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NCLEX RN Fundamentals
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NCLEX-RN Practice Questions For 2... HESI RN FUNDAMENTALS EXIT EXA... Nclex questions for
Teacher 33 terms 125 terms Teacher 71 terms
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C. Implementation
The nurse encourages a patient
with a history of heart failure to
Teaching a patient about alternating activity and rest is a
reduce energy expenditure by
component of patient education, which falls into the
alternating activity and rest.
implementation phase. This is an example of putting an
Which nursing process phase is
individualized plan into action. Other components of
this?
implementation include assisting with hygienic care, promoting
a. Diagnosis
physical comfort, supporting respiratory and elimination
b. Planning
functions, facilitating ingestion of food/fluids, managing the
c. Implementation
patient's surroundings, promoting a therapeutic relationship, and
d. Evaluation
carrying out other therapeutic nursing activities.
The nurse on the medical- c. Clinical decision-making and nursing judgment are used to find
surgical unit is interested in which evidence works for each specific situation in clinical
implementing evidence-based practice.
practice. The nurse knows when
evidence-based practice is Evidence-based practice is based on evidence from nurses
utilized: working with actual patients to find the best interventions for the
a. National health agencies best outcomes. It is through this evidence that nurses develop
create clinical practice and improve their practice to achieve even greater patient
guidelines that must be used. outcomes. It is imperative that nurses continue to learn and
b. Findings from randomized improve their skills and use updated techniques as technology
trials are used to plan care. changes and patients have increasing acuity.
c. Clinical decision-making and
nursing judgment are used to
find which evidence works for
each specific situation in clinical
practice.
d. Nursing interventions are
statistically analyzed by a nurse
in relation to patient outcomes
to discover evidence for
appropriate patient
interventions.
,New nurses in orientation are b. Patient belongings lost when transferred to their hospital room
learning about completion of
incident reports. Which of the Any time a patient's belongings are lost an incident report must
following incidents would be filed. This can help identify people and departments involved,
require an incident report be ways to prevent the occurrence in the future, and even help in
filed? locating belongings.
a. Medication given 30 minutes
before scheduled time
b. Patient belongings lost when
transferred to their hospital
room
c. Frayed electrical cord on an
IV pump
d. Medication order
A nurse enters a patient's room c. Ask the patient to call when out of the bathroom and give the
to deliver medications that are medications at that time
due and discovers the patient is
in the bathroom. Which of the The nurse should return when the patient is available to take the
following actions by the nurse is medications so the nurse can verify the medications have been
appropriate? taken. The nurse should never leave medications on the bedside
a. Place the medication on the table.
bedside table A, B, C are incorrect because medications should never be left in
b. Place the medication on the the patient room.
bedside table and tell the
patient not to forget to take
them
c. Ask the patient to call when
out of the bathroom and give
the medications at that time
d. Ask the patient to call when
out of the bathroom and leave
the medications on the bedside
table
d. Inspection, Auscultation, Percussion, Palpation
The nurse is preparing to
When performing an abdominal assessment, inspection and
perform a focused assessment
auscultation should be performed prior to percussion and
of the patient's abdomen. Which
palpation because the last two techniques will alter bowel
of the following choices is the
sounds. Inspection is looking at the appearance of the abdomen
correct order in which the
while the patient is lying supine, with their arms by their side, and
focused assessment is
head resting on a pillow. (If the neck is flexed, abdominal
performed?
muscles may become flexed, and this can alter the appearance
a. Palpation, Auscultation,
during assessment.).
Inspection, Percussion
Auscultation is performed over all four quadrants. Consider, are
b. Inspection, Palpation,
bowel sounds present? What are the quality and quantity of the
Percussion, Auscultation
bowel sounds? Note any regional differences among the four
c. Percussion, Palpation,
quadrants. Percussion is performed by the fingers to test for
Inspection, Auscultation
dullness (solid mass) and tympany (air or gas). Palpation is
d. Inspection, Auscultation,
performed to discover any pain or tenderness. When palpating,
Percussion, Palpation
apply slow, steady pressure and avoid sharp movements that
may cause discomfort.
, b. Intact skin
The primary defense from infection is intact skin. Breaks in the
A patient is in the clinic with
skin allow a route for infection to invade.
complaints of "not feeling well."
A is incorrect because fever is a secondary defense against
The nurse knows the patient's
infection. Fever is significant when above 100.4℉ or 38℃.
primary defense against
C is incorrect because inflammation is a secondary defense
infection is:
against infection. Inflammation produces redness, pain, swelling,
a. Fever
and warmth as a result of infection, irritation, or injury. The body
b. Intact skin
heals during the inflammatory process as leukocytes and
c. Inflammation
proteins migrate to the area in order to fight infection and repair
d. Lethargy
damage.
D is incorrect because lethargy is not a defense against infection.
Lethargy can be a symptom of infection.
The nurse on the medical unit is d. Have a certified medical interpreter translate
caring for a patient who does
not speak English, and the nurse Medical interpreters are certified in translation for scenarios like
does not understand the this. Rigorous training and testing is performed before becoming
patient's language. Which of the a medical interpreter, so this is the best way to interpret for a
following is most appropriate patient and prevent mistakes and misunderstandings.
for the nurse to do when
speaking with the patient?
a. Have the patient's wife
translate
b. Speak using medical
terminology to avoid
misunderstanding
c. Keep in mind translation is
more important than nonverbal
communication
d. Have a certified medical
interpreter translate
The nurse is completing the c. Contact the surgeon to inform them the patient has questions
preoperative checklist for a regarding the procedure
patient scheduled for surgery. In
reviewing the chart, the nurse Before any invasive procedure, the surgeon must inform the
finds the consent has not been patient of what the procedure entails, the purpose for the
signed by the patient. When the procedure, and the potential risks associated with that
patient starts asking questions procedure before the consent is signed by the patient. (Hence
regarding the surgery, what is the term "informed consent.") If the consent has not been signed
the next action the nurse should and the patient has questions, the healthcare provider has not
take? reviewed the procedure and risks involved and needs to do so
a. Have the patient sign the before the procedure.
consent
b. Tell the patient all questions
will be answered by the surgeon
before the anesthesiologist
administers anesthetic
c. Contact the surgeon to inform
them the patient has questions
regarding the procedure
d. Answer all the patient's
questions
, The nurse is caring for a patient c. "I believe the patient needs a urinary catheter."
who had an endoscopic total
hysterectomy and is now Making a recommendation to the healthcare provider is part of
experiencing urinary retention. SBAR.
The nurse is preparing to
contact the healthcare provider The following is an example of how the nurse could effectively
using SBAR (situation use SBAR in this patient situation:
background assessment • Situation: "Mrs. Jones is experiencing urinary retention."
recommendation). Which of the • Background: "She had an endoscopic total hysterectomy."
following questions is a part of • Assessment: "Her vital signs have been stable today. She is
SBAR communication? taking PO fluids but has had no urine output in the last five hours.
a. "Could you tell me what I Her bladder is distended."
need to do?" • Recommendation: "I recommend that you see her and we insert
b. "What do you need to know an indwelling urinary Foley catheter and measure urine output
about the patient?" every two hours."
c. "I believe the patient needs a
urinary catheter."
d. "Why do you think the patient
is unable to urinate?"
A patient is recovering from a a. Restlessness
total abdominal hysterectomy.
When assessed by the nurse Early signs of shock include restlessness, anxiousness,
eight hours after the procedure, nervousness, and irritability. This is due to the sympathetic
which of the following would the nervous system release of epinephrine, which also decreases
nurse identify as an early sign of perfusion to the skin causing pallor, coolness, and clamminess.
shock? Other signs of shock include hypotension and confusion.
a. Restlessness
b. Warm, dry skin that is pale
c. Heart rate of 115 bpm
d. Urine output 50 mL/hr
A patient is admitted to the d. Arterial blood gas (ABG)
emergency room complaining
of shortness of breath. The nurse An ABG evaluates gas exchange in the lungs, which will provide
knows the patient will be the needed information regarding oxygenation status. An arterial
evaluated for hypoxia and blood gas reveals pH, carbon dioxide and oxygen partial
anticipates the healthcare pressures, bicarbonate level (HCO3-), and pH.
provider ordering which test?
a. Complete blood cell count
(CBC)
b. Sputum culture
c. Hemoglobin (Hgb)
d. Arterial blood gas (ABG)
Emergency medical services d. Carotid
brings an unconscious adult in
to the emergency room. When Rapid assessment of an unconscious adult patient begins with
the nurse performs a rapid checking circulation, which is checked at the carotid artery. If a
assessment, the location to patient is hypotensive (decreased blood pressure), the most
check the pulse is: likely place to be able to feel a pulse is the carotid artery.
a. Radial
b. Brachial
c. Femoral
d. Carotid
NCLEX RN Fundamentals
Save
Students also studied
Flashcard sets Study guides
NCLEX-RN Practice Questions For 2... HESI RN FUNDAMENTALS EXIT EXA... Nclex questions for
Teacher 33 terms 125 terms Teacher 71 terms
TutorDk Preview carmelstar0607 Preview BESTEXAMINER
C. Implementation
The nurse encourages a patient
with a history of heart failure to
Teaching a patient about alternating activity and rest is a
reduce energy expenditure by
component of patient education, which falls into the
alternating activity and rest.
implementation phase. This is an example of putting an
Which nursing process phase is
individualized plan into action. Other components of
this?
implementation include assisting with hygienic care, promoting
a. Diagnosis
physical comfort, supporting respiratory and elimination
b. Planning
functions, facilitating ingestion of food/fluids, managing the
c. Implementation
patient's surroundings, promoting a therapeutic relationship, and
d. Evaluation
carrying out other therapeutic nursing activities.
The nurse on the medical- c. Clinical decision-making and nursing judgment are used to find
surgical unit is interested in which evidence works for each specific situation in clinical
implementing evidence-based practice.
practice. The nurse knows when
evidence-based practice is Evidence-based practice is based on evidence from nurses
utilized: working with actual patients to find the best interventions for the
a. National health agencies best outcomes. It is through this evidence that nurses develop
create clinical practice and improve their practice to achieve even greater patient
guidelines that must be used. outcomes. It is imperative that nurses continue to learn and
b. Findings from randomized improve their skills and use updated techniques as technology
trials are used to plan care. changes and patients have increasing acuity.
c. Clinical decision-making and
nursing judgment are used to
find which evidence works for
each specific situation in clinical
practice.
d. Nursing interventions are
statistically analyzed by a nurse
in relation to patient outcomes
to discover evidence for
appropriate patient
interventions.
,New nurses in orientation are b. Patient belongings lost when transferred to their hospital room
learning about completion of
incident reports. Which of the Any time a patient's belongings are lost an incident report must
following incidents would be filed. This can help identify people and departments involved,
require an incident report be ways to prevent the occurrence in the future, and even help in
filed? locating belongings.
a. Medication given 30 minutes
before scheduled time
b. Patient belongings lost when
transferred to their hospital
room
c. Frayed electrical cord on an
IV pump
d. Medication order
A nurse enters a patient's room c. Ask the patient to call when out of the bathroom and give the
to deliver medications that are medications at that time
due and discovers the patient is
in the bathroom. Which of the The nurse should return when the patient is available to take the
following actions by the nurse is medications so the nurse can verify the medications have been
appropriate? taken. The nurse should never leave medications on the bedside
a. Place the medication on the table.
bedside table A, B, C are incorrect because medications should never be left in
b. Place the medication on the the patient room.
bedside table and tell the
patient not to forget to take
them
c. Ask the patient to call when
out of the bathroom and give
the medications at that time
d. Ask the patient to call when
out of the bathroom and leave
the medications on the bedside
table
d. Inspection, Auscultation, Percussion, Palpation
The nurse is preparing to
When performing an abdominal assessment, inspection and
perform a focused assessment
auscultation should be performed prior to percussion and
of the patient's abdomen. Which
palpation because the last two techniques will alter bowel
of the following choices is the
sounds. Inspection is looking at the appearance of the abdomen
correct order in which the
while the patient is lying supine, with their arms by their side, and
focused assessment is
head resting on a pillow. (If the neck is flexed, abdominal
performed?
muscles may become flexed, and this can alter the appearance
a. Palpation, Auscultation,
during assessment.).
Inspection, Percussion
Auscultation is performed over all four quadrants. Consider, are
b. Inspection, Palpation,
bowel sounds present? What are the quality and quantity of the
Percussion, Auscultation
bowel sounds? Note any regional differences among the four
c. Percussion, Palpation,
quadrants. Percussion is performed by the fingers to test for
Inspection, Auscultation
dullness (solid mass) and tympany (air or gas). Palpation is
d. Inspection, Auscultation,
performed to discover any pain or tenderness. When palpating,
Percussion, Palpation
apply slow, steady pressure and avoid sharp movements that
may cause discomfort.
, b. Intact skin
The primary defense from infection is intact skin. Breaks in the
A patient is in the clinic with
skin allow a route for infection to invade.
complaints of "not feeling well."
A is incorrect because fever is a secondary defense against
The nurse knows the patient's
infection. Fever is significant when above 100.4℉ or 38℃.
primary defense against
C is incorrect because inflammation is a secondary defense
infection is:
against infection. Inflammation produces redness, pain, swelling,
a. Fever
and warmth as a result of infection, irritation, or injury. The body
b. Intact skin
heals during the inflammatory process as leukocytes and
c. Inflammation
proteins migrate to the area in order to fight infection and repair
d. Lethargy
damage.
D is incorrect because lethargy is not a defense against infection.
Lethargy can be a symptom of infection.
The nurse on the medical unit is d. Have a certified medical interpreter translate
caring for a patient who does
not speak English, and the nurse Medical interpreters are certified in translation for scenarios like
does not understand the this. Rigorous training and testing is performed before becoming
patient's language. Which of the a medical interpreter, so this is the best way to interpret for a
following is most appropriate patient and prevent mistakes and misunderstandings.
for the nurse to do when
speaking with the patient?
a. Have the patient's wife
translate
b. Speak using medical
terminology to avoid
misunderstanding
c. Keep in mind translation is
more important than nonverbal
communication
d. Have a certified medical
interpreter translate
The nurse is completing the c. Contact the surgeon to inform them the patient has questions
preoperative checklist for a regarding the procedure
patient scheduled for surgery. In
reviewing the chart, the nurse Before any invasive procedure, the surgeon must inform the
finds the consent has not been patient of what the procedure entails, the purpose for the
signed by the patient. When the procedure, and the potential risks associated with that
patient starts asking questions procedure before the consent is signed by the patient. (Hence
regarding the surgery, what is the term "informed consent.") If the consent has not been signed
the next action the nurse should and the patient has questions, the healthcare provider has not
take? reviewed the procedure and risks involved and needs to do so
a. Have the patient sign the before the procedure.
consent
b. Tell the patient all questions
will be answered by the surgeon
before the anesthesiologist
administers anesthetic
c. Contact the surgeon to inform
them the patient has questions
regarding the procedure
d. Answer all the patient's
questions
, The nurse is caring for a patient c. "I believe the patient needs a urinary catheter."
who had an endoscopic total
hysterectomy and is now Making a recommendation to the healthcare provider is part of
experiencing urinary retention. SBAR.
The nurse is preparing to
contact the healthcare provider The following is an example of how the nurse could effectively
using SBAR (situation use SBAR in this patient situation:
background assessment • Situation: "Mrs. Jones is experiencing urinary retention."
recommendation). Which of the • Background: "She had an endoscopic total hysterectomy."
following questions is a part of • Assessment: "Her vital signs have been stable today. She is
SBAR communication? taking PO fluids but has had no urine output in the last five hours.
a. "Could you tell me what I Her bladder is distended."
need to do?" • Recommendation: "I recommend that you see her and we insert
b. "What do you need to know an indwelling urinary Foley catheter and measure urine output
about the patient?" every two hours."
c. "I believe the patient needs a
urinary catheter."
d. "Why do you think the patient
is unable to urinate?"
A patient is recovering from a a. Restlessness
total abdominal hysterectomy.
When assessed by the nurse Early signs of shock include restlessness, anxiousness,
eight hours after the procedure, nervousness, and irritability. This is due to the sympathetic
which of the following would the nervous system release of epinephrine, which also decreases
nurse identify as an early sign of perfusion to the skin causing pallor, coolness, and clamminess.
shock? Other signs of shock include hypotension and confusion.
a. Restlessness
b. Warm, dry skin that is pale
c. Heart rate of 115 bpm
d. Urine output 50 mL/hr
A patient is admitted to the d. Arterial blood gas (ABG)
emergency room complaining
of shortness of breath. The nurse An ABG evaluates gas exchange in the lungs, which will provide
knows the patient will be the needed information regarding oxygenation status. An arterial
evaluated for hypoxia and blood gas reveals pH, carbon dioxide and oxygen partial
anticipates the healthcare pressures, bicarbonate level (HCO3-), and pH.
provider ordering which test?
a. Complete blood cell count
(CBC)
b. Sputum culture
c. Hemoglobin (Hgb)
d. Arterial blood gas (ABG)
Emergency medical services d. Carotid
brings an unconscious adult in
to the emergency room. When Rapid assessment of an unconscious adult patient begins with
the nurse performs a rapid checking circulation, which is checked at the carotid artery. If a
assessment, the location to patient is hypotensive (decreased blood pressure), the most
check the pulse is: likely place to be able to feel a pulse is the carotid artery.
a. Radial
b. Brachial
c. Femoral
d. Carotid
