Fundamentals of Nursing NCLEX
Questions
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. - ANS - 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 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. - ANS - 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 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 - ANS - 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 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 - ANS - 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.
\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. - ANS - 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 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
Questions
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. - ANS - 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 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. - ANS - 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 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 - ANS - 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 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 - ANS - 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.
\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. - ANS - 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 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
