NCLEX-RN Exam Review: Fundamentals of Nursing
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1. The nurse encour- Correct answer: C
ages a patient Teaching a patient about alternating activity and rest is a component of patient
with a history of education, which falls into the implementation phase. This is an example of
heart failure to re- putting an individualized plan into action. Other components of implementa-
duce energy ex- tion include assisting with hygienic care, promoting physical comfort, support-
penditure by alter- ing respiratory and elimination functions, facilitating ingestion of food/fluids,
nating activity and managing the patient's surroundings, promoting a therapeutic relationship,
rest. Which nurs- and carrying out other therapeutic nursing activities.
ing process phase is A is incorrect because diagnosis is identifying the problem. When choosing
this? the diagnoses for a particular client, the nurse must first identify common-
A. Diagnosis alities among the assessment data collected. Categorization of related data
B. Planning reveals the existence of a problem and the need for nursing intervention. The
C. Implementation patient's identified problems are then defined in the nursing diagnoses.
D. Evaluation B is incorrect because planning is creating an individualized plan. The plan-
ning phase includes assigning priorities to the diagnoses, specifying the
goals, identifying the interventions/outcomes, documenting the plan, and
communicating the plan to nursing staff.
Dis incorrect because evaluation is assessing patient response to an individ-
ualized plan.
*Remember that dividing the nursing process into separate steps is actually
artificial. The process functions as an integrated whole, with the steps being
interrelated, interdependent, and recurrent.
2. 3. New nurses in ori- Correct answer: B.
entation are learn- Any time a patient's belongings are lost an incident report must be filed.
ing about comple- This can help identify people and departments involved, ways to prevent the
tion of incident re- occurrence in the future, and even help in locating belongings.
potts. Which of the A is incorrect because administering a medication 30 minutes before sched-
following incidents uled time is not an error. Nurses are generally required to administer
would require an scheduled meds within 30 minutes before or after they are scheduled.
incident report be C is incorrect because this equipment should be taken out of service and the
filed? biomedical department notified, but this situation does not require an incident
, NCLEX-RN Exam Review: Fundamentals of Nursing
Study online at https://quizlet.com/_eirdv1
A. Medication given report to be completed.
30 minutes before Dis incorrect because the healthcare provider can be notified and the order
scheduled time clarified. An incident report is not needed.
B. Patient belong- *Remember: The client's chart is client-focused. The incident report is inci-
ings lost when trans- dent-focused. In the incident report, the nurse must include the time and
ferred to their hospi- place of the incident and must objectively describe what happened, who was
tal room involved, how the client responded, actions that were performed at the time
C. Frayed electrical of the event, and the name of the physician who was notified.
cord on an IV pump
D. Medication order
missing route of ad-
ministration
3. 3. A nurse enters Rationale:
a patient's room to Correct answer: C
deliver medications The nurse should return when the patient is available to take the medications
that are due and dis- so the nurse can verify the medications have been taken. The nurse should
covers the patient never leave medications on the bedside table.
is in the bathroom. Remember, the rights of medication administration:
Which of the follow- 1. Right patient: use two identifiers
ing actions by the 2. Right medication: check the med label AND the order
nurse is appropri- 3. Right dose: check the order, perform calculation if necessary, and refer to
ate? the drug book if needed to confirm safe dose.
4. Right route: is the route appropriate? Can the patient safely take the med
A. Place the medica- by this route?
tion on the bedside 5. Right time: check the frequency, confirm that the right dose was given at the
table right time, and check when the last dose was given.
B. Place the medica- 6. Right documentation: document AFTER giving the meds. Include any perti-
tion on the bedside nent details, such as the injection site.
table and tell the pa- 7. Right reason: confirm the rationale for the ordered medication. Why is the
tient not to forget to patient getting it?
take them
, NCLEX-RN Exam Review: Fundamentals of Nursing
Study online at https://quizlet.com/_eirdv1
C. Ask the patient to Right response: besurethatthe drugled tothedesiredeffect.Monitor forsideef-
call when out of the fects oradverse reactions aftergivingit.
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
4. 3. The nurse is Correct answer: D
preparing to per- When performing an abdominal assessment, inspection and auscultation
form a focused as- should be performed prior to percussion and palpation because the last two
sessment of the techniques will alter bowel sounds. Inspection is looking at the appearance of
patient's abdomen. the abdomen while the patient is lying supine, with their arms by their side,
Which of the fol- and head resting on a pillow. (If the neck is flexed, abdominal muscles may
lowing choices is become flexed, and this can alter the appearance dur ing assessment.).
the correct order in Auscultation is performed over all four quadrants. Consider, are bowel sounds
which the focused present? What are the quality and quantity of the bowel sounds? Note any
assessment is per- regional differences among the four quadrants. Percussion is performed by
formed? the fingers to test for dullness (solid mass) and tympany (air or gas). Palpation
A. Palpation, Auscul- is performed to discover any pain or tenderness. When palpating, apply slow,
tation, Inspection, steady pressure and avoid sharp movements that may cause discomfort.
Percussion A is incorrect because bowel sounds will be altered by palpating before
B. Inspection, Pal- auscultating.
pation, Percussion, B is incorrect because bowel sounds will be altered by palpating and per-
Auscultation cussing before auscultating. Note: This IPPA sequence is the correct sequence
C. Percussion, Pal- for assessing other body systems, but not correct in the abdominal assess-
pation, Inspection, ment.
Auscultation C is incorrect because bowel sounds will be altered by performing the auscul-
D. Inspection, Aus- tation last.
, NCLEX-RN Exam Review: Fundamentals of Nursing
Study online at https://quizlet.com/_eirdv1
cultation, Percus-
sion, Palpation
5. 3. A patient is Rationale:
in the clinic with Correct answer: B.
complaints of "not The primary defense from infection is intact skin. Breaks in the skin allow a
feeling well." The route for infection to invade.
nurse knows the pa- A is incorrect because fever is a secondary defense against infection. Fever is
tient's primary de- significant when above 100.4 °F or 38 °C .
fense against infec- C is incorrect because inflammation is a secondary defense against infection.
tion is: Inflammation produces redness, pain, swelling, and warmth as a result of
A. Fever infection, irritation, or injury. The body heals during the inflammatory process
B. Intact skin as leukocytes and proteins migrate to the area in order to fight infection and
C. Inflammation repair damage.
D. Lethargy D is incorrect because lethargy is not a defense against infection. Lethargy can
be a symptom of infection.
6. 3. The nurse on the Rationale:
medical unit is car- Correct answer: D
ing for a patient who Medical interpreters are certified in translation for scenarios like this. Rigorous
does not speak Eng- training and testing is performed before becoming a medical interpreter,
lish, and the nurse so this is the best way to interpret for a patient and prevent mistakes and
does not under- misunderstandings.
stand the patient's
language. Which of A is incorrect because family members are emotionally involved in a situation
the following is most and cannot necessarily remain neutral. A family member may try to interpret
appropriate for the in a way to persuade the patient. The family member is not a professionally
nurse to do when trained interpreter and we cannot assume they have a knowledge and under-
speaking with the standing of medical terminology.
patient? B is incorrect because medical terminology will not prevent misunderstand-
A. Have the patient's ings as these words are not well understood.
wife translate
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1. The nurse encour- Correct answer: C
ages a patient Teaching a patient about alternating activity and rest is a component of patient
with a history of education, which falls into the implementation phase. This is an example of
heart failure to re- putting an individualized plan into action. Other components of implementa-
duce energy ex- tion include assisting with hygienic care, promoting physical comfort, support-
penditure by alter- ing respiratory and elimination functions, facilitating ingestion of food/fluids,
nating activity and managing the patient's surroundings, promoting a therapeutic relationship,
rest. Which nurs- and carrying out other therapeutic nursing activities.
ing process phase is A is incorrect because diagnosis is identifying the problem. When choosing
this? the diagnoses for a particular client, the nurse must first identify common-
A. Diagnosis alities among the assessment data collected. Categorization of related data
B. Planning reveals the existence of a problem and the need for nursing intervention. The
C. Implementation patient's identified problems are then defined in the nursing diagnoses.
D. Evaluation B is incorrect because planning is creating an individualized plan. The plan-
ning phase includes assigning priorities to the diagnoses, specifying the
goals, identifying the interventions/outcomes, documenting the plan, and
communicating the plan to nursing staff.
Dis incorrect because evaluation is assessing patient response to an individ-
ualized plan.
*Remember that dividing the nursing process into separate steps is actually
artificial. The process functions as an integrated whole, with the steps being
interrelated, interdependent, and recurrent.
2. 3. New nurses in ori- Correct answer: B.
entation are learn- Any time a patient's belongings are lost an incident report must be filed.
ing about comple- This can help identify people and departments involved, ways to prevent the
tion of incident re- occurrence in the future, and even help in locating belongings.
potts. Which of the A is incorrect because administering a medication 30 minutes before sched-
following incidents uled time is not an error. Nurses are generally required to administer
would require an scheduled meds within 30 minutes before or after they are scheduled.
incident report be C is incorrect because this equipment should be taken out of service and the
filed? biomedical department notified, but this situation does not require an incident
, NCLEX-RN Exam Review: Fundamentals of Nursing
Study online at https://quizlet.com/_eirdv1
A. Medication given report to be completed.
30 minutes before Dis incorrect because the healthcare provider can be notified and the order
scheduled time clarified. An incident report is not needed.
B. Patient belong- *Remember: The client's chart is client-focused. The incident report is inci-
ings lost when trans- dent-focused. In the incident report, the nurse must include the time and
ferred to their hospi- place of the incident and must objectively describe what happened, who was
tal room involved, how the client responded, actions that were performed at the time
C. Frayed electrical of the event, and the name of the physician who was notified.
cord on an IV pump
D. Medication order
missing route of ad-
ministration
3. 3. A nurse enters Rationale:
a patient's room to Correct answer: C
deliver medications The nurse should return when the patient is available to take the medications
that are due and dis- so the nurse can verify the medications have been taken. The nurse should
covers the patient never leave medications on the bedside table.
is in the bathroom. Remember, the rights of medication administration:
Which of the follow- 1. Right patient: use two identifiers
ing actions by the 2. Right medication: check the med label AND the order
nurse is appropri- 3. Right dose: check the order, perform calculation if necessary, and refer to
ate? the drug book if needed to confirm safe dose.
4. Right route: is the route appropriate? Can the patient safely take the med
A. Place the medica- by this route?
tion on the bedside 5. Right time: check the frequency, confirm that the right dose was given at the
table right time, and check when the last dose was given.
B. Place the medica- 6. Right documentation: document AFTER giving the meds. Include any perti-
tion on the bedside nent details, such as the injection site.
table and tell the pa- 7. Right reason: confirm the rationale for the ordered medication. Why is the
tient not to forget to patient getting it?
take them
, NCLEX-RN Exam Review: Fundamentals of Nursing
Study online at https://quizlet.com/_eirdv1
C. Ask the patient to Right response: besurethatthe drugled tothedesiredeffect.Monitor forsideef-
call when out of the fects oradverse reactions aftergivingit.
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
4. 3. The nurse is Correct answer: D
preparing to per- When performing an abdominal assessment, inspection and auscultation
form a focused as- should be performed prior to percussion and palpation because the last two
sessment of the techniques will alter bowel sounds. Inspection is looking at the appearance of
patient's abdomen. the abdomen while the patient is lying supine, with their arms by their side,
Which of the fol- and head resting on a pillow. (If the neck is flexed, abdominal muscles may
lowing choices is become flexed, and this can alter the appearance dur ing assessment.).
the correct order in Auscultation is performed over all four quadrants. Consider, are bowel sounds
which the focused present? What are the quality and quantity of the bowel sounds? Note any
assessment is per- regional differences among the four quadrants. Percussion is performed by
formed? the fingers to test for dullness (solid mass) and tympany (air or gas). Palpation
A. Palpation, Auscul- is performed to discover any pain or tenderness. When palpating, apply slow,
tation, Inspection, steady pressure and avoid sharp movements that may cause discomfort.
Percussion A is incorrect because bowel sounds will be altered by palpating before
B. Inspection, Pal- auscultating.
pation, Percussion, B is incorrect because bowel sounds will be altered by palpating and per-
Auscultation cussing before auscultating. Note: This IPPA sequence is the correct sequence
C. Percussion, Pal- for assessing other body systems, but not correct in the abdominal assess-
pation, Inspection, ment.
Auscultation C is incorrect because bowel sounds will be altered by performing the auscul-
D. Inspection, Aus- tation last.
, NCLEX-RN Exam Review: Fundamentals of Nursing
Study online at https://quizlet.com/_eirdv1
cultation, Percus-
sion, Palpation
5. 3. A patient is Rationale:
in the clinic with Correct answer: B.
complaints of "not The primary defense from infection is intact skin. Breaks in the skin allow a
feeling well." The route for infection to invade.
nurse knows the pa- A is incorrect because fever is a secondary defense against infection. Fever is
tient's primary de- significant when above 100.4 °F or 38 °C .
fense against infec- C is incorrect because inflammation is a secondary defense against infection.
tion is: Inflammation produces redness, pain, swelling, and warmth as a result of
A. Fever infection, irritation, or injury. The body heals during the inflammatory process
B. Intact skin as leukocytes and proteins migrate to the area in order to fight infection and
C. Inflammation repair damage.
D. Lethargy D is incorrect because lethargy is not a defense against infection. Lethargy can
be a symptom of infection.
6. 3. The nurse on the Rationale:
medical unit is car- Correct answer: D
ing for a patient who Medical interpreters are certified in translation for scenarios like this. Rigorous
does not speak Eng- training and testing is performed before becoming a medical interpreter,
lish, and the nurse so this is the best way to interpret for a patient and prevent mistakes and
does not under- misunderstandings.
stand the patient's
language. Which of A is incorrect because family members are emotionally involved in a situation
the following is most and cannot necessarily remain neutral. A family member may try to interpret
appropriate for the in a way to persuade the patient. The family member is not a professionally
nurse to do when trained interpreter and we cannot assume they have a knowledge and under-
speaking with the standing of medical terminology.
patient? B is incorrect because medical terminology will not prevent misunderstand-
A. Have the patient's ings as these words are not well understood.
wife translate
