Fundamentals Of Nursing NCLEX Quiz 3

1. The nurse is assessing a postoperative adult patient. Which of the following should the nurse document as subjective data?

Vital signs

Laboratory test result

Patient’s description of pain

Electrocardiographic (ECG) waveforms

Subjective data come directly from the patient and usually are recorded as direct quotations that reflect the patient’s opinions or feelings about a situation. Vital signs. laboratory test result. and ECG waveforms are examples of objective data.

Explanation

Subjective data come directly from the patient and usually are recorded as direct quotations that reflect the patient’s opinions or feelings about a situation. Vital signs. laboratory test result. and ECG waveforms are examples of objective data.

2. A male patient has a soft wrist-safety device. Which assessment finding should the nurse consider abnormal?

A palpable radial pulse

A palpable ulnar pulse

Cool. pale fingers

Pink nail beds

A safety device on the wrist may impair circulation and restrict blood supply to body tissues. Therefore. the nurse should assess the patient for signs of impaired circulation. such as cool. pale fingers. A palpable radial or lunar pulse and pink nail beds are normal findings.

Explanation

A safety device on the wrist may impair circulation and restrict blood supply to body tissues. Therefore. the nurse should assess the patient for signs of impaired circulation. such as cool. pale fingers. A palpable radial or lunar pulse and pink nail beds are normal findings.

3. When administering drug therapy to a male geriatric patient. the nurse must stay especially alert for adverse effects. Which factor makes geriatric patients to adverse drug effects?

Faster drug clearance

Aging-related physiological changes

Increased amount of neurons

Enhanced blood flow to the GI tract

Aging-related physiological changes account for the increased frequency of adverse drug reactions in geriatric patients. Renal and hepatic changes cause drugs to clear more slowly in these patients. With increasing age. neurons are lost and blood flow to the GI tract decreases.

Explanation

Aging-related physiological changes account for the increased frequency of adverse drug reactions in geriatric patients. Renal and hepatic changes cause drugs to clear more slowly in these patients. With increasing age. neurons are lost and blood flow to the GI tract decreases.

4. Nurse Clarisse is teaching a patient about a newly prescribed drug. What could cause a geriatric patient to have difficulty retaining knowledge about prescribed medications?

Decreased plasma drug levels

Sensory deficits

Lack of family support

History of Tourette syndrome

Sensory deficits could cause a geriatric patient to have difficulty retaining knowledge about prescribed medications. Decreased plasma drug levels do not alter the patient’s knowledge about the drug. A lack of family support may affect compliance. not knowledge retention. Toilette syndrome is unrelated to knowledge retention.

Explanation

Sensory deficits could cause a geriatric patient to have difficulty retaining knowledge about prescribed medications. Decreased plasma drug levels do not alter the patient’s knowledge about the drug. A lack of family support may affect compliance. not knowledge retention. Toilette syndrome is unrelated to knowledge retention.

5. Before administering the evening dose of a prescribed medication. the nurse on the evening shift finds an unlabeled. filled syringe in the patient's medication drawer. What should the nurse in charge do?

Discard the syringe to avoid a medication error

Obtain a label for the syringe from the pharmacy

Use the syringe because it looks like it contains the same medication the nurse was prepared to give

Call the day nurse to verify the contents of the syringe

As a safety precaution. the nurse should discard an unlabeled syringe that contains medication. The other options are considered unsafe because they promote error.

Explanation

As a safety precaution. the nurse should discard an unlabeled syringe that contains medication. The other options are considered unsafe because they promote error.

6. A female patient who speaks a little English has emergency gallbladder surgery. during discharge preparation. which nursing action would best help this patient understand wound care instruction?

Asking frequently if the patient understands the instruction

Asking an interpreter to replay the instructions to the patient.

Writing out the instructions and having a family member read them to the patient

Demonstrating the procedure and having the patient return the demonstration

Demonstrating by the nurse with a return demonstration by the patient ensures that the patient can perform wound care correctly. Patients may claim to understand discharge instruction when they do not. An interpreter of family member may communicate verbal or written instructions inaccurately.

Explanation

Demonstrating by the nurse with a return demonstration by the patient ensures that the patient can perform wound care correctly. Patients may claim to understand discharge instruction when they do not. An interpreter of family member may communicate verbal or written instructions inaccurately.

7. The nurse in charge is transferring a patient from the bed to a chair. Which action does the nurse take during this patient transfer?

Position the head of the bed flat

Helps the patient dangle the legs

Stands behind the patient

Places the chair facing away from the bed

After placing the patient in high Fowler’s position and moving the patient to the side of the bed. the nurse helps the patient sit on the edge of the bed and dangle the legs; the nurse then faces the patient and places the chair next to and facing the head of the bed.

Explanation

After placing the patient in high Fowler’s position and moving the patient to the side of the bed. the nurse helps the patient sit on the edge of the bed and dangle the legs; the nurse then faces the patient and places the chair next to and facing the head of the bed.

8. When examining a patient with abdominal pain the nurse in charge should assess:

Any quadrant first

The symptomatic quadrant first

The symptomatic quadrant last

The symptomatic quadrant either second or third

The nurse should systematically assess all areas of the abdomen. if time and the patient’s condition permit. concluding with the symptomatic area. Otherwise. the nurse may elicit pain in the symptomatic area. causing the muscles in other areas to tighten. This would interfere with further assessment.

Explanation

The nurse should systematically assess all areas of the abdomen. if time and the patient’s condition permit. concluding with the symptomatic area. Otherwise. the nurse may elicit pain in the symptomatic area. causing the muscles in other areas to tighten. This would interfere with further assessment.

9. A female patient with a terminal illness is in denial. Indicators of denial include:

Shock dismay

Numbness

Stoicism

Preparatory grief

Shock and dismay are early signs of denial-the first stage of grief. The other options are associated with depression—a later stage of grief.

Explanation

Shock and dismay are early signs of denial-the first stage of grief. The other options are associated with depression—a later stage of grief.

10. Which of the following planes divides the body longitudinally into anterior and posterior regions?

Frontal plane

Sagittal plane

Midsagittal plane

Transverse plane

Frontal or coronal plane runs longitudinally at a right angle to a sagittal plane dividing the body in anterior and posterior regions. A sagittal plane runs longitudinally dividing the body into right and left regions; if exactly midline. it is called a midsagittal plane. A transverse plane runs horizontally at a right angle to the vertical axis. dividing the structure into superior and inferior regions.

Explanation

Frontal or coronal plane runs longitudinally at a right angle to a sagittal plane dividing the body in anterior and posterior regions. A sagittal plane runs longitudinally dividing the body into right and left regions; if exactly midline. it is called a midsagittal plane. A transverse plane runs horizontally at a right angle to the vertical axis. dividing the structure into superior and inferior regions.