperature is a particularly relevant data point for this client with hypothermia as it indicates the patient's baseline status and response to treatment. The electronic thermometer is safer than glass and is relatively accurate. Mercury thermometers are no longer used in the hospital setting. The accuracy of tympanic thermometers is debatable.  Which of the following clients would have the most difficulty maintaining thermoregulation? 1)Young child playing soccer during the summer 2)Middle-aged adult snow skiing 3)Young adult playing golf on a hot day 4)Older adult raking leaves on a cold day Answer: 4) Older adult raking leaves on a cold day Nclex questions with answers |Fundamentals of Nursing with rationale 100% correct and verified Nclex questions with answers |Fundamentals of Nursing with rationale 100% correct and verified 3)An empty corner at the nurse's station 4)A conference room at the end of the hall Answer: 4) A conference room at the end of the hall Rationale: The best environment in which to discuss sensitive matters is a quiet room where conversation can occur in private, particularly when the space is nonthreatening. The patient might be distracted if conversation takes place in a room where others (e.g., patients and visitors) are present. The hallway outside the patient's room and the nurses' station are public areas and should not be used for private conversation.  A patient is admitted to the medical surgical floor with a kidney infection. The nurse introduces herself to the patient and begins her admission assessment. Which goal is most appropriate for this phase of the nurse-patient relationship? The patient will be able to: 1)Describe how to operate the bed and call for the nurse. 2)Discuss communication patterns and roles within the family. 3)Openly express his concerns about the hospitalization. 4)State expectations related to discharge. Nclex questions with answers |Fundamentals of Nursing with rationale 100% correct and verified Nclex questions with answers |Fundamentals of Nursing with rationale 100% correct and verified Answer: 1) Describe how to operate the bed and call for the nurse. Rationale: This is the orientation phase of the relationship. The orientation phase begins when the nurse introduces herself to the patient and begins to gather data. In this phase, the nurse and patient are getting to know each other. As part of the orientation phase, the nurse will orient the patient to the hospital room and routines. In the preinteraction phase, the nurse gathers information about the patient before she meets him. Discussion of personal information, particularly if sensitive or complex, is suitable for the working phase of the nurse-patient interaction. The patient expressing feelings and concerns also occurs during the working phase. During the working phase, care is communicated, thoughts and feelings are expressed, and honest verbal and nonverbal communication occurs. Stating expectations related to discharge is most appropriate for the termination phase—the conclusion of the relationship.  A local church organizes a group for people who are having difficulty coping with the death of a loved one. Which type of group has been organized? 1)Work-related social support group Nclex questions with answers |Fundamentals of Nursing with rationale 100% correct and verified Nclex questions with answers |Fundamentals of Nursing with rationale 100% correct and verified 2)Therapy group 3)Task group 4)Community committee Answer: 2) Therapy group Rationale: Therapy groups are designed to help individual members cope with issues, such as the death of a spouse, divorce, or motherhood. Work-related social support groups help members of a profession cope with work-associated stress. Task groups meet to accomplish a specified task. Community- based committees meet to discuss community issues.  A mother comes to the emergency department after receiving a phone call informing her that her son was involved in a motor vehicle accident. When she approaches the triage desk, she frantically asks, "How is my son?" Which response by the nurse is best? 1) "He's being examined now; he's awake and talking. We'll take you to see him soon." 2) "Don't worry, I'm sure he'll be fine; we have an excellent trauma team caring for him." 3) "Everything will be okay; please take a seat and I'll check on him for you." 4) "Your son is strong and has youth on his side; I'm sure he'll be fine." Nclex questions with answers |Fundamentals of Nursing with rationale 100% correct and verified Nclex questions with answers |Fundamentals of Nursing with rationale 100% correct and verified 3) Dizziness Rationale: Orthostatic hypotension, cognitive impairment, difficulty with walking or balance, weakness, dizziness, and drowsiness from certain medications place the patient at risk for falling. A history of right appendectomy and hyperthyroidism do not place that patient at risk for falling.  The nurse is teaching a child and family about firearm safety. The nurse should instruct the child to take which step first if he sees a gun at a friend's house? 1)Leave the area. 2)Do not touch the gun. 3)Stop where he is. 4)Tell an adult. Answer: 3) Stop where he is. Rationale: Nclex questions with answers |Fundamentals of Nursing with rationale 100% correct and verified Nclex questions with answers |Fundamentals of Nursing with rationale 100% correct and verified The child should be instructed to stop where he is. This allows him to think about the next steps he has memorized. Next, he should avoid touching the gun, leave the area, and immediately go tell an adult.  A patient is agitated and continues to try to get out of bed. The nurse tries unsuccessfully to reorient him. What should the nurse do next? 1)Apply a vest restraint. 2)Move the patient to a quieter room. 3)Ask another nurse to care for the patient. 4)Provide comfort measures. Answer: 4) Provide comfort measures. Rationale: Patients sometimes become agitated because they are uncomfortable or in pain. Providing comfort measures may decrease agitation. If the patient continues to be agitated, the nurse should encourage a family member or friend to sit with the patient. Applying a physical restraint should be kept as a last resort for use only when less restrictive measures fail. The patient should be placed in a room near the nurses' station so he can be checked frequently if there is no one available to provide one-on-one supervision. A quieter room would probably not help. Nclex questions with answers |Fundamentals of Nursing with rationale 100% correct and verified Nclex questions with answers |Fundamentals of Nursing with rationale 100% correct and verified  While teaching a health promotion group of adults, the nurse notices one person who is clutching his throat with both hands. What should the nurse do first? 1) Call 9-1-1. 2)Encourage the person to cough vigorously. 3)Ask, "Are you choking?" 4)Give five back blows. Answer: 3) Ask, "Are you choking?" Rationale: Clutching the throat is the universal sign of choking. The first action when you suspect airway obstruction is to ask, "Are you choking?" If the person indicates "yes," or if the person cannot cough, speak, or breathe, that indicates choking. You must first be certain the person is choking because you can cause harm when you perform the choking maneuver. You would not call 9-1-1, encourage coughing, or give five back blows until you first establish that the person is choking. The client Nclex questions with answers |Fundamentals of Nursing with rationale 100% correct and verified Nclex questions with answers |Fundamentals of Nursing with rationale 100% correct and verified Answer: 2) Bathing every other day Rationale: As a person ages, sebaceous glands become less active, causing skin to dry. Older people may find it necessary to bathe every 2 days, increase the use of moisturizers, and decrease soap use to prevent further drying of skin. Older adults should brush their teeth after every meal and at bedtime to prevent tooth decay. It is recommended that people of all ages brush their teeth at least twice a day, so that option does not represent a change in an older adult's hygiene practices.  A woman of Orthodox Jewish faith who underwent a hysterectomy for cancer is being cared for on the surgical floor. Which healthcare team member(s) could be assigned to bathe this patient? Choose all correct answers. 1)Male nursing assistant 2)Male licensed practical nurse 3)Female graduate nurse 4)Female registered nurse Answer: 3)Female graduate nurse 4)Female registered nurse Nclex questions with answers |Fundamentals of Nursing with rationale 100% correct and verified Nclex questions with answers |Fundamentals of Nursing with rationale 100% correct and verified Rationale: Orthodox Judaism prohibits personal care being provided by a member of the opposite sex. The patient who underwent a hysterectomy is female; therefore, out of respect for her religious beliefs, she should not be bathed by the male licensed practical nurse or nursing assistant.  A 75-year-old patient who is 5 feet 7 inches tall and weighs 170 pounds is admitted with dehydration. A nursing diagnosis of Risk for Impaired Skin Integrity is identified for this patient. Which factor places the client at Risk for Impaired Skin Integrity? Answer: Dehydration Rationale: Dehydration places the patient at risk for impaired skin integrity. Dehydration, caused by fluid volume deficit, causes the skin to become dry and crack easily, impairing skin integrity. People who are very thin or very obese are more likely to experience impaired skin integrity. This patient is of normal height and weight; therefore, his body stature does not place him at risk. There is nothing to suggest that this patient has an impaired nutritional status. Nclex questions with answers |Fundamentals of Nursing with rationale 100% correct and verified Nclex questions with answers |Fundamentals of Nursing with rationale 100% correct and verified  The nurse notes a lesion that appears to be caused by tissue compression on the right hip of a patient who suffered a stroke 5 days ago. How should the nurse document this finding? 1)Maceration 2)Abrasion 3)Excoriation 4)Pressure ulcer Answer: 4) Pressure ulcer Rationale: The nurse should document a lesion caused by tissue compression and inadequate perfusion as a pressure ulcer. Abrasion, a rubbing away of the epidermal layer of skin, is commonly caused by shearing forces that occur when a patient moves or is moved in bed. Maceration is a softening of skin from prolonged moisture. Excoriation is a loss of the superficial layers of the skin caused by the digestive enzymes in feces.  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? Nclex questions with answers |Fundamentals of Nursing with rationale 100% correct and verified Nclex questions with answers |Fundamentals of Nursing with rationale 100% correct and verified 2) Intact skin Rationale: 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.  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? 1)A clean gown and gloves must be worn when in contact with the client. 2)Everyone who enters the room must wear a N-95 respirator mask. 3)All linen and trash must be marked as contaminated and send to biohazard waste. 4)Place the client in a room with a client with an upper respiratory infection. Answer: 1) A clean gown and gloves must be worn when in contact with the client. Rationale: A clean gown and gloves must be worn when any contact is anticipated with the client or with Nclex questions with answers |Fundamentals of Nursing with rationale 100% correct and verified Nclex questions with answers |Fundamentals of Nursing with rationale 100% correct and verified 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.  A client requires protective isolation. Which client can be safely paired with this client in a client- care assignment? One 1)admitted with unstable diabetes mellitus. 2)who underwent surgical repair of a perforated bowel. 3)with a stage 3 sacral pressure ulcer. 4)admitted with a urinary tract infection. Answer: 1) admitted with unstable diabetes mellitus. Rationale: 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 Nclex questions with answers |Fundamentals of Nursing with rationale 100% correct and verified Nclex questions with answers |Fundamentals of Nursing with rationale 100% correct and verified infection.  Which action demonstrates a break in sterile technique? 1)Remaining 1 foot away from nonsterile areas 2)Placing sterile items on the sterile field 3)Avoiding the border of the sterile drape 4)Reaching 1 foot over the sterile field Answer: 4) Reaching 1 foot over the sterile field Rationale: 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.  Nclex questions with answers |Fundamentals of Nursing with rationale 100% correct and verified Nclex questions with answers |Fundamentals of Nursing with rationale 100% correct and verified Answer: 2) Patient's dentures lost after transfer Rationale: 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.  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: 1)Separates the health record according to discipline 2)Organizes documentation around the patient's problems 3)Highlights the patient's concerns, problems, and strengths 4) Is designed to streamline documentation Answer: 1) Separates the health record according to discipline Nclex questions with answers |Fundamentals of Nursing with rationale 100% correct and verified Nclex questions with answers |Fundamentals of Nursing with rationale 100% correct and verified Rationale: 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.  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? 1)NA 2)NDA 3)NKA 4)NPO Answer: 3) NKA Rationale: Nclex questions with answers |Fundamentals of Nursing with rationale 100% correct and verified Nclex questions with answers |Fundamentals of Nursing with rationale 100% correct and verified 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.  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: 1)Are comprehensive charting forms that integrate assessments and nursing actions 2)Contain only graphic information, such as I&O, vital signs, and medication administration 3)Are used to record routine aspects of care; they do not contain assessment data 4)Contain vital data collected upon admission, which can be compared with newly collected data Answer: 1) Are comprehensive charting forms that integrate assessments and nursing actions Rationale: 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.  Nclex questions with answers |Fundamentals of Nursing with rationale 100% correct and verified Nclex questions with answers |Fundamentals of Nursing with rationale 100% correct and verified 3)Civil service 4)Religious orders Answer: 4) Religious orders Rationale: 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.  Which of the following is/are an example(s) of a health restoration activity? Select all that apply. 1)Administering an antibiotic every day 2)Teaching the importance of hand washing Nclex questions with answers |Fundamentals of Nursing with rationale 100% correct and verified Nclex questions with answers |Fundamentals of Nursing with rationale 100% correct and verified 3)Assessing a client's surgical incision 4)Advising a woman to get an annual mammogram after age 50 years Answer: 1) Administering an antibiotic every day 3) Assessing a client's surgical incision Rationale: 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.  Which of the following aspects of nursing is essential to defining it as both a profession and a discipline? 1)Established standards of care 2)Professional organizations 3)Practice supported by scientific research 4)Activities determined by a scope of practice Answer: 3) Practice supported by scientific research Nclex questions with answers |Fundamentals of Nursing with rationale 100% correct and verified Nclex questions with answers |Fundamentals of Nursing with rationale 100% correct and verified Rationale: 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.  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? 1)Team nursing 2)Case method nursing 3)Functional nursing 4)Primary nursing Answer: 3) Functional nursing Nclex questions with answers |Fundamentals of Nursing with rationale 100% correct and verified Nclex questions with answers |Fundamentals of Nursing with rationale 100% correct and verified 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.  Critical thinking and the nursing process have which of the following in common? Both: 1)Are important to use in nursing practice 2)Use an ordered series of steps 3)Are patient-specific processes 4)Were developed specifically for nursing Answer: 1) Are important to use in nursing practice Rationale: Nurses make many decisions: some require using the nursing process, whereas others are not client related but require critical thinking. The nursing process has specific steps; critical thinking does not. Neither is linear. Critical thinking applies to any discipline.  In which step of the nursing process does the nurse analyze data and identify client problems? Nclex questions with answers |Fundamentals of Nursing with rationale 100% correct and verified Nclex questions with answers |Fundamentals of Nursing with rationale 100% correct and verified 1)Assessment 2)Diagnosis 3)Planning outcomes 4)Evaluation Answer: 2) Diagnosis Rationale: In the assessment phase, the nurse gathers data from many sources for analysis in the diagnosis phase. In the diagnosis phase, the nurse identifies the client's health status. In the planning outcomes phase, the nurse formulates goals and outcomes. In the evaluation phase, which occurs after implementing interventions, the nurse gathers data about the client's responses to nursing care to determine whether client outcomes were met.  In which phase of the nursing process does the nurse decide whether her actions have successfully treated the client's health problem? Nclex questions with answers |Fundamentals of Nursing with rationale 100% correct and verified Nclex questions with answers |Fundamentals of Nursing with rationale 100% correct and verified Answer: Evaluation Rationale: In the assessment phase, the nurse gathers data from many sources for analysis in the diagnosis phase. In the diagnosis phase, the nurse identifies the client's health status. In the planning outcomes phase, the nurse and client decide on goals they want to achieve. In the intervention planning phase, the nurse identifies specific interventions to help achieve the identified goal. During the implementation phase, the nurse carries out the interventions or delegates them to other health care team members. During the evaluation phase, the nurse judges whether her actions have been successful in treating or preventing the identified client health problem.  What is the most basic reason that self-knowledge is important for nurses? Because it helps the nurse to: 1) Identify personal biases that may affect his thinking and actions 2) Identify the most effective interventions for a patient 3)Communicate more efficiently with colleagues, patients, and families 4)Learn and remember new procedures and techniques Answer: 1) Identify personal biases that may affect his thinking and actions Nclex questions with answers |Fundamentals of Nursing with rationale 100% correct and verified Nclex questions with answers |Fundamentals of Nursing with rationale 100% correct and verified intellectual humility, and fair-mindedness, to name a few. Critical thinking skills refer to the cognitive activities used in complex thinking processes. A few examples of these skills involve recognizing the need for more information, recognizing gaps in one's own knowledge, and separating relevant from irrelevant data. Critical thinking, which consists of intellectual skills and attitudes, can be used in all aspects of life.  The nurse is preparing to admit a patient from the emergency department. The transferring nurse reports that the patient with chronic lung disease has a 30+ year history of tobacco use. The nurse used to smoke a pack of cigarettes a day at one time and worked very hard to quit smoking. She immediately thinks to herself, "I know I tend to feel negatively about people who use tobacco, especially when they have a serious lung condition; I figure if I can stop smoking, they should be able to. I must remember how physically and psychologically difficult that is, and be very careful not to let be judgmental of this patient." This best illustrates: 1)Theoretical knowledge 2)Self-knowledge 3)Using reliable resources 4)Use of the nursing process Nclex questions with answers |Fundamentals of Nursing with rationale 100% correct and verified Nclex questions with answers |Fundamentals of Nursing with rationale 100% correct and verified Answer: 2) Self-knowledge Rationale: Personal knowledge (2) is self-understanding—awareness of one's beliefs, values, biases, and so on. That best describes the nurse's awareness that her bias can affect her patient care. Theoretical knowledge consists of information, facts, principles, and theories in nursing and related disciplines; it consists of research findings and rationally constructed explanations of phenomena. Using reliable resources is a critical thinking skill. The nursing process is a problem-solving process consisting of the steps of assessing, diagnosing, planning outcomes, planning interventions, implementing, and evaluating. The nurse has not yet met this patient, so she could not have begun the nursing process.  Which organization's standards require that all patients be assessed specifically for pain? 1)American Nurses Association (ANA) 2)State nurse practice acts 3)National Council of State Boards of Nursing (NCSBN) 4)The Joint Commission Answer: 4) The Joint Commission Nclex questions with answers |Fundamentals of Nursing with rationale 100% correct and verified Nclex questions with answers |Fundamentals of Nursing with rationale 100% correct and verified Rationale: The Joint Commission has developed assessment standards, including that all clients be assessed for pain. The ANA has developed standards for clinical practice, including those for assessment, but not specifically for pain. State nurse practice acts regulate nursing practice in individual states. The NCSBN asserts that the scope of nursing includes a comprehensive assessment but does not specifically include pain.  Which of the following is an example of data that should be validated? 1)The urinalysis report indicates there are white blood cells in the urine. 2)The client states she feels feverish; you measure the oral temperature at 98°F. 3)The client has clear breath sounds; you count a respiratory rate of 18. 4)The chest x-ray report indicates the client has pneumonia in the right lower lobe. Answer: 2) The client states she feels feverish; you measure the oral temperature at 98°F. Rationale: Nclex questions with answers |Fundamentals of Nursing with rationale 100% correct and verified Nclex questions with answers |Fundamentals of Nursing with rationale 100% correct and verified The nurse is recording assessment data. She writes, "The patient seems worried about his surgery. Other than that, he had a good night." Which errors did the nurse make? Select all that apply. 1)Used a vague generality 2)Did not use the patient's exact words 3)Used a "waffle" word (e.g., appears) 4)Recorded an inference rather than a cue Answer: 1) Used a vague generality 3)Used a "waffle" word (e.g., appears) 4)Recorded an inference rather than a cue Rationale: The nurse recorded a vague generality: "he has had a good night." The nurse did not use the patient's exact words, but she did not quote the patient at all, so that is not one of her errors. The nurse used the "waffle" word, "seems" worried instead of documenting what the patient said or did to lead her to that conclusion. The nurse recorded these inferences: worried and had a good night.  A patient is admitted with shortness of breath, so the nurse immediately listens to his breath sounds. Which type of assessment is the nurse performing? 1)Ongoing assessment Nclex questions with answers |Fundamentals of Nursing with rationale 100% correct and verified Nclex questions with answers |Fundamentals of Nursing with rationale 100% correct and verified 2)Comprehensive physical assessment 3)Focused physical assessment 4)Psychosocial assessment Answer: 3) Focused physical assessment Rationale: The nurse is performing a focused physical assessment, which is done to obtain data about an identified problem, in this case shortness of breath. An ongoing assessment is performed as needed, after the initial data are collected, preferably with each patient contact. A comprehensive physical assessment includes an interview and a complete examination of each body system. A psychosocial assessment examines both psychological and social factors affecting the patient. The nurse conducting a psychosocial assessment would gather information about stressors, lifestyle, emotional health, social influences, coping patterns, communication, and personal responses to health and illness, to name a few aspects.  The nurse is assessing vital signs for a patient just admitted to the hospital. Ideally, and if there are no contraindications, how should the nurse position the patient for this portion of the admission Nclex questions with answers |Fundamentals of Nursing with rationale 100% correct and verified Nclex questions with answers |Fundamentals of Nursing with rationale 100% correct and verified assessment? 1)Sitting upright 2)Lying flat on the back with knees flexed 3)Lying flat on the back with arms and legs fully extended 4)Side-lying with the knees flexed Answer: 1) Sitting upright Rationale: If the patient is able, the nurse should have the patient sit upright to obtain vital signs in order to allow the nurse to easily access the anterior and posterior chest for auscultation of heart and breath sounds. It allows for full lung expansion and is the preferred position for measuring blood pressure. Additionally, patients might be more comfortable and feel less vulnerable when sitting upright (rather than lying down on the back) and can have direct eye contact with the examiner. However, other positions can be suitable when the patient's physical condition restricts the comfort or ability of the patient to sit upright.  For all body systems except the abdomen, what is the preferred order for the nurse to perform the following examination techniques? A.Palpation B.Auscultation Nclex questions with answers |Fundamentals of Nursing with rationale 100% correct and verified Nclex questions with answers |Fundamentals of Nursing with rationale 100% correct and verified 3)Allow the child to help with the examination. 4)Perform invasive procedures (e.g., otoscopic) last. Answer: 2) Demonstrate equipment before using it. Rationale: The nurse should modify his examination by demonstrating equipment before using it to examine a school-age child. The nurse should make sure parents are not present during the physical examination of an adolescent, but they usually help younger children feel more secure. The nurse should allow a preschooler to help with the examination when possible, but not usually a school- age child. Toddlers are often fearful of invasive procedures, so those should be performed last in this age group. It is best to perform invasive procedures last for all age groups; therefore, this does not represent a modification.  The nurse must examine a patient who is weak and unable to sit unaided or to get out of bed. How should she position the patient to begin and perform most of the physical examination? 1)Dorsal recumbent 2)Semi-Fowler's Nclex questions with answers |Fundamentals of Nursing with rationale 100% correct and verified Nclex questions with answers |Fundamentals of Nursing with rationale 100% correct and verified 3)Lithotomy 4)Sims' Answer: 2) Semi-Fowler's Rationale: If a patient is unable to sit up, the nurse should place him lying flat on his back, with the head of the bed elevated. Dorsal recumbent position is used for abdominal assessment if the patient has abdominal or pelvic pain. The patient in dorsal recumbent is on his back with knees flexed and soles of feet flat on the bed. Lithotomy position is used for female pelvic examination. It is similar to dorsal recumbent position, except that the patient's legs are well separated and thighs are acutely flexed. Feet are usually placed in stirrups. Fold sheet or bath blanket crosswise over thighs and legs so that genital area is easily exposed. Keep patient covered as much as possible. The patient in Sim's position is on left side with right knee flexed against abdomen and left knee slightly flexed. Left arm is behind body; right arm is placed comfortably. Sims' position is used to examine the rectal area. In semi-Fowler's position, the patient is supine with the head of the bed elevated and legs slightly elevated.  The nurse should use the diaphragm of the stethoscope to auscultate which of the following? 1)Heart murmurs 2) Jugular venous hums Nclex questions with answers |Fundamentals of Nursing with rationale 100% correct and verified Nclex questions with answers |Fundamentals of Nursing with rationale 100% correct and verified 3)Bowel sounds 4)Carotid bruits Answer: 3) Bowel sounds Rationale: The bell of the stethoscope should be used to hear low-pitched sounds, such as murmurs, bruits, and jugular hums. The diaphragm should be used to hear high-pitched sounds that normally occur in the heart, lungs, and abdomen.  The nurse calculates a body mass index (BMI) of 18 for a young adult woman who comes to the physician's office for a college physical. This patient is considered: 1)Obese 2)Overweight 3)Average 4)Underweight Answer: 4) Underweight Nclex questions with answers |Fundamentals of Nursing with rationale 100% correct and verified