NCLEX RN ATI FUNDAMENTALS OF NURSING PROCTORED EXAM 2024/25 QUESTION WITH NGN GRADED A+ WITH VERIFIED QUESTIONS AND DETAILED RATIONALES Ace Your Test

NCLEX-PN
®




250
QUESTION
NEXT GENERATION NCLEX RN ATI FUNDAMENTALS OF NURSING PROCTORED EXAM 2024/25
WITH NGN GRADED A+ WITH VERIFIED QUESTIONS AND DETAILED RATIONALES

,
, Contributors v

How to use this book vii


P A R T O N E
Fundamentals of nursing 1

P A R T T W O
Medical-surgical nursing 27

P A R T T H R E E
Maternal-infant nursing 75

P A R T F O U R
Pediatric nursing 97

P A R T F I V E
Psychiatric and mental
health nursing 119




iii

,
, P A R T O N E




Fundamentals
of nursing




1

, Basic physical care

1. A nurse is caring for a client who sustained a
chemical burn in his right eye. She’s preparing to irri-
Answer: 2, 3, 5

gate the eye with sterile normal saline solution. Which Rationale: The nurse should place absorbent pads in
steps are appropriate when performing the procedure? the area of the shoulder to prevent saturating the
Select all that apply. client’s clothing and bed linens. She should also wash
her hands and put on gloves to reduce the transmis-
□ 1. Tilt the client’s head toward his left eye.
sion of microorganisms. The solution should be direct-
□ 2. Place absorbent pads in the area of the client’s ed from the inner to outer canthus of the eye to pre-
shoulder. vent contamination of the unaffected eye. The head
should be tilted toward the affected (right) eye to facil-
□ 3. Wash hands and put on gloves.
itate drainage and to prevent irrigating solution from
□ 4. Place the irrigation syringe directly on the entering the left eye. The irrigation syringe should be
cornea. held about 1" (2.5 cm) above the eye to prevent in-
jury to the cornea. In a chemical exposure, the eye
□ 5. Direct the solution onto the exposed conjuncti- should be irrigated for at least 10 minutes.
val sac from the inner to outer canthus.
Nursing process step: Implementation
□ 6. Irrigate the eye for 1 minute.
Client needs category: Physiological integrity
Client needs subcategory: Reduction of risk poten-
tial
Cognitive level: Application



2. A nurse is caring for a client who underwent car-
diac catheterization. He starts bleeding from his left
Answer:

femoral access site. Identify the area where the nurse
should apply pressure.




Rationale: The femoral artery is punctured approxi-
mately 2 inches above the access site.
Nursing process step: Implementation
Client needs category: Physiological integrity
Client needs subcategory: Reduction of risk poten-
tial
Cognitive level: Application


2 F U N D AM E N T A L S OF N U R SI NG

,3. A nurse is preparing to leave a contact isolation
room. Place the following steps in ascending chrono-
Answer:

logical order as to how protective wear should be re- 2. Remove gloves.
moved. Use all the options.
3. Remove mask.
1. Remove eyewear.
4. Remove gown.
2. Remove gloves.
1. Remove eyewear.
3. Remove mask.
5. Wash hands for a minimum of 10 seconds.
4. Remove gown.
Rationale: Removal of gloves, then mask, gown, and
5. Wash hands for a minimum of 10 seconds. eyewear, and then washing hands for a minimum of
10 seconds limits the possibility of contact with conta-
minants.
Nursing process step: Implementation
Client needs category: Safe, effective care environ-
ment
Client needs subcategory: Safety and infection con-
trol
Cognitive level: Comprehension




4. A client is ordered to receive a sodium phosphate
enema for relief of constipation. Proper administration
Answer: 2, 3, 6

of the enema includes which steps? Select all that Rationale: To administer an enema, the nurse should
apply. place the client in Sims’ position or a knee-chest posi-
tion. Washing hands and putting on gloves are neces-
□ 1. Chill the solution by placing it in the refrigerator
sary to reduce the transmission of microorganisms. To
for 10 minutes.
promote the effectiveness of the enema, the nurse
□ 2. Assist the client into Sims’ position. should encourage the client to retain the solution for
at least 5 minutes. The solution should be warmed
□ 3. Wash hands and put on gloves. rather than chilled to promote comfort. To administer
□ 4. Insert the tip of the container 1⁄2" into the rec- the solution effectively and deliver it to the appropriate
tum. location, the nurse should insert the full length of the
tip into the rectum. The nurse should compress the
□ 5. Allow gravity to instill the solution. container to deliver the solution under positive pres-
□ 6. Encourage the client to retain the solution for sure and not by gravity.
5 to 15 minutes. Nursing process step: Implementation
Client needs category: Physiological integrity
Client needs subcategory: Basic care and comfort
Cognitive level: Application




B A S I C P H Y S I C AL C A R E 3

, 5. A nurse is completing the intake and output Answer: 1380
record for a client who was restarted on his regular
diet after being on nothing-by-mouth status for labora- Rationale: There are 30 ml in each ounce and
tory studies. The client has had the following intake 240 ml in each cup. The fluid intake for this client
and output during the shift: includes 4 oz (120 ml) of cranberry juice, 8 oz
(240 ml) of coffee, 1⁄2 cup (120 ml) of fruit-flavored
Intake: 4 oz of cranberry juice, 1⁄2 cup of oatmeal,
gelatin, 1 cup (240 ml) of cream of mushroom soup,
2 slices of toast, 8 oz of black decaffeinat-
6 oz (180 ml) of milk, and 16 oz (480 ml) of water,
ed coffee, tuna fish sandwich, 1⁄2 cup of
for a total of 1,380.
fruit-flavored gelatin, 1 cup of cream of
mushroom soup, 6 oz. of 1% milk, 16 oz Nursing process step: Implementation
of water
Client needs category: Physiological integrity
Output: 1,300 ml of urine
Client needs subcategory: Basic care and comfort
How many milliliters should the nurse document as
the client’s intake? Cognitive level: Application




6. A hospitalized client asks the nurse for “something Answer: 1, 2, 3, 6
for pain.” What information is most important for the
nurse to gather before administering the medication? Rationale: The nurse needs to know when the last
Select all that apply. dose was administered. Some clients request pain
medication earlier than is ordered by the physician.
□ 1. Administration time of the last dose
Pain, the fifth vital sign, should be assessed using a
□ 2. Client’s pain level on a scale of 1 to 10 pain scale and documented in the nursing notes
whenever a pain medication is given. Pain is usually
□ 3. Type of medication the client has been taking reassessed about 30 minutes after the medication is
□ 4. Beeper number of the client’s physician given. Physicians commonly order several different
types of pain medication based on the client’s condi-
□ 5. Client’s most current height and weight tion. It is important for the nurse to know which med-
□ 6. Effectiveness of prior dose of medication ication and which route was used to administer prior
dosages. Evaluating the effectiveness of medications is
also an important nursing function when managing
the client’s pain. Therefore, she should ask the client if
the prior dose was helpful. Knowing the beeper num-
ber of the client’s physician is not as important as the
other choices, although most nurses know the name
of their clients’ physicians. Most medications aren’t or-
dered based on the client’s height, and weight. This in-
formation would have been obtained on admission.
Nursing process step: Data collection
Client needs category: Physiological integrity
Client needs subcategory: Basic care and comfort
Cognitive level: Application




4 F U N D AM E N T A L S OF N U R SI NG