RN NCLEX FUNDAMENTALS EXAM | ALL
QUESTIONS AND CORRECT ANSWERS
WITH RATIONALES | GRADED A+ |
VERIFIED ANSWERS | LATEST VERSION |
STUDY THIS ONE!
The nurse is preparing to educate a patient regarding administration of
enoxaparin injections. Which of the following questions would be most
appropriate for the nurse to ask the patient?
a. "Are you able to use a computer?"
b. "Is your spouse here yet?"
c. "Are you ready to give yourself an injection?"
d. "What is your preferred way of learning?" ------CORRECT ANSWER------
---------d. "What is your preferred way of learning?"
Patient education is very important for patients to understand how
injections are performed in order to prevent errors and complications.
Everyone has different learning styles, so the nurse must identify how
the patient learns best in order to provide appropriate patient
education.
C is incorrect because it is closed-ended and is inappropriate to ask
until after the patient has been educated about enoxaparin and how to
safely administer this drug. The nurse may administer the injection
first and then assess readiness for self-injection at the next
scheduled dose.
The emergency room nurse is caring for a patient who has become
belligerent and is yelling at the staff. Which of the following interventions by
the nurse is the most appropriate for this patient?
a. Speak clearly and louder than the patient to prevent having to repeat
what the nurse has said.
b. Stand near the door of the room and stay calm.
c. Have other members of the healthcare team enter the room to
demonstrate ability to gain control of the situation.
,d. Ask the patient about what they do at home when they feel like this. ------
CORRECT ANSWER---------------b. Stand near the door of the room and
stay calm.
Patients who are belligerent are unpredictable and may be a risk to
themselves or others. Standing near the door prevents the patient
from blocking the exit and allows for a rapid exit by the nurse, if
necessary.
The nurse should attempt to de-escalate the situation emotionally by
staying calm and composed. Listen to what the patient is saying and
explain that you understand that they are upset. Often the cause of
anger and belligerence is fear.
The nurse has administered dilaudid to a patient experiencing pain. When
reassessing the patient's pain, the nurse discovers the patient's
respirations have decreased from 22 to 8, and the patient is snoring. When
documenting the occasion, which of the following statements is best?
a. Too much dilaudid was administered; monitoring patient frequently and
appears stable, family at bedside informed of the situation
b. Incident report completed due to patient receiving too much dilaudid and
experienced drop in respirations; resting quietly and charge nurse notified
c. Dilaudid 1 mg IV push. Vitals afterward: respirations 8, blood pressure
102/72, pulse 68. Monitoring patient every 15 minutes and healthcare
provider notified. See graphic for additional vital signs.
d. Difficult to arouse after dilaudid administered; snoring respirations noted,
vital signs stable, oxygen ready for administration, healthcare provider notifi
------CORRECT ANSWER---------------c. Dilaudid 1 mg IV push. Vitals
afterward: respirations 8, blood pressure 102/72, pulse 68. Monitoring
patient every 15 minutes and healthcare provider notified. See graphic for
additional vital signs.
Documentation should be objective, giving an explanation of exactly
what occurred including dosage, route, vital signs, patient status,
what the nurse is doing to help the patient, and notification of the
healthcare provider.
D is incorrect because it does not state the dose given and the words
"vital signs stable" are the nurse's subjective opinion.
,The nurse is preparing to measure vital signs on a patient. When
measuring respirations, which of the following is the best method?
a. Tell the patient respirations are going to be counted
b. Place the patient on a cardiac monitor for respiration rate
c. Instruct the patient to take a deep breath every 4 or 5 seconds
d. Count respirations while holding the patient's wrist ------CORRECT
ANSWER---------------d. Count respirations while holding the patient's wrist
Count the patient's respirations while holding the patient's wrist as if
measuring radial pulse. This will distract the patient and help them
breathe normally. This method will get the most accurate
measurement for respirations. Normal adult respiratory rate is 12-2-
breaths per minute. The thorax of the adult patient should rise and fall
with each breath (costal breathing) with expiration lasting slightly
longer than inspiration. Factors that can affect breathing include pain,
fever, anxiety, drugs, and disease.
The unlicensed assistive personnel (UAP) has just taken vital signs on a
75-year-old patient and tells the nurse the pulse is 48 bpm. What is the
best response by the nurse?
a. "I will notify the healthcare provider immediately."
b. "Recheck the pulse for a full minute to make sure it is accurate."
c. "Call for a rapid response while I recheck the pulse."
d. "Go ahead and document it in the patient's chart." ------CORRECT
ANSWER---------------b. "Recheck the pulse for a full minute to make sure it
is accurate."
Unlicensed assistive personnel (UAP) are sometimes trained to check
a pulse for 15 seconds and multiply by 4 (or for 30 seconds and
multiply by 2 in order) to obtain a pulse rate. It is best to count the
pulse for a full minute, especially in patients who have irregular heart
rates. The nurse should ask the UAP to recheck the pulse.
, The nurse is performing a neurologic assessment on a patient admitted for
possible stroke. Which of the following techniques will ensure an accurate
assessment?
a. Perform testing rapidly so stroke treatment is not delayed
b. Administer an anxiolytic before the assessment
c. Compare the exam from one side of the body to the other
d. Place the patient in the supine position ------CORRECT ANSWER---------
------c. Compare the exam from one side of the body to the other
Comparing the physical assessment findings on both sides of the
body is imperative when stroke is suspected. This will ensure the
affected and unaffected sides are covered during the assessment.
The nurse has just completed a respiratory assessment on a patient and
noted high-pitched musical sounds. These sounds would be documented
as:
a. Normal vesicular sounds
b. Rhonchi
c. Crackles
d. Wheezes ------CORRECT ANSWER---------------d. Wheezes
Wheezes are usually high-pitched, squeaky, and musical in nature.
Wheezes indicate a narrowing of the airways and are not an expected
finding in the respiratory assessment.
The nurse is performing the respiratory assessment on a 64-year-old
patient and believes crackles are heard. Which of the following should the
nurse do to confirm the findings?
a. Ask the patient if they have had crackles before
b. Have the patient breathe through their nose
c. Have the patient breathe deeper when auscultating the bases of the
lungs
d. Check the patient's medical record to see if crackles were auscultated
previously ------CORRECT ANSWER---------------c. Have the patient breathe
deeper when auscultating the bases of the lungs
QUESTIONS AND CORRECT ANSWERS
WITH RATIONALES | GRADED A+ |
VERIFIED ANSWERS | LATEST VERSION |
STUDY THIS ONE!
The nurse is preparing to educate a patient regarding administration of
enoxaparin injections. Which of the following questions would be most
appropriate for the nurse to ask the patient?
a. "Are you able to use a computer?"
b. "Is your spouse here yet?"
c. "Are you ready to give yourself an injection?"
d. "What is your preferred way of learning?" ------CORRECT ANSWER------
---------d. "What is your preferred way of learning?"
Patient education is very important for patients to understand how
injections are performed in order to prevent errors and complications.
Everyone has different learning styles, so the nurse must identify how
the patient learns best in order to provide appropriate patient
education.
C is incorrect because it is closed-ended and is inappropriate to ask
until after the patient has been educated about enoxaparin and how to
safely administer this drug. The nurse may administer the injection
first and then assess readiness for self-injection at the next
scheduled dose.
The emergency room nurse is caring for a patient who has become
belligerent and is yelling at the staff. Which of the following interventions by
the nurse is the most appropriate for this patient?
a. Speak clearly and louder than the patient to prevent having to repeat
what the nurse has said.
b. Stand near the door of the room and stay calm.
c. Have other members of the healthcare team enter the room to
demonstrate ability to gain control of the situation.
,d. Ask the patient about what they do at home when they feel like this. ------
CORRECT ANSWER---------------b. Stand near the door of the room and
stay calm.
Patients who are belligerent are unpredictable and may be a risk to
themselves or others. Standing near the door prevents the patient
from blocking the exit and allows for a rapid exit by the nurse, if
necessary.
The nurse should attempt to de-escalate the situation emotionally by
staying calm and composed. Listen to what the patient is saying and
explain that you understand that they are upset. Often the cause of
anger and belligerence is fear.
The nurse has administered dilaudid to a patient experiencing pain. When
reassessing the patient's pain, the nurse discovers the patient's
respirations have decreased from 22 to 8, and the patient is snoring. When
documenting the occasion, which of the following statements is best?
a. Too much dilaudid was administered; monitoring patient frequently and
appears stable, family at bedside informed of the situation
b. Incident report completed due to patient receiving too much dilaudid and
experienced drop in respirations; resting quietly and charge nurse notified
c. Dilaudid 1 mg IV push. Vitals afterward: respirations 8, blood pressure
102/72, pulse 68. Monitoring patient every 15 minutes and healthcare
provider notified. See graphic for additional vital signs.
d. Difficult to arouse after dilaudid administered; snoring respirations noted,
vital signs stable, oxygen ready for administration, healthcare provider notifi
------CORRECT ANSWER---------------c. Dilaudid 1 mg IV push. Vitals
afterward: respirations 8, blood pressure 102/72, pulse 68. Monitoring
patient every 15 minutes and healthcare provider notified. See graphic for
additional vital signs.
Documentation should be objective, giving an explanation of exactly
what occurred including dosage, route, vital signs, patient status,
what the nurse is doing to help the patient, and notification of the
healthcare provider.
D is incorrect because it does not state the dose given and the words
"vital signs stable" are the nurse's subjective opinion.
,The nurse is preparing to measure vital signs on a patient. When
measuring respirations, which of the following is the best method?
a. Tell the patient respirations are going to be counted
b. Place the patient on a cardiac monitor for respiration rate
c. Instruct the patient to take a deep breath every 4 or 5 seconds
d. Count respirations while holding the patient's wrist ------CORRECT
ANSWER---------------d. Count respirations while holding the patient's wrist
Count the patient's respirations while holding the patient's wrist as if
measuring radial pulse. This will distract the patient and help them
breathe normally. This method will get the most accurate
measurement for respirations. Normal adult respiratory rate is 12-2-
breaths per minute. The thorax of the adult patient should rise and fall
with each breath (costal breathing) with expiration lasting slightly
longer than inspiration. Factors that can affect breathing include pain,
fever, anxiety, drugs, and disease.
The unlicensed assistive personnel (UAP) has just taken vital signs on a
75-year-old patient and tells the nurse the pulse is 48 bpm. What is the
best response by the nurse?
a. "I will notify the healthcare provider immediately."
b. "Recheck the pulse for a full minute to make sure it is accurate."
c. "Call for a rapid response while I recheck the pulse."
d. "Go ahead and document it in the patient's chart." ------CORRECT
ANSWER---------------b. "Recheck the pulse for a full minute to make sure it
is accurate."
Unlicensed assistive personnel (UAP) are sometimes trained to check
a pulse for 15 seconds and multiply by 4 (or for 30 seconds and
multiply by 2 in order) to obtain a pulse rate. It is best to count the
pulse for a full minute, especially in patients who have irregular heart
rates. The nurse should ask the UAP to recheck the pulse.
, The nurse is performing a neurologic assessment on a patient admitted for
possible stroke. Which of the following techniques will ensure an accurate
assessment?
a. Perform testing rapidly so stroke treatment is not delayed
b. Administer an anxiolytic before the assessment
c. Compare the exam from one side of the body to the other
d. Place the patient in the supine position ------CORRECT ANSWER---------
------c. Compare the exam from one side of the body to the other
Comparing the physical assessment findings on both sides of the
body is imperative when stroke is suspected. This will ensure the
affected and unaffected sides are covered during the assessment.
The nurse has just completed a respiratory assessment on a patient and
noted high-pitched musical sounds. These sounds would be documented
as:
a. Normal vesicular sounds
b. Rhonchi
c. Crackles
d. Wheezes ------CORRECT ANSWER---------------d. Wheezes
Wheezes are usually high-pitched, squeaky, and musical in nature.
Wheezes indicate a narrowing of the airways and are not an expected
finding in the respiratory assessment.
The nurse is performing the respiratory assessment on a 64-year-old
patient and believes crackles are heard. Which of the following should the
nurse do to confirm the findings?
a. Ask the patient if they have had crackles before
b. Have the patient breathe through their nose
c. Have the patient breathe deeper when auscultating the bases of the
lungs
d. Check the patient's medical record to see if crackles were auscultated
previously ------CORRECT ANSWER---------------c. Have the patient breathe
deeper when auscultating the bases of the lungs
