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RN NCLEX FUNDAMENTALS EXAM | ALL QUESTIONS
AND CORRECT ANSWERS WITH RATIONALES |
GRADED A+ | VERIFIED ANSWERS | LATEST VERSION
| STUDY THIS ONE
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 - (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.
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d. Nursing interventions are statistically analyzed by a nurse in relation to patient
outcomes to discover evidence for appropriate patient interventions. -
(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 - (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.
,3|Page
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 - (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 - (answers)d. Inspection,
Auscultation, Percussion, Palpation
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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 - (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℃.
RN NCLEX FUNDAMENTALS EXAM | ALL QUESTIONS
AND CORRECT ANSWERS WITH RATIONALES |
GRADED A+ | VERIFIED ANSWERS | LATEST VERSION
| STUDY THIS ONE
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 - (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.
,2|Page
d. Nursing interventions are statistically analyzed by a nurse in relation to patient
outcomes to discover evidence for appropriate patient interventions. -
(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 - (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.
,3|Page
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 - (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 - (answers)d. Inspection,
Auscultation, Percussion, Palpation
, 4|Page
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 - (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℃.
