Fundamentals Of Nursing NCLEX Quiz 2

1.

Which of the following symptoms is the best indicator of imminent death?

A.

A weak. slow pulse
B.

Increased muscle tone
C.

Fixed. dilated pupils
D.

Slow. shallow respirations

Correct Answer
C. Fixed. dilated pupils

Explanation
Fixed. dilated pupils are sign of imminent death. Pulse becomes weak but rapid. muscles become weak and atonic. and periods of apnea occur during respiration.

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2.

A nurse caring for a patient with an infectious disease who requires isolation should refers to guidelines published by the:

A.

National League for Nursing (NLN)
B.

Centers for Disease Control (CDC)
C.

American Medical Association (AMA)
D.

American Nurses Association (ANA)

Correct Answer
B. Centers for Disease Control (CDC)

Explanation
The Center of Disease Control (CDC) publishes and frequently updates guidelines on caring for patients who require isolation. The National League of Nursing’s (NLN’s) major function is accrediting nursing education programs in the United States. The American Medical Association (AMA) is a national organization of physicians. The American Nurses’ Association (ANA) is a national organization of registered nurses.

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3.

To institute appropriate isolation precautions. the nurse must first know the:

A.

Organism’s mode of transmission
B.

Organism’s Gram-staining characteristics
C.

Organism’s susceptibility to antibiotics
D.

Patient’s susceptibility to the organism

Correct Answer
A. Organism’s mode of transmission

Explanation
Before instituting isolation precaution. the nurse must first determine the organism’s mode of transmission. For example. an organism transmitted through nasal secretions requires that the patient be kept in respiratory isolation. which involves keeping the patient in a private room with the door closed and wearing a mask. a gown. and gloves when coming in direct contact with the patient. The organism’s Gram-straining characteristics reveal whether the organism is gram-negative or gram-positive. an important criterion in the physician’s choice for drug therapy and the nurse’s development of an effective plan of care. The nurse also needs to know whether the organism is susceptible to antibiotics. but this could take several days to determine; if she waits for the results before instituting isolation precautions. the organism could be transmitted in the meantime. The patient’s susceptibility to the organism has already been established. The nurse would not be instituting isolation precautions for a non-infected patient.

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4.

Which is the correct procedure for collecting a sputum specimen for culture and sensitivity testing?

A.

Have the patient place the specimen in a container and enclose the container in a plastic bag
B.

Have the patient expectorate the sputum while the nurse holds the container
C.

Have the patient expectorate the sputum into a sterile container
D.

Offer the patient an antiseptic mouthwash just before he expectorate the sputum

Correct Answer
C. Have the patient expectorate the sputum into a sterile container

Explanation
Placing the specimen in a sterile container ensures that it will not become contaminated. The other answers are incorrect because they do not mention sterility and because antiseptic mouthwash could destroy the organism to be cultured (before sputum collection. the patient may use only tap water for nursing the mouth).

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5.

An autoclave is used to sterilize hospital supplies because:

A.

More articles can be sterilized at a time
B.

Steam causes less damage to the materials
C.

A lower temperature can be obtained
D.

Pressurized steam penetrates the supplies better

Correct Answer
D. Pressurized steam penetrates the supplies better

Explanation
An autoclave. an apparatus that sterilizes equipment by means of high-temperature pressurized steam. is used because it can destroy all forms of microorganisms. including spores.

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6.

The best way to decrease the risk of transferring pathogens to a patient when removing contaminated gloves is to:

A.

Wash the gloves before removing them
B.

Gently pull on the fingers of the gloves when removing them
C.

Gently pull just below the cuff and invert the gloves when removing them
D.

Remove the gloves and then turn them inside out

Correct Answer
C. Gently pull just below the cuff and invert the gloves when removing them

Explanation
Turning the gloves inside out while removing them keeps all contaminants inside the gloves. They should then be placed in a plastic bag with soiled dressings and discarded in a soiled utility room garbage pail (double bagged). The other choices can spread pathogens within the environment.

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7.

After having an I.V. line in place for 72 hours. a patient complains of tenderness. burning. and swelling. Assessment of the I.V. site reveals that it is warm and erythematous. This usually indicates:

A.

Infection
B.

Infiltration
C.

Phlebitis
D.

Bleeding

Correct Answer
C. Phlebitis

Explanation
Tenderness. warmth. swelling. and. in some instances. a burning sensation are signs and symptoms of phlebitis. Infection is less likely because no drainage or fever is present. Infiltration would result in swelling and pallor. not erythema. near the insertion site. The patient has no evidence of bleeding.

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8.

To ensure homogenization when diluting powdered medication in a vial. the nurse should:

A.

Shake the vial vigorously
B.

Roll the vial gently between the palms
C.

Invert the vial and let it stand for 1 minute
D.

Do nothing after adding the solution to the vial

Correct Answer
B. Roll the vial gently between the palms

Explanation
Gently rolling a sealed vial between the palms produces sufficient heat to enhance dissolution of a powdered medication. Shaking the vial vigorously can break down the medication and alter its pharmacologic action. Inverting the vial or leaving it alone does not ensure thorough homogenization of the powder and the solvent.

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9.

The nurse is teaching a patient to prepare a syringe with 40 units of U-100 NPH insulin for self-injection. The patient’s first priority concerning self-injection in this situation is to:

A.

Assess the injection site
B.

Select the appropriate injection site
C.

Check the syringe to verify that the nurse has removed the prescribed insulin dose
D.

Clean the injection site in a circular manner with alcohol sponge

Correct Answer
C. Check the syringe to verify that the nurse has removed the prescribed insulin dose

Explanation
When the nurse teaches the patient to prepare an insulin injection. the patient’s first priority is to validate the dose accuracy. The next steps are to select the site. assess the site. and clean the site with alcohol before injecting the insulin.

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10.

The physician’s order reads “Administer 1 g cefazolin sodium (Ancef) in 150 ml of normal saline solution in 60 minutes.” What is the flow rate if the drop factor is 10 gtt = 1 ml?

A.

25 gtt/minute
B.

37 gtt/minute
C.

50 gtt/minute
D.

60 gtt/minute

Correct Answer
A. 25 gtt/minute

Explanation
.

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