Fundamentals Of Nursing NCLEX Quiz 8

1. Which document addresses the client's right to information. informed consent. and treatment refusal?

Standard of Nursing Practice

Patient’s Bill of Rights

Nurse Practice Act

Code for Nurses

The Patient’s Bill of Rights addresses the client’s right to information. informed consent. timely responses to requests for services. and treatment refusal. A legal document. it serves as a guideline for the nurse’s decision making. Standards of Nursing Practice. the Nurse Practice Act. and the Code for Nurses contain nursing practice parameters and primarily describe the use of the nursing process in providing care.

Explanation

The Patient’s Bill of Rights addresses the client’s right to information. informed consent. timely responses to requests for services. and treatment refusal. A legal document. it serves as a guideline for the nurse’s decision making. Standards of Nursing Practice. the Nurse Practice Act. and the Code for Nurses contain nursing practice parameters and primarily describe the use of the nursing process in providing care.

2. A male client is admitted to the hospital with blunt chest trauma after a motor vehicle accident. The first nursing priority for this client would be to:

Assess the client’s airway

Provide pain relief

Encourage deep breathing and coughing

Splint the chest wall with a pillow

The first priority is to evaluate airway patency before assessing for signs of obstruction. sternal retraction. stridor. or wheezing. Airway management is always the nurse’s first priority. Pain management and splinting are important for the client’s comfort. but would come after airway assessment. Coughing and deep breathing may be contraindicated if the client has internal bleeding and other injuries.

Explanation

The first priority is to evaluate airway patency before assessing for signs of obstruction. sternal retraction. stridor. or wheezing. Airway management is always the nurse’s first priority. Pain management and splinting are important for the client’s comfort. but would come after airway assessment. Coughing and deep breathing may be contraindicated if the client has internal bleeding and other injuries.

3. Nurse Elijah has been teaching a client about a high-protein diet. The teaching is successful if the client identifies which meal as high in protein?

Baked beans. hamburger. and milk

Spaghetti with cream sauce. broccoli. and tea

Bouillon. spinach. and soda

Chicken cutlet. spinach. and soda

Baked beans. hamburger. and milk are all excellent sources of protein. The spaghetti-broccoli-tea choice is high in carbohydrates. The bouillon-spinach-soda choice provides liquid and sodium as well as some iron. vitamins. and carbohydrates. Chicken provides protein but the chicken-spinach-soda combination provides less protein than the baked beans-hamburger-milk selection.

Explanation

Baked beans. hamburger. and milk are all excellent sources of protein. The spaghetti-broccoli-tea choice is high in carbohydrates. The bouillon-spinach-soda choice provides liquid and sodium as well as some iron. vitamins. and carbohydrates. Chicken provides protein but the chicken-spinach-soda combination provides less protein than the baked beans-hamburger-milk selection.

4. A female client is admitted to the emergency department with complaints of chest pain shortness of breath. The nurse's assessment reveals jugular vein distention. The nurse knows that when a client has jugular vein distension. it's typically due to:

A neck tumor

An electrolyte imbalance

Dehydration

Fluid overload

Fluid overload causes the volume of blood within the vascular system to increase. This increase causes the vein to distend. which can be seen most obviously in the neck veins. A neck tumor doesn’t typically cause jugular vein distention. An electrolyte imbalance may result in fluid overload. but it doesn’t directly contribute to jugular vein distention.

Explanation

Fluid overload causes the volume of blood within the vascular system to increase. This increase causes the vein to distend. which can be seen most obviously in the neck veins. A neck tumor doesn’t typically cause jugular vein distention. An electrolyte imbalance may result in fluid overload. but it doesn’t directly contribute to jugular vein distention.

5. If a blood pressure cuff is too small for a client. blood pressure readings taken with such a cuff may do which of the following?

Fail to show changes in blood pressure

Produce a false-high measurement

Cause sciatic nerve damage

Produce a false-low measurement

Using an undersized blood pressure cuff produces a falsely elevated blood pressure because the cuff can’t record brachial artery measurements unless it’s excessively inflated. The sciatic nerve wouldn’t be damaged by hyperinflation of the blood pressure cuff because the sciatic nerve is located in the lower extremity.

Explanation

Using an undersized blood pressure cuff produces a falsely elevated blood pressure because the cuff can’t record brachial artery measurements unless it’s excessively inflated. The sciatic nerve wouldn’t be damaged by hyperinflation of the blood pressure cuff because the sciatic nerve is located in the lower extremity.

6. Which one do you like?

Option 1

Option 2

Option 3

Option 4

The question asks for a personal preference, and the answer given is "Option 1."

Explanation

The question asks for a personal preference, and the answer given is "Option 1."

7. The nurse in charge is caring for an Italian client. He's complaining of pain. but he falls asleep right after his complaint and before the nurse can assess his pain. The nurse concludes that:

He may have a low threshold for pain

He was faking pain

Someone else gave him medication

The pain went away

People of Italian heritage tend to verbalize discomfort and pain. The pain was real to the client. and he may need medication when he wakes up.

Explanation

People of Italian heritage tend to verbalize discomfort and pain. The pain was real to the client. and he may need medication when he wakes up.

8. The nurse inspects a client's pupil size and determines that it's 2 mm in the left eye and 3 mm in the right eye. Unequal pupils are known as:

Anisocoria

Ataxia

Cataract

Diplopia

Unequal pupils are called anisocoria. Ataxia is uncoordinated actions of involuntary muscle use. A cataract is an opacity of the eye’s lens. Diplopia is double vision.

Explanation

Unequal pupils are called anisocoria. Ataxia is uncoordinated actions of involuntary muscle use. A cataract is an opacity of the eye’s lens. Diplopia is double vision.

9. Which one do you like?

Option 1

Option 2

Option 3

Option 4

not-available-via-ai

Explanation

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10. Following a tonsillectomy. a female client returns to the medical-surgical unit. The client is lethargic and reports having a sore throat. Which position would be most therapeutic for this client?

Semi-Fowler’s

Supine

High-Fowler’s

Side-lying

Because of lethargy. the post tonsillectomy client is at risk for aspirating blood from the surgical wound. Therefore. placing the client in the side-lying position until he awake is best. The semi-Fowler’s. supine. and high-Fowler’s position don’t allow for adequate oral drainage in a lethargic post tonsillectomy client. and increase the risk of blood aspiration.

Explanation

Because of lethargy. the post tonsillectomy client is at risk for aspirating blood from the surgical wound. Therefore. placing the client in the side-lying position until he awake is best. The semi-Fowler’s. supine. and high-Fowler’s position don’t allow for adequate oral drainage in a lethargic post tonsillectomy client. and increase the risk of blood aspiration.