Fundamentals Of Nursing NCLEX Quiz 31

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Fundamentals Of Nursing NCLEX Quizzes & Trivia

All questions are shown, but the results will only be given after you’ve finished the quiz. You are given 1 minute per question, a total of 10 minutes in this quiz.


Questions and Answers
  • 1. 

    A child is admitted to the pediatric unit with a diagnosis of suspected meningococcal meningitis. Which of the following nursing measures should the nurse do FIRST?

    • A.

      Institute seizure precautions

    • B.

      Assess neurologic status

    • C.

      Place in respiratory isolation

    • D.

      Assess vital signs

    Correct Answer
    C. Place in respiratory isolation
    Explanation
    The initial therapeutic management of acute bacterial meningitis includes isolation precautions. initiation of antimicrobial therapy and maintenance of optimum hydration. Nurses should take necessary precautions to protect themselves and others from possible infection.

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  • 2. 

    A client is diagnosed with methicillin-resistant staphylococcus aureus pneumonia. What type of isolation is MOST appropriate for this client?

    • A.

      Reverse isolation

    • B.

      Respiratory isolation

    • C.

      Standard precautions

    • D.

      Contact isolation

    Correct Answer
    D. Contact isolation
    Explanation
    Contact or Body Substance Isolation (BSI) involves the use of barrier protection (e.g. gloves. mask. gown. or protective eyewear as appropriate) whenever direct contact with any body fluid is expected. When determining the type of isolation to use. one must consider the mode of transmission. The hands of personnel continues to be the principal mode of transmission for methicillin resistant staphylococcus aureus (MRSA). Because the organism is limited to the sputum in this example. precautions are taken if contact with the patient”s sputum is expected. A private room and BSI. along with good hand washing techniques. are the best defense against the spread of MRSA pneumonia.

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  • 3. 

    Several clients are admitted to an adult medical unit. The nurse would ensure airborne precautions for a client with which of the following medical conditions?

    • A.

      A diagnosis of AIDS and cytomegalovirus

    • B.

      A positive PPD with an abnormal chest x-ray

    • C.

      A tentative diagnosis of viral pneumonia

    • D.

      Advanced carcinoma of the lung

    Correct Answer
    B. A positive PPD with an abnormal chest x-ray
    Explanation
    The client who must be placed in airborne precautions is the client with a positive PPD (purified protein derivative) who has a positive x-ray for a suspicious tuberculin lesion.

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  • 4. 

    Which of the following is the FIRST priority in preventing infections when providing care for a client?

    • A.

      Handwashing

    • B.

      Wearing gloves

    • C.

      Using a barrier between client’s furniture and nurse’s bag

    • D.

      Wearing gowns and goggles

    Correct Answer
    A. Handwashing
    Explanation
    Handwashing remains the most effective way to avoid spreading infection. However. too often nurses do not practice good handwashing techniques and do not teach families to do so. Nurses need to wash their hands before and after touching the client and before entering the nursing bag.

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  • 5. 

    An adult woman is admitted to an isolation unit in the hospital after tuberculosis was detected during a pre-employment physical. Although frightened about her diagnosis. she is anxious to cooperate with the therapeutic regimen. The teaching plan includes information regarding the most common means of transmitting the tubercle bacillus from one individual to another. Which contamination is usually responsible?

    • A.

      Hands.

    • B.

      Droplet nuclei.

    • C.

      Milk products.

    • D.

      Eating utensils.

    Correct Answer
    B. Droplet nuclei.
    Explanation
    Hands are the primary method of transmission of the common cold. The most frequent means of transmission of the tubercle bacillus is by droplet nuclei. The bacillus is present in the air as a result of coughing. sneezing. and expectoration of sputum by an infected person. The tubercle bacillus is not transmitted by means of contaminated food. Contact with contaminated food or water could cause outbreaks of salmonella. infectious hepatitis. typhoid. or cholera. The tubercle bacillus is not transmitted by eating utensils. Some exogenous microbes can be transmitted via reservoirs such as linens or eating utensils.

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  • 6. 

    A 2-year-old is to be admitted in the pediatric unit. He is diagnosed with febrile seizures. In preparing for his admission. which of the following is the most important nursing action?

    • A.

      Order a stat admission CBC.

    • B.

      Place a urine collection bag and specimen cup at the bedside.

    • C.

      Place a cooling mattress on his bed.

    • D.

      Pad the side rails of his bed.

    Correct Answer
    D. Pad the side rails of his bed.
    Explanation
    Preparing for routine laboratory studies is not as high a priority as preventing injury and promoting safety. Preparing for routine laboratory studies is not as high a priority as preventing injury and promoting safety. A cooling blanket must be ordered by the physician and is usually not used unless other methods for the reduction of fever have not been successful. The child has a diagnosis of febrile seizures. Precautions to prevent injury and promote safety should take precedence.

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  • 7. 

    A young adult is being treated for second and third-degree burns over 25% of his body and is now ready for discharge. The nurse evaluates his understanding of discharge instructions relating to wound care and is satisfied that he is prepared for home care when he makes which statement?

    • A.

      “I will need to take sponge baths at home to avoid exposing the wounds to unsterile bath water.”

    • B.

      “If any healed areas break open I should first cover them with a sterile dressing and then report it.”

    • C.

      “I must wear my Jobst elastic garment all day and can only remove it when I’m going to bed.”

    • D.

      “I can expect occasional periods of low-grade fever and can take Tylenol every 4 hours.”

    Correct Answer
    B. “If any healed areas break open I should first cover them with a sterile dressing and then report it.”
    Explanation
    Bathing or showering in the usual manner is permitted. using a mild detergent soap such as Ivory Snow. This cleanses the wounds. especially those that are still open. and removes dead tissue. The client is taught to report changes in wound healing such as blister formation. signs of infection. and opening of a previously healed area. Sterile dressings are applied until the wound is assessed and a plan of care developed. The Jobs garment is designed to place constant pressure on the new healthy tissue that is forming to promote adherence to the underlying structure in order to prevent hypertrophic scarring. In order to be effective. the garment must be worn for 23 hours daily. It is removed for wound assessment and wound care and to permit bathing. The client must be aware that infection of the wound may occur; signs of infection. including fever. redness. pain. warmth in and around the wound and increased or foul smelling drainage must be reported immediately.

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  • 8. 

    An eighty five year old man was admitted for surgery for benign prostatic hypertrophy. Preoperatively he was alert. oriented. cooperative. and knowledgeable about his surgery. Several hours after surgery. the evening nurse found him acutely confused. agitated. and trying to climb over the protective side rails on his bed. The most appropriate nursing intervention that will calm an agitated client is:

    • A.

      Limit visits by staff.

    • B.

      Encourage family phone calls.

    • C.

      Position in a bright. busy area.

    • D.

      Speak soothingly and provide quiet music.

    Correct Answer
    D. Speak soothingly and provide quiet music.
    Explanation
    The client needs frequent visits by the staff to orient him and to assess his safety. Phone calls from his family will not help a client who is trying to climb over the side rails and may even add to his danger. Putting the client in a bright. busy area would probably add to his confusion. The environment is an important factor in the prevention of injuries. Talking softly and providing quiet music have a calming effect on the agitated client.

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  • 9. 

    Ms. Smith is admitted for internal radiation for cancer of the cervix. The nurse knows the client understands the procedure when she makes which of the following remarks the night before the procedure?

    • A.

      She says to her husband. “Please bring me a hamburger and french fries tomorrow when you come. I hate hospital food.”

    • B.

      “I told my daughter who is pregnant to either come to see me tonight or wait until I go home from the hospital.”

    • C.

      “I understand it will be several weeks before all the radiation leaves my body.”

    • D.

      “I brought several craft projects to do while the radium is inserted.”

    Correct Answer
    B. “I told my daughter who is pregnant to either come to see me tonight or wait until I go home from the hospital.”
    Explanation
    The client will be on a clear liquid or very low residue diet. Hamburgers and french fries are not allowed. People who are pregnant should not come in close contact with someone who has internal radiation therapy. The radioactivity could possibly damage the fetus. This statement is not true. As soon as the radiation source is removed (probably 36 to 72 hours after insertion). the client is no longer contaminated with radioactivity. Craft projects usually require the client to sit. The client must remain flat with very little head elevation during the time the rods are in place.

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  • 10. 

    The nurse in charge is evaluating the infection control procedures on the unit. Which finding indicates a break in technique and the need for education of staff?

    • A.

      The nurse aide is not wearing gloves when feeding an elderly client.

    • B.

      A client with active tuberculosis is asked to wear a mask when he leaves his room to go to another department for testing.

    • C.

      A nurse with open. weeping lesions of the hands puts on gloves before giving direct client care.

    • D.

      The nurse puts on a mask. a gown. and gloves before entering the room of a client on strict isolation.

    Correct Answer
    C. A nurse with open. weeping lesions of the hands puts on gloves before giving direct client care.
    Explanation
    There is no need to wear gloves when feeding a client. However. universal precautions (treating all blood and body fluids as if they are infectious) should be observed in all situations. A client with active tuberculosis should be on respiratory precautions. Having the client wear a mask when leaving his private room is appropriate. Persons with exudative lesions or weeping dermatitis should not give direct client care or handle client-care equipment until the condition resolves. Strict isolation requires the use of mask. gown. and gloves.

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