Fundamentals Of Nursing NCLEX Quiz 6

1. The nurse in charge is assessing a patient's abdomen. Which examination technique should the nurse use first?

Auscultation

Inspection

Percussion

Palpation

Inspection always comes first when performing a physical examination. Percussion and palpation of the abdomen may affect bowel motility and therefore should follow auscultation.

Explanation

Inspection always comes first when performing a physical examination. Percussion and palpation of the abdomen may affect bowel motility and therefore should follow auscultation.

2. A female patient is diagnosed with deep-vein thrombosis. Which nursing diagnosis should receive highest priority at this time?

Impaired gas exchanges related to increased blood flow

Fluid volume excess related to peripheral vascular disease

Risk for injury related to edema

Altered peripheral tissue perfusion related to venous congestion

Altered peripheral tissue perfusion related to venous congestion” takes highest priority because venous inflammation and clot formation impede blood flow in a patient with deep-vein thrombosis. Option A is incorrect because impaired gas exchange is related to decreased. not increased. blood flow. Option B is inappropriate because no evidence suggest that this patient has a fluid volume excess. Option C may be warranted but is secondary to altered tissue perfusion.

Explanation

Altered peripheral tissue perfusion related to venous congestion” takes highest priority because venous inflammation and clot formation impede blood flow in a patient with deep-vein thrombosis. Option A is incorrect because impaired gas exchange is related to decreased. not increased. blood flow. Option B is inappropriate because no evidence suggest that this patient has a fluid volume excess. Option C may be warranted but is secondary to altered tissue perfusion.

3. Which intervention is an example of primary prevention?

Administering digoxin (Lanoxicaps) to a patient with heart failure

Administering a measles. mumps. and rubella immunization to an infant

Obtaining a Papanicolaou smear to screen for cervical cancer

Using occupational therapy to help a patient cope with arthritis

Immunizing an infant is an example of primary prevention. which aims to prevent health problems. Administering digoxin to treat heart failure and obtaining a smear for a screening test are examples for secondary prevention. which promotes early detection and treatment of disease. Using occupational therapy to help a patient cope with arthritis is an example of tertiary prevention. which aims to help a patient deal with the residual consequences of a problem or to prevent the problem from recurring.

Explanation

Immunizing an infant is an example of primary prevention. which aims to prevent health problems. Administering digoxin to treat heart failure and obtaining a smear for a screening test are examples for secondary prevention. which promotes early detection and treatment of disease. Using occupational therapy to help a patient cope with arthritis is an example of tertiary prevention. which aims to help a patient deal with the residual consequences of a problem or to prevent the problem from recurring.

4. A female patient is receiving furosemide (Lasix). 40 mg P.O. b.i.D. in the plan of care. the nurse should emphasize teaching the patient about the importance of consuming:

Fresh. green vegetables

Bananas and oranges

Lean red meat

Creamed corn

Because furosemide is a potassium-wasting diuretic. the nurse should plan to teach the patient to increase intake of potassium-rich foods. such as bananas and oranges. Fresh. green vegetables; lean red meat; and creamed corn are not good sources of potassium.

Explanation

Because furosemide is a potassium-wasting diuretic. the nurse should plan to teach the patient to increase intake of potassium-rich foods. such as bananas and oranges. Fresh. green vegetables; lean red meat; and creamed corn are not good sources of potassium.

5. Which statement regarding heart sounds is correct?

S1 and S2 sound equally loud over the entire cardiac area.

S1 and S2 sound fainter at the apex

S1 and S2 sound fainter at the base

S1 is loudest at the apex. and S2 is loudest at the base

The S1 sound—the “lub” sound—is loudest at the apex of the heart. It sounds longer. lower. and louder there than the S2 sounds. The S2—the “dub” sound—is loudest at the base. It sounds shorter. sharper. higher. and louder there than S1.

Explanation

The S1 sound—the “lub” sound—is loudest at the apex of the heart. It sounds longer. lower. and louder there than the S2 sounds. The S2—the “dub” sound—is loudest at the base. It sounds shorter. sharper. higher. and louder there than S1.

6. Nurse Nikki is revising a client's care plan. During which step of the nursing process does such revision take place?

Assessment

Planning

Implementation

Evaluation

During the evaluation step of the nursing process the nurse determines whether the goals established in the care plan have been achieved. and evaluates the success of the plan. If a goal is unmet or partially met the nurse reexamines the data and revises the plan. Assessment involves data collection. Planning involves setting priorities. establishing goals. and selecting appropriate interventions.

Explanation

During the evaluation step of the nursing process the nurse determines whether the goals established in the care plan have been achieved. and evaluates the success of the plan. If a goal is unmet or partially met the nurse reexamines the data and revises the plan. Assessment involves data collection. Planning involves setting priorities. establishing goals. and selecting appropriate interventions.

7. When positioned properly. the tip of a central venous catheter should lie in the:

Superior vena cava

Basilica vein

Jugular vein

Subclavian vein

When the central venous catheter is positioned correctly. its tip lies in the superior vena cava. inferior vena cava. or the right atrium—that is. in central venous circulation. Blood flows unimpeded around the tip. allowing the rapid infusion of large amounts of fluid directly into circulation. The basilica. jugular. and subclavian veins are common insertion sites for central venous catheters.

Explanation

When the central venous catheter is positioned correctly. its tip lies in the superior vena cava. inferior vena cava. or the right atrium—that is. in central venous circulation. Blood flows unimpeded around the tip. allowing the rapid infusion of large amounts of fluid directly into circulation. The basilica. jugular. and subclavian veins are common insertion sites for central venous catheters.

8. The nurse in charge must monitor a patient receiving chloramphenicol for adverse drug reaction. What is the most toxic reaction to chloramphenicol?

Lethal arrhythmias

Malignant hypertension

Status epilepticus

Bone marrow suppression

The most toxic reaction to chloramphenicol is bone marrow suppression. Chloramphenicol is not known to cause lethal arrhythmias. malignant hypertension. or status epilepticus.

Explanation

The most toxic reaction to chloramphenicol is bone marrow suppression. Chloramphenicol is not known to cause lethal arrhythmias. malignant hypertension. or status epilepticus.

9. A 65-year-old female who has diabetes mellitus and has sustained a large laceration on her left wrist asks the nurse. "How long will it take for my scars to disappear?" which statement would be the nurse's best response?

“The contraction phase of wound healing can take 2 to 3 years.”

“Wound healing is very individual but within 4 months the scar should fade.”

“With your history and the type of location of the injury. it’s hard to say.”

“If you don’t develop an infection. the wound should heal any time between 1 and 3 years from now.”

Wound healing in a client with diabetes will be delayed. Providing the client with a time frame could give the client false information.

Explanation

Wound healing in a client with diabetes will be delayed. Providing the client with a time frame could give the client false information.

10. The nurse in charge identifies a patient's responses to actual or potential health problems during which step of the nursing process?

Assessment

Nursing diagnosis

Planning

Evaluation

The nurse identifies human responses to actual or potential health problems during the nursing diagnosis step of the nursing process. During the assessment step. the nurse systematically collects data about the patient or family. During the planning step. the nurse develops strategies to resolve or decrease the patient’s problem. During the evaluation step. the nurse determines the effectiveness of the plan of care.

Explanation

The nurse identifies human responses to actual or potential health problems during the nursing diagnosis step of the nursing process. During the assessment step. the nurse systematically collects data about the patient or family. During the planning step. the nurse develops strategies to resolve or decrease the patient’s problem. During the evaluation step. the nurse determines the effectiveness of the plan of care.