Fundamentals Of Nursing NCLEX Quiz 5

1. Which pulse should the nurse palpate during rapid assessment of an unconscious male adult?

Radial

Brachial

Femoral

Carotid

During a rapid assessment. the nurse’s first priority is to check the patient’s vital functions by assessing his airway. breathing. and circulation. To check a patient’s circulation. the nurse must assess his heart and vascular network function. This is done by checking his skin color. temperature. mental status and. most importantly. his pulse. The nurse should use the carotid artery to check a patient’s circulation. In a patient with a circulatory problems or a history of compromised circulation. the radial pulse may not be palpable. The brachial pulse is palpated during rapid assessment of an infant.

Explanation

During a rapid assessment. the nurse’s first priority is to check the patient’s vital functions by assessing his airway. breathing. and circulation. To check a patient’s circulation. the nurse must assess his heart and vascular network function. This is done by checking his skin color. temperature. mental status and. most importantly. his pulse. The nurse should use the carotid artery to check a patient’s circulation. In a patient with a circulatory problems or a history of compromised circulation. the radial pulse may not be palpable. The brachial pulse is palpated during rapid assessment of an infant.

2. Which nursing action is essential when providing continuous enteral feeding?

Elevating the head of the bed

Positioning the patient on the left side

Warming the formula before administering it

Hanging a full day’s worth of formula at one time

Elevating the head of the bed during enteral feeding minimizes the risk of aspiration and allows the formula to flow in the patient’s intestines. When such elevation is contraindicated. the patient should be positioned on the right side. The nurse should give enteral feeding at room temperature to minimize GI distress. To limit microbial growth. the nurse should hang only the amount of formula that can be infused in 3 hours.

Explanation

Elevating the head of the bed during enteral feeding minimizes the risk of aspiration and allows the formula to flow in the patient’s intestines. When such elevation is contraindicated. the patient should be positioned on the right side. The nurse should give enteral feeding at room temperature to minimize GI distress. To limit microbial growth. the nurse should hang only the amount of formula that can be infused in 3 hours.

3. An employer establishes a physical exercise area in the workplace and encourages all employees to use it. This is an example of which level of health promotion?

Primary prevention

Secondary prevention

Tertiary prevention

Passive prevention

Primary prevention precedes disease and applies to health patients. Secondary prevention focuses on patients who have health problems and are at risk for developing complications. Tertiary prevention enables patients to gain health from others’ activities without doing anything themselves.

Explanation

Primary prevention precedes disease and applies to health patients. Secondary prevention focuses on patients who have health problems and are at risk for developing complications. Tertiary prevention enables patients to gain health from others’ activities without doing anything themselves.

4. When teaching a female patient how to take a sublingual tablet. the nurse should instruct the patient to place the table on the:

Top of the tongue

Roof of the mouth

Floor of the mouth

Inside of the cheek

The nurse should instruct the patient to touch the tip of the tongue to the roof of the mouth and then place the sublingual tablet on the floor of the mouth. Sublingual medications are absorbed directly into the bloodstream form the oral mucosa. bypassing the GI and hepatic systems. No drug is administered on top of the tongue or on the roof of the mouth. With the buccal route. the tablet is placed between the gum and the cheek.

Explanation

The nurse should instruct the patient to touch the tip of the tongue to the roof of the mouth and then place the sublingual tablet on the floor of the mouth. Sublingual medications are absorbed directly into the bloodstream form the oral mucosa. bypassing the GI and hepatic systems. No drug is administered on top of the tongue or on the roof of the mouth. With the buccal route. the tablet is placed between the gum and the cheek.

5. The physician prescribes 250 mg of a drug. The drug vial reads 500 mg/ml. how much of the drug should the nurse give?

2 ml

1 ml

½ ml

¼ ml

The nurse should give ½ ml of the drug. The dosage is calculated as follows: (250 mg/X=500 mg/1 ml) (500x=250)(X=1/2 ml)

Explanation

The nurse should give ½ ml of the drug. The dosage is calculated as follows: (250 mg/X=500 mg/1 ml) (500x=250)(X=1/2 ml)

6. Which action by the nurse in charge is essential when cleaning the area around a Jackson-Pratt wound drain?

Cleaning from the center outward in a circular motion

Removing the drain before cleaning the skin

Cleaning briskly around the site with alcohol

Wearing sterile gloves and a mask

The nurse always should clean around a wound drain. moving from center outward in ever-larger circles. because the skin near the drain site is more contaminated than the site itself. The nurse should never remove the drain before cleaning the skin. Alcohol should never be used to clean around a drain; it may irritate the skin and has no lasting effect on bacteria because it evaporates. The nurse should wear sterile gloves to prevent contamination. but a mask is not necessary.

Explanation

The nurse always should clean around a wound drain. moving from center outward in ever-larger circles. because the skin near the drain site is more contaminated than the site itself. The nurse should never remove the drain before cleaning the skin. Alcohol should never be used to clean around a drain; it may irritate the skin and has no lasting effect on bacteria because it evaporates. The nurse should wear sterile gloves to prevent contamination. but a mask is not necessary.

7. The doctor orders dextrose 5% in water. 1.000 ml to be infused over 8 hours. The I.V. tubing delivers 15 drops per milliliter. The nurse in charge should run the I.V. infusion at a rate of:

15 drop per minute

21 drop per minute

32 drop per minute

125 drops per minute

Giving 1.000 ml over 8 hours is the same as giving 125 ml over 1 hour (60 minutes) to find the number of milliliters per minute: (125/60 min = X/1 minute) || (60X = 125X = 2.1 ml/minute)..To find the number of drops/minute: (2.1 ml/X gtts = 1 ml/15 gtts) || (X = 32 gtts/minute. or 32 drops/minute)

Explanation

Giving 1.000 ml over 8 hours is the same as giving 125 ml over 1 hour (60 minutes) to find the number of milliliters per minute: (125/60 min = X/1 minute) || (60X = 125X = 2.1 ml/minute)..To find the number of drops/minute: (2.1 ml/X gtts = 1 ml/15 gtts) || (X = 32 gtts/minute. or 32 drops/minute)

8. Nurse Mackey is monitoring a patient for adverse reactions during barbiturate therapy. What is the major disadvantage of barbiturate use?

Prolonged half-life

Poor absorption

Potential for drug dependence

Potential for hepatotoxicity

Patients can become dependent on barbiturates. especially with prolonged use. Because of the rapid distribution of some barbiturates. no correlation exists between duration of action and half-life. Barbiturates are absorbed well and do not cause hepatotoxicity. although existing hepatic damage does require cautions use of the drug because barbiturates are metabolized in the liver.

Explanation

Patients can become dependent on barbiturates. especially with prolonged use. Because of the rapid distribution of some barbiturates. no correlation exists between duration of action and half-life. Barbiturates are absorbed well and do not cause hepatotoxicity. although existing hepatic damage does require cautions use of the drug because barbiturates are metabolized in the liver.

9. A female patient undergoes a total abdominal hysterectomy. When assessing the patient 10 hours later. the nurse identifies which finding as an early sign of shock?

Restlessness

Pale. warm. dry skin

Heart rate of 110 beats/minute

Urine output of 30 ml/hour

Early in shock. hyperactivity of the sympathetic nervous system causes increased epinephrine secretion. which typically makes the patient restless. anxious. nervous. and irritable. It also decreases tissue perfusion to the skin. causing pale. cool clammy skin. An above-normal heart rate is a late sign of shock. A urine output of 30 ml/hour is within normal limits.

Explanation

Early in shock. hyperactivity of the sympathetic nervous system causes increased epinephrine secretion. which typically makes the patient restless. anxious. nervous. and irritable. It also decreases tissue perfusion to the skin. causing pale. cool clammy skin. An above-normal heart rate is a late sign of shock. A urine output of 30 ml/hour is within normal limits.

10. What does the nurse in charge do when making a surgical bed?

Leaves the bed in the high position when finished

Places the pillow at the head of the bed

Rolls the patient to the far side of the bed

Tucks the top sheet and blanket under the bottom of the bed

When making a surgical bed. the nurse leaves the bed in the high position when finished. After placing the top linens on the bed without pouching them. the nurse fanfolds these linens to the side opposite from where the patient will enter and places the pillow on the bedside chair. All these actions promote transfer of the postoperative patient from the stretcher to the bed. When making an occupied bed or unoccupied bed. the nurse places the pillow at the head of the bed and tucks the top sheet and blanket under the bottom of the bed. When making an occupied bed. the nurse rolls the patient to the far side of the bed.

Explanation

When making a surgical bed. the nurse leaves the bed in the high position when finished. After placing the top linens on the bed without pouching them. the nurse fanfolds these linens to the side opposite from where the patient will enter and places the pillow on the bedside chair. All these actions promote transfer of the postoperative patient from the stretcher to the bed. When making an occupied bed or unoccupied bed. the nurse places the pillow at the head of the bed and tucks the top sheet and blanket under the bottom of the bed. When making an occupied bed. the nurse rolls the patient to the far side of the bed.