NCLEX Practice Questions On Fundamentals Of Nursing

1. Nurse Monica is handling a female client who had undergone a mastectomy. Which is the best position in which she should place the client?

Head of bed elevated at least 30° with the affected arm elevated on a pillow.

Forward side-lying position.

Supine position with the affected arm remain flat.

Head of bed elevated at least 30° with the unaffected arm elevated on a pillow.

Position a post-mastectomy client with the head of bed elevated at least 30 degrees. with the affected arm elevated on a pillow to promote lymphatic fluid return after the removal of axillary lymph nodes.

Explanation

Position a post-mastectomy client with the head of bed elevated at least 30 degrees. with the affected arm elevated on a pillow to promote lymphatic fluid return after the removal of axillary lymph nodes.

2. Nurse Aaron is inserting a nasogastric tube to a stroke client. He understands that the best position for the insertion is?

Low Fowlers.

Sims position.

Trendelenburg.

High Fowlers.

The best position during a nasogastric tube insertion is sitting or High fowlers position in order to prevent the risk of aspiration.

Explanation

The best position during a nasogastric tube insertion is sitting or High fowlers position in order to prevent the risk of aspiration.

3. A nurse is caring for a client with severe burns of the face and head. The nurse will place the client in which position?

Trendelenburg.

Head of bed elevated.

Supine position.

Prone position.

For clients with burns on the face and head. the best position is to elevate the head of bed to reduce the occurence of facial edema.

Explanation

For clients with burns on the face and head. the best position is to elevate the head of bed to reduce the occurence of facial edema.

4. The nurse caring for a client with a pneumothorax and who has had a chest tube inserted notes continuous gentle bubbling in the suction control chamber. What action is most appropriate of the nurse?

Increase the suction pressure so that the bubbling becomes vigorous.

Do nothing since this is an expected finding.

Immediately clamp the chest tube and notify the physician.

Check for an air leak because the bubbling should be intermittent.

Continuous gentle bubbling should be noted in the suction control chamber. Bubbling should be continuous in the suction control chamber and not intermittent.Option A: Increasing the suction pressure only increases the rate of evaporation of water in the drainage system. and this is not done without any prescription of the physician.Options C and D: Chest tubes should only be clamped to check for an air leak or when changing drainage devices.

Explanation

Continuous gentle bubbling should be noted in the suction control chamber. Bubbling should be continuous in the suction control chamber and not intermittent.Option A: Increasing the suction pressure only increases the rate of evaporation of water in the drainage system. and this is not done without any prescription of the physician.Options C and D: Chest tubes should only be clamped to check for an air leak or when changing drainage devices.

5. The nurse is handling a client with a chest tube. Suddenly. the chest drainage system is accidentally disconnected. what is the most appropriate action for the nurse to take?

Secure the chest tube using a tape.

Clamp the chest tube immediately.

Place the end of the chest tube in a container of normal sterile saline.

Apply an occlusive dressing and notify the physician.

If a chest drainage system is disconnected. the nurse can place the end of the chest tube in a container of normal sterile saline to prevent air from entering the chest tube. thereby preventing negative respiratory pressure.Option A: The nurse should tape the chest tube securely to prevent it from being disconnected. rather than taping it after it has been disconnected.Option B: The nurse should not clamp the chest tube because doing so increases the risk of tension pneumothorax.Option D: The nurse should apply an occlusive dressing if the chest tube is pulled out and not if the system is disconnected.

Explanation

If a chest drainage system is disconnected. the nurse can place the end of the chest tube in a container of normal sterile saline to prevent air from entering the chest tube. thereby preventing negative respiratory pressure.Option A: The nurse should tape the chest tube securely to prevent it from being disconnected. rather than taping it after it has been disconnected.Option B: The nurse should not clamp the chest tube because doing so increases the risk of tension pneumothorax.Option D: The nurse should apply an occlusive dressing if the chest tube is pulled out and not if the system is disconnected.

6. Which of the following does not match with the appropriate position?

Vaginal examination: lithotomy position.

Thyroidectomy: fowler’s position.

Hemorrhoidectomy: lateral position.

Hypophysectomy: Prone position.

Hypophysectomy is the surgical removal of the hypophysis (pituitary gland). After the surgery. the client head of bed is elevated to prevent increase intracranial pressure.

Explanation

Hypophysectomy is the surgical removal of the hypophysis (pituitary gland). After the surgery. the client head of bed is elevated to prevent increase intracranial pressure.

7. The nurse is assessing the functioning of a chest tube drainage system in a client with hemothorax. Which of the following findings should prompt the nurse to notify the physician?

Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation.

Drainage system maintained below the client’s chest.

Drainage amount of 100ml in the drainage collection chamber.

Occlusive dressing in place over the chest tube insertion site.

Drainage of more than 70 to 100 mL/hour is not normal and requires the immediate notification of the physician.

Explanation

Drainage of more than 70 to 100 mL/hour is not normal and requires the immediate notification of the physician.

8. While changing the tapes on a tracheostomy tube. the client coughs and the tube is dislodged. Which is the initial nursing action?

Call a respiratory therapist to reinsert the tracheotomy.

Cover the tracheostomy site with a sterile dressing.

Call the physician to reinsert the tracheotomy.

Grasp the retention sutures to spread the opening.

If the tube is dislodged accidentally. the initial nursing action is to grasp the retention sutures and spread the opening.Options A and C: Calling respiratory therapist or the physician will delay treatment in this emergency situation.Option B: Covering the tracheostomy site will block the airway.

Explanation

If the tube is dislodged accidentally. the initial nursing action is to grasp the retention sutures and spread the opening.Options A and C: Calling respiratory therapist or the physician will delay treatment in this emergency situation.Option B: Covering the tracheostomy site will block the airway.

9. A nurse is supervising a student nurse who is performing tracheostomy care for a client. Which of the following actions by the student should the nurse intervene?

Removing the inner cannula and cleaning using universal precaution.

Suctioning the tracheostomy tube before performing tracheostomy care.

Changing the old tracheotomy ties and securing the tube in place.

Replacing the inner cannula and cleaning the site of the stoma.

When performing tracheostomy care. a sterile field is set up and sterile technique is required. Standard precautions such as washing hands must also be maintained but are not enough when performing tracheostomy care. The presence of tracheostomy tube provides direct access to the lungs for organisms. so sterile technique is used to prevent infection.

Explanation

When performing tracheostomy care. a sterile field is set up and sterile technique is required. Standard precautions such as washing hands must also be maintained but are not enough when performing tracheostomy care. The presence of tracheostomy tube provides direct access to the lungs for organisms. so sterile technique is used to prevent infection.

10. Nurse Ian is handling a client with gastroesophageal reflux disease. Which of the following position will best help the client in this case?

Right Lateral Recumbent.

Supine position.

Reverse Trendelenburg position.

Sims position.

Reverse Trendelenburg position is advised to a client to promote gastric emptying and prevent gastroesophageal reflux.

Explanation

Reverse Trendelenburg position is advised to a client to promote gastric emptying and prevent gastroesophageal reflux.