Complete Nclex Real Practice Test Questions & Answers For Fundamentals Of Nursing Accurate With Rationale (latest 2024)

Which action should the nurse take when preparing patient-controlled analgesia for a postoperative patient? Answer 2) Ask another nurse to double-check the setup before patient use. Rationale: As a safeguard to reduce the risk of dosing errors, the nurse should request another nurse to double-check the setup before patient use. The nurse should reassure the patient that the pump has a lockout feature that prevents him from overdosing even if he continues to push the dose administration button. The nurse should also instruct the patient to administer a dose before potentially painful activities, such as walking. Patient-controlled analgesia is contraindicated for those who are cognitively impaired. . The nurse administered codeine sulfate 30 mg orally to a patient who underwent a craniotomy 3 days ago for a brain tumor. How soon after administration should the nurse reassess the patient's pain? Answer 4) In 60 minutes Rationale: Codeine administered by the oral route reaches peak concentration in 60 minutes; therefore, the nurse should reassess the patient's pain 60 minutes after administration. The nurse should reassess pain after 10 minutes when administering codeine by the intramuscular or subcutaneous routes. Drugs administered by the intravenous (IV) route are effective almost immediately; however, codeine is not recommended for IV administration. . Which nonsteroidal anti-inflammatory drug might be administered to inhibit platelet aggregation in a patient at risk for thrombophlebitis? Answer 3) Aspirin (Ecotrin) Rationale: Aspirin is a unique NSAID that inhibits platelet aggregation. Low-dose aspirin therapy is commonly administered to decrease the risk of thrombophlebitis, myocardial infarction, and stroke. Ibuprofen, celecoxib, and indomethacin are NSAIDs, but they do not inhibit platelet aggregation. . A client who is receiving epidural analgesia complains of nausea and loss of motor function in his legs. The nurse obtains his blood pressure and notes a drop in his blood pressure from the previous reading. Which complication is the patient most likely experiencing? Answer 3) Epidural catheter migration Rationale: The patient is exhibiting signs of epidural catheter migration, which include nausea, a decrease in blood pressure, and loss of motor function without an identifiable cause. Signs of infection at the catheter site include redness, swelling, and drainage. Loss of motor function is not a typical side effect associated with epidural analgesics. These are common signs of catheter migration, not spinal cord damage. . Which of the following clients is experiencing an abnormal change in vital signs? A client whose (select all that apply): Answer 1) Blood pressure (BP) was 132/80 mm Hg sitting and 120/60 mm Hg upon standing 3) Heart rate was 76 before eating and 60 after eating Rationale: The BP change is abnormal; a BP change greater than 10 mm Hg may indicate postural hypotension. The change in heart rate is abnormal; the heart rate usually increases slightly after eating rather than decreasing. The temperatures are within normal range for the rectal route, and temperature increases throughout the day. It is normal to have an increased respiratory rate after exercise. . The nurse assesses clients' breath sounds. Which one requires immediate medical attention? A client who has: Answer 3) Stridor Rationale: Stridor is a sign of respiratory distress, possibly airway obstruction. Crackles and rhonchi indicate fluid in the lung; wheezes are caused by the narrowing of the airway. Crackles, rhonchi, and wheezes indicate respiratory illness and are potentially serious but do not necessarily indicate respiratory distress that requires immediate medical attention. . The nurse assesses the client's pedal pulses as having a pulse volume of 1 on a scale of 0 to 3. Based on this assessment finding, it would be important for the nurse to also assess the: Answer 2) Blood pressure Rationale: If the leg pulses are weak, the nurse should assess the blood pressure to further explore the reason for the low pulse volume. If the blood pressure is low, then a low pulse volume would be expected. The pulse deficit is the difference between the apical and radial pulse. The apical pulse would not be helpful to assess peripheral circulation. The pulse pressure is the difference between the systolic and diastolic pressures. Which of the following clients has indications of orthostatic hypotension? A client whose blood pressure is: Answer 4) 146/88 when lying down and 130/78 when standing, and reports feeling dizzy Rationale: Orthostatic hypotension is a drop of 10 mm Hg or more in blood pressure upon moving to a standing position, with complaints of feeling dizzy and/or faint. . A client who has experienced prolonged exposure to the cold is admitted to the hospital. Which method of taking a temperature would be most appropriate for this client? Answer 3) Rectal with an electronic thermometer Rationale: The rectal route is the most accurate for assessing core temperature, especially when it is critical to get an accurate temperature. Therefore, in this situation it is preferred. Temperature is a particularly relevant data point for this client with hypothermia as it indicates the patient's baseline status and response to treatment. The electronic thermometer is safer than glass and is relatively accurate. Mercury thermometers are no longer used in the hospital setting. The accuracy of tympanic thermometers is debatable. Which of the following clients would have the most difficulty maintaining thermoregulation? Answer 4) Older adult raking leaves on a cold day Rationale: Older adults have more difficulty maintaining body heat because of their slower metabolism, loss of subcutaneous fat, and decreased vasomotor control. . Which of the following clients should have an apical pulse taken? A client who is: Answer 3) An infant with no history of cardiac defect Rationale: An apical pulse should be taken if the radial pulse is weak and/or irregular, if the rate is 60 or 100, if the patient is on cardiac medications, or when assessing children up to 3 years. It is difficult to palpate a peripheral pulse on infants and young children.