Fundamentals of Nursing NCLEX Challenge Exam (Quiz #3: 75 Questions) -
1. Question 1 point(s)
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?
A. Bathe the patient's entire body using 8 to 10 washcloths.
B. Assist the patient to a chair and provide bathing supplies.
C. Saturate a towel and blanket in a plastic bag, and then bathe the patient.
D. Assist the patient to the bathtub and provide a bath chair.
Incorrect
Correct Answer: A. Bathe the patient’s entire body using 8 to 10 washcloths.
A towel bath is a modification of the bed bath in which the NAP places a large towel and
a bath blanket into a plastic bag, saturates them with a commercially prepared mixture
of moisturizer, non rinse cleaning agent, and water; warms in them in a microwave, and
then uses them to bathe the patient. A bag bath is a modification of the towel bath, in
which the NAP uses 8 to 10 washcloths instead of a towel or blanket. Each part of the
patient’s body is bathed with a fresh cloth.
Option B: A bag bath is not given in a chair or in the tub. The bag bath is one
alternative to the traditional bed bath used in some nursing homes. The bath is
performed with a series of 10 washcloths and a no-rinse liquid cleanser. Close
the door and windows to prevent cold drafts and wash hands with warm water
before beginning.
Option C: Moisten the washcloths with water and put in a plastic bag with the
cleanser. Warm the bag in the microwave for 60 to 90 seconds. Test the
temperature of the clothes before touching a resident with them and be careful
when you open the bag, as steam can burn.
Option D: Take the bag to the resident’s bedside. When you are not cleaning a body
part, keep it covered. Only expose as much of the resident’s body as necessary to
adequately clean him or her. Be especially sensitive to exposing genitals,
4/93
, Fundamentals of Nursing NCLEX Challenge Exam (Quiz #3: 75 Questions) -
buttocks, and breasts. Bathing can be an extremely stressful experience
for residents, so try to make it as easy as possible.
1 point(s)
2. Question
For a morbidly obese patient, which intervention should the nurse choose to counteract
the pressure created by the skin folds?
A. Cover the mattress with a sheepskin.
B. Keep the linens wrinkle free.
C. Separate the skin folds with towels.
D. Apply petrolatum barrier creams.
Incorrect
Correct Answer: C. Separate the skin folds with towels.
Separating the skin folds with towels relieves the pressure of skin rubbing on skin. Skin folds,
in particular, may be difficult for the patient to clean thoroughly; the abdominal folds and
groins may be ignored, leading to an increased risk of skin breakdown in these areas.
Option A: Sheepskins are not recommended for use at all. Skin folds present a
challenge in the management of patients who are morbidly obese. The weight
from excess adipose tissue in skinfold areas can have an increased risk of skin
injury such as friction, maceration, skin tears and pressure ulcer development.
Option B: Skin folds and areas vulnerable to skin injury should be cleaned and dried
several times a day. Alcohol-based lotions and harsh soaps, as well as talcum
powders, should be avoided in these areas. If necessary, dry cloths to absorb
moisture can be left in skin folds in between washing and drying of the skin folds.
5/93
, Fundamentals of Nursing NCLEX Challenge Exam (Quiz #3: 75 Questions) -
Option D: Petrolatum barrier creams are used to minimize moisture caused by
incontinence. Patient hydration should also be considered in the nutrition plan
for the patients and the health of their skin.
1 point(s)
3. Question
A client exhibits all of the following during a physical assessment. Which of these is considered
a primary defense against infection?
A. Fever
B. Intact skin
C. Inflammation
D. Lethargy
Incorrect
Correct Answer: B. Intact skin
Intact skin is considered a primary defense against infection. Usually, the skin prevents
invasion by microorganisms unless it is damaged (for example, by an injury, insect bite,
or burn). Mucous membranes, such as the lining of the mouth, nose, and eyelids, are
also effective barriers. Typically, mucous membranes are coated with secretions that
fight microorganisms. For example, the mucous membranes of the eyes are bathed in
tears, which contain an enzyme called lysozyme that attacks bacteria and helps protect
the eyes from infection. Fever, the inflammatory response, and phagocytosis (a process
of killing pathogens) are considered secondary defenses against infection.
Option A: Body temperature increases as a protective response to infection and
injury. An elevated body temperature (fever) enhances the body’s defense
mechanisms, although it can cause discomfort. A part of the brain called the
hypothalamus controls body temperature. Fever results from an actual resetting of
the hypothalamus’s thermostat. The body raises its temperature to a higher level by
6/93
, Fundamentals of Nursing NCLEX Challenge Exam (Quiz #3: 75 Questions) -
moving (shunting) blood from the skin surface to the interior of the body,
thus reducing heat loss.
Option C: Any injury, including an invasion by microorganisms, causes
inflammation in the affected area. Inflammation, a complex reaction, results from
many different conditions. During inflammation, the blood supply increases,
helping carry immune cells to the affected area. Because of the increased blood
flow, an infected area near the surface of the body becomes red and warm. The
walls of blood vessels become more porous, allowing fluid and white blood cells to
pass into the affected tissue. The increase in fluid causes the inflamed tissue to
swell. The white blood cells attack the invading microorganisms and release
substances that continue the process of inflammation.
Option D: Lethargy refers to a state of lacking energy. People who are
experiencing fatigue or tiredness can also be said to be lethargic because of low
energy. The same medical conditions that can lead to tiredness or fatigue can also
lead to lethargy.
1 point(s)
4. Question
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?
A. A clean gown and gloves must be worn when in contact with the client.
B. Everyone who enters the room must wear a N-95 respirator mask.
C. All linen and trash must be marked as contaminated and send to biohazard waste.
D. Place the client in a room with a client with an upper respiratory infection.
Incorrect
7/93
1. Question 1 point(s)
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?
A. Bathe the patient's entire body using 8 to 10 washcloths.
B. Assist the patient to a chair and provide bathing supplies.
C. Saturate a towel and blanket in a plastic bag, and then bathe the patient.
D. Assist the patient to the bathtub and provide a bath chair.
Incorrect
Correct Answer: A. Bathe the patient’s entire body using 8 to 10 washcloths.
A towel bath is a modification of the bed bath in which the NAP places a large towel and
a bath blanket into a plastic bag, saturates them with a commercially prepared mixture
of moisturizer, non rinse cleaning agent, and water; warms in them in a microwave, and
then uses them to bathe the patient. A bag bath is a modification of the towel bath, in
which the NAP uses 8 to 10 washcloths instead of a towel or blanket. Each part of the
patient’s body is bathed with a fresh cloth.
Option B: A bag bath is not given in a chair or in the tub. The bag bath is one
alternative to the traditional bed bath used in some nursing homes. The bath is
performed with a series of 10 washcloths and a no-rinse liquid cleanser. Close
the door and windows to prevent cold drafts and wash hands with warm water
before beginning.
Option C: Moisten the washcloths with water and put in a plastic bag with the
cleanser. Warm the bag in the microwave for 60 to 90 seconds. Test the
temperature of the clothes before touching a resident with them and be careful
when you open the bag, as steam can burn.
Option D: Take the bag to the resident’s bedside. When you are not cleaning a body
part, keep it covered. Only expose as much of the resident’s body as necessary to
adequately clean him or her. Be especially sensitive to exposing genitals,
4/93
, Fundamentals of Nursing NCLEX Challenge Exam (Quiz #3: 75 Questions) -
buttocks, and breasts. Bathing can be an extremely stressful experience
for residents, so try to make it as easy as possible.
1 point(s)
2. Question
For a morbidly obese patient, which intervention should the nurse choose to counteract
the pressure created by the skin folds?
A. Cover the mattress with a sheepskin.
B. Keep the linens wrinkle free.
C. Separate the skin folds with towels.
D. Apply petrolatum barrier creams.
Incorrect
Correct Answer: C. Separate the skin folds with towels.
Separating the skin folds with towels relieves the pressure of skin rubbing on skin. Skin folds,
in particular, may be difficult for the patient to clean thoroughly; the abdominal folds and
groins may be ignored, leading to an increased risk of skin breakdown in these areas.
Option A: Sheepskins are not recommended for use at all. Skin folds present a
challenge in the management of patients who are morbidly obese. The weight
from excess adipose tissue in skinfold areas can have an increased risk of skin
injury such as friction, maceration, skin tears and pressure ulcer development.
Option B: Skin folds and areas vulnerable to skin injury should be cleaned and dried
several times a day. Alcohol-based lotions and harsh soaps, as well as talcum
powders, should be avoided in these areas. If necessary, dry cloths to absorb
moisture can be left in skin folds in between washing and drying of the skin folds.
5/93
, Fundamentals of Nursing NCLEX Challenge Exam (Quiz #3: 75 Questions) -
Option D: Petrolatum barrier creams are used to minimize moisture caused by
incontinence. Patient hydration should also be considered in the nutrition plan
for the patients and the health of their skin.
1 point(s)
3. Question
A client exhibits all of the following during a physical assessment. Which of these is considered
a primary defense against infection?
A. Fever
B. Intact skin
C. Inflammation
D. Lethargy
Incorrect
Correct Answer: B. Intact skin
Intact skin is considered a primary defense against infection. Usually, the skin prevents
invasion by microorganisms unless it is damaged (for example, by an injury, insect bite,
or burn). Mucous membranes, such as the lining of the mouth, nose, and eyelids, are
also effective barriers. Typically, mucous membranes are coated with secretions that
fight microorganisms. For example, the mucous membranes of the eyes are bathed in
tears, which contain an enzyme called lysozyme that attacks bacteria and helps protect
the eyes from infection. Fever, the inflammatory response, and phagocytosis (a process
of killing pathogens) are considered secondary defenses against infection.
Option A: Body temperature increases as a protective response to infection and
injury. An elevated body temperature (fever) enhances the body’s defense
mechanisms, although it can cause discomfort. A part of the brain called the
hypothalamus controls body temperature. Fever results from an actual resetting of
the hypothalamus’s thermostat. The body raises its temperature to a higher level by
6/93
, Fundamentals of Nursing NCLEX Challenge Exam (Quiz #3: 75 Questions) -
moving (shunting) blood from the skin surface to the interior of the body,
thus reducing heat loss.
Option C: Any injury, including an invasion by microorganisms, causes
inflammation in the affected area. Inflammation, a complex reaction, results from
many different conditions. During inflammation, the blood supply increases,
helping carry immune cells to the affected area. Because of the increased blood
flow, an infected area near the surface of the body becomes red and warm. The
walls of blood vessels become more porous, allowing fluid and white blood cells to
pass into the affected tissue. The increase in fluid causes the inflamed tissue to
swell. The white blood cells attack the invading microorganisms and release
substances that continue the process of inflammation.
Option D: Lethargy refers to a state of lacking energy. People who are
experiencing fatigue or tiredness can also be said to be lethargic because of low
energy. The same medical conditions that can lead to tiredness or fatigue can also
lead to lethargy.
1 point(s)
4. Question
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?
A. A clean gown and gloves must be worn when in contact with the client.
B. Everyone who enters the room must wear a N-95 respirator mask.
C. All linen and trash must be marked as contaminated and send to biohazard waste.
D. Place the client in a room with a client with an upper respiratory infection.
Incorrect
7/93
