NCLEX RN Fundamentals Questions With Accurate Answers.
The nurse encourages a patient with a history of heart failure to reduce
energy expenditure by alternating activity and rest. Which nursing process
phase is this?
a. Diagnosis
b. Planning
c. Implementation
d. Evaluation - accurate answers-C. Implementation
Teaching a patient about alternating activity and rest is a component of
patient education, which falls into the implementation phase. This is an
example of putting an individualized plan into action. Other components of
implementation include assisting with hygienic care, promoting physical
comfort, supporting respiratory and elimination functions, facilitating
ingestion of food/fluids, managing the patient's surroundings, promoting a
therapeutic relationship, and carrying out other therapeutic nursing activities.
The nurse on the medical-surgical unit is interested in implementing
evidence-based practice. The nurse knows when evidence-based practice is
utilized:
a. National health agencies create clinical practice guidelines that must be
used.
b. Findings from randomized trials are used to plan care.
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. -
accurate answers-c. Clinical decision-making and nursing judgment are used
to find which evidence works for each specific situation in clinical practice.
Evidence-based practice is based on evidence from nurses working with
actual patients to find the best interventions for the best outcomes. It is
through this evidence that nurses develop and improve their practice to
achieve even greater patient outcomes. It is imperative that nurses continue
to learn and improve their skills and use updated techniques as technology
changes and patients have increasing acuity.
New nurses in orientation are learning about completion of incident reports.
Which of the following incidents would require an incident report be filed?
,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 - accurate answers-b. Patient belongings lost when
transferred to their hospital room
Any time a patient's belongings are lost an incident report must be filed. This
can help identify people and departments involved, ways to prevent the
occurrence in the future, and even help in locating belongings.
A nurse enters a patient's room to deliver medications that are due and
discovers the patient is in the bathroom. Which of the following actions by the
nurse is appropriate?
a. Place the medication on the bedside table
b. Place the medication on the 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 - accurate answers-c. Ask the patient to call when out of
the bathroom and give the medications at that time
The nurse should return when the patient is available to take the medications
so the nurse can verify the medications have been taken. The nurse should
never leave medications on the bedside table.
A, B, C are incorrect because medications should never be left in the patient
room.
The nurse is preparing to perform a focused assessment of the patient's
abdomen. Which of the following choices is the correct order in which the
focused assessment is performed?
a. Palpation, Auscultation, Inspection, Percussion
b. Inspection, Palpation, Percussion, Auscultation
c. Percussion, Palpation, Inspection, Auscultation
d. Inspection, Auscultation, Percussion, Palpation - accurate answers-d.
Inspection, Auscultation, Percussion, Palpation
When performing an abdominal assessment, inspection and auscultation
should be performed prior to percussion and palpation because the last two
,techniques will alter bowel sounds. Inspection is looking at the appearance of
the abdomen while the patient is lying supine, with their arms by their side,
and head resting on a pillow. (If the neck is flexed, abdominal muscles may
become flexed, and this can alter the appearance during assessment.).
Auscultation is performed over all four quadrants. Consider, are bowel sounds
present? What are the quality and quantity of the bowel sounds? Note any
regional differences among the four quadrants. Percussion is performed by
the fingers to test for dullness (solid mass) and tympany (air or gas).
Palpation is performed to discover any pain or tenderness. When palpating,
apply slow, steady pressure and avoid sharp movements that may cause
discomfort.
A patient is in the clinic with complaints of "not feeling well." The nurse knows
the patient's primary defense against infection is:
a. Fever
b. Intact skin
c. Inflammation
d. Lethargy - accurate answers-b. Intact skin
The primary defense from infection is intact skin. Breaks in the skin allow a
route for infection to invade.
A is incorrect because fever is a secondary defense against infection. Fever is
significant when above 100.4℉ or 38℃.
C is incorrect because inflammation is a secondary defense against infection.
Inflammation produces redness, pain, swelling, and warmth as a result of
infection, irritation, or injury. The body heals during the inflammatory process
as leukocytes and proteins migrate to the area in order to fight infection and
repair 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 caring for a patient who does not speak
English, and the nurse does not understand the patient's language. Which of
the following is most appropriate 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 - accurate answers-d. Have a
certified medical interpreter translate
Medical interpreters are certified in translation for scenarios like this.
Rigorous training and testing is performed before becoming a medical
interpreter, so this is the best way to interpret for a patient and prevent
mistakes and misunderstandings.
The nurse is completing the preoperative checklist for a patient scheduled for
surgery. In reviewing the chart, the nurse finds the consent has not been
signed by the patient. When the patient starts asking questions regarding the
surgery, what is the next action the nurse should take?
a. Have the patient sign the 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 - accurate answers-c. Contact the surgeon
to inform them the patient has questions regarding the procedure
Before any invasive procedure, the surgeon must inform the patient of what
the procedure entails, the purpose for the procedure, and the potential risks
associated with that procedure before the consent is signed by the patient.
(Hence the term "informed consent.") If the consent has not been signed and
the patient has questions, the healthcare provider has not reviewed the
procedure and risks involved and needs to do so before the procedure.
The nurse is caring for a patient who had an endoscopic total hysterectomy
and is now experiencing urinary retention. The nurse is preparing to contact
the healthcare provider using SBAR (situation background assessment
recommendation). Which of the following questions is a part of SBAR
communication?
a. "Could you tell me what I need to do?"
b. "What do you need to know about the patient?"
c. "I believe the patient needs a urinary catheter."
d. "Why do you think the patient is unable to urinate?" - accurate answers-c. "I
believe the patient needs a urinary catheter."
Making a recommendation to the healthcare provider is part of SBAR.
The nurse encourages a patient with a history of heart failure to reduce
energy expenditure by alternating activity and rest. Which nursing process
phase is this?
a. Diagnosis
b. Planning
c. Implementation
d. Evaluation - accurate answers-C. Implementation
Teaching a patient about alternating activity and rest is a component of
patient education, which falls into the implementation phase. This is an
example of putting an individualized plan into action. Other components of
implementation include assisting with hygienic care, promoting physical
comfort, supporting respiratory and elimination functions, facilitating
ingestion of food/fluids, managing the patient's surroundings, promoting a
therapeutic relationship, and carrying out other therapeutic nursing activities.
The nurse on the medical-surgical unit is interested in implementing
evidence-based practice. The nurse knows when evidence-based practice is
utilized:
a. National health agencies create clinical practice guidelines that must be
used.
b. Findings from randomized trials are used to plan care.
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. -
accurate answers-c. Clinical decision-making and nursing judgment are used
to find which evidence works for each specific situation in clinical practice.
Evidence-based practice is based on evidence from nurses working with
actual patients to find the best interventions for the best outcomes. It is
through this evidence that nurses develop and improve their practice to
achieve even greater patient outcomes. It is imperative that nurses continue
to learn and improve their skills and use updated techniques as technology
changes and patients have increasing acuity.
New nurses in orientation are learning about completion of incident reports.
Which of the following incidents would require an incident report be filed?
,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 - accurate answers-b. Patient belongings lost when
transferred to their hospital room
Any time a patient's belongings are lost an incident report must be filed. This
can help identify people and departments involved, ways to prevent the
occurrence in the future, and even help in locating belongings.
A nurse enters a patient's room to deliver medications that are due and
discovers the patient is in the bathroom. Which of the following actions by the
nurse is appropriate?
a. Place the medication on the bedside table
b. Place the medication on the 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 - accurate answers-c. Ask the patient to call when out of
the bathroom and give the medications at that time
The nurse should return when the patient is available to take the medications
so the nurse can verify the medications have been taken. The nurse should
never leave medications on the bedside table.
A, B, C are incorrect because medications should never be left in the patient
room.
The nurse is preparing to perform a focused assessment of the patient's
abdomen. Which of the following choices is the correct order in which the
focused assessment is performed?
a. Palpation, Auscultation, Inspection, Percussion
b. Inspection, Palpation, Percussion, Auscultation
c. Percussion, Palpation, Inspection, Auscultation
d. Inspection, Auscultation, Percussion, Palpation - accurate answers-d.
Inspection, Auscultation, Percussion, Palpation
When performing an abdominal assessment, inspection and auscultation
should be performed prior to percussion and palpation because the last two
,techniques will alter bowel sounds. Inspection is looking at the appearance of
the abdomen while the patient is lying supine, with their arms by their side,
and head resting on a pillow. (If the neck is flexed, abdominal muscles may
become flexed, and this can alter the appearance during assessment.).
Auscultation is performed over all four quadrants. Consider, are bowel sounds
present? What are the quality and quantity of the bowel sounds? Note any
regional differences among the four quadrants. Percussion is performed by
the fingers to test for dullness (solid mass) and tympany (air or gas).
Palpation is performed to discover any pain or tenderness. When palpating,
apply slow, steady pressure and avoid sharp movements that may cause
discomfort.
A patient is in the clinic with complaints of "not feeling well." The nurse knows
the patient's primary defense against infection is:
a. Fever
b. Intact skin
c. Inflammation
d. Lethargy - accurate answers-b. Intact skin
The primary defense from infection is intact skin. Breaks in the skin allow a
route for infection to invade.
A is incorrect because fever is a secondary defense against infection. Fever is
significant when above 100.4℉ or 38℃.
C is incorrect because inflammation is a secondary defense against infection.
Inflammation produces redness, pain, swelling, and warmth as a result of
infection, irritation, or injury. The body heals during the inflammatory process
as leukocytes and proteins migrate to the area in order to fight infection and
repair 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 caring for a patient who does not speak
English, and the nurse does not understand the patient's language. Which of
the following is most appropriate 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 - accurate answers-d. Have a
certified medical interpreter translate
Medical interpreters are certified in translation for scenarios like this.
Rigorous training and testing is performed before becoming a medical
interpreter, so this is the best way to interpret for a patient and prevent
mistakes and misunderstandings.
The nurse is completing the preoperative checklist for a patient scheduled for
surgery. In reviewing the chart, the nurse finds the consent has not been
signed by the patient. When the patient starts asking questions regarding the
surgery, what is the next action the nurse should take?
a. Have the patient sign the 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 - accurate answers-c. Contact the surgeon
to inform them the patient has questions regarding the procedure
Before any invasive procedure, the surgeon must inform the patient of what
the procedure entails, the purpose for the procedure, and the potential risks
associated with that procedure before the consent is signed by the patient.
(Hence the term "informed consent.") If the consent has not been signed and
the patient has questions, the healthcare provider has not reviewed the
procedure and risks involved and needs to do so before the procedure.
The nurse is caring for a patient who had an endoscopic total hysterectomy
and is now experiencing urinary retention. The nurse is preparing to contact
the healthcare provider using SBAR (situation background assessment
recommendation). Which of the following questions is a part of SBAR
communication?
a. "Could you tell me what I need to do?"
b. "What do you need to know about the patient?"
c. "I believe the patient needs a urinary catheter."
d. "Why do you think the patient is unable to urinate?" - accurate answers-c. "I
believe the patient needs a urinary catheter."
Making a recommendation to the healthcare provider is part of SBAR.
