Fundamental Skills NCLEX EAQ's

The nurse is performing nursing care therapies and including the client as an active participant in the care. Which basic step is involved in this situation? 1 Planning 2 Evaluation 3 Assessment 4 Implementation

4 Implementation

Which nursing assessment questions assess the faith, belief, fellowship, and community aspect of a client's spirituality? Select all that apply. 1 "What gives meaning to your life?" 2 "What is your source of power, hope, and belief during difficult times?" 3 "In what way do your beliefs help or strengthen you for coping with illness?" 4 "How has the illness affected your capability to express what is essential in life?" 5 "How do you feel the changes caused by the illness are affecting or will affect your life?"

1, 2, 3 "What gives meaning to your life?" "What is your source of power, hope, and belief during difficult times?" "In what way do your beliefs help or strengthen you for coping with illness?"

Which developmental changes should be evaluated in girls around 12 years of age? 1 Motor skills 2 Visual acuity 3 Skeletal growth 4 Hormonal changes

3 Skeletal Growth Girls around the age of 12 years of age may develop scoliosis (a lateral curvature of the spine); therefore, skeletal growth should be evaluated.

The nurse is assessing a Latino-Caribbean client who was brought to the hospital by family members. The family reports the client started crying, shouting, trembling, had uncontrolled jerking of the extremities, and then fell into a trance-like state. What condition does the nurse suspect? 1 Bulimia nervosa 2 Anorexia nervosa 3 Shenjing shuairuo 4 Ataque de nervios

4 Ataque de nervios Ataque de nervios is a Latino-Caribbean culture-bound syndrome that usually happens in response to specific stressors. This culture-bound syndrome is characterized by crying, uncontrollable spasms, trembling, shouting, dissociation, and trance-like states.

When trying to promote effective learning in a client with a newly diagnosed disease, what should the nurse consider? 1 Client's past experiences 2 Client's personal resources 3 Stress of the total situation 4 Type of onset of the disease

1 Client's past experiences Past experiences have the most meaningful influence on present learning. Although the client's personal resources, the stress of the total situation, and the type of onset of the disease affect learning, their influence is not as great as past experiences.

Which warning signals should the nurse observe in a child suspected to be a victim of abuse? Select all that apply. 1 The child doesn't want to be touched by anyone. 2 The child sleeps for an average of 15 hours a day. 3 The child frequently visits the emergency department. 4 The child suffers from fever and tenderness in the abdomen. 5 The child looks at the caregiver before answering any question.

1, 3, 5 The child may become scared if touched. The physical abuse may cause injuries and the child may visit the emergency department frequently. An abused child may look at the caregiver before answering any question due to fear.

Arrange the order of donning personal protective equipment (PPE) while caring for a client with isolation precautions.

1. Apply the cover gown, pull the sleeves down to the wrists, and tie the gown securely at the neck and waist 2.Apply either a surgical mask or a respirator around the mouth and nose 3.Apply eyewear or goggles snugly around the face and eyes 4.Apply clean gloves within the gown 5.Bring the glove cuffs over the edge of the gown sleeves

A registered nurse is teaching a nursing student about caring for a client before leaving the healthcare facility. Which statement made by the nursing student indicates the need for further education? 1 "I should teach the client about potential food-drug interactions." 2 "I should involve the client and his or her family in the referral process." 3 "I should give limited information about the client to the healthcare provider who received the referral." 4 "I should teach the client and his or her family about safe and effective use of medications and medical equipment."

3 "I should give limited information about the client to the healthcare provider who received the referral." The nurse should provide as much client information as possible to the healthcare provider who received the referral because this action helps to avoid the provider asking duplicate questions and helps to avoid the omission of important information.

A nurse is providing immediate postoperative care to a client who had a lung resection for a malignancy. The client has a closed chest tube drainage system connected to suction. Which assessment finding requires additional evaluation by the nurse? 1 A column of water 20 cm high in the suction control chamber 2 75 mL of bright red blood in the drainage collection chamber 3 An intact occlusive dressing at the insertion site 4 Constant bubbling in the water seal chamber

4 Constant bubbling in the water seal chamber Constant bubbling in the water seal chamber is indicative of an air leak. The nurse should assess the entire length of the system from the container to the client's chest wall tube insertion site to find the source of the air leak. If the source of the air leak is not found in the system and bubbling continues, the leak is most likely within the client's chest or at the insertion site. This could cause the lung to collapse because of a buildup of air pressure within the plural cavity, and therefore the healthcare provider should be notified. In this type of surgical procedure, 75 mL of blood in the chest tube collection chamber is an expected finding in the early postoperative period. A column of water 20 cm high in the suction control chamber and an intact occlusive dressing at the chest tube insertion site are also expected assessment findings.

Which nursing intervention is most appropriate for a client in skeletal traction? 1 Add and remove weights as the client desires. 2 Assess the pin sites at least every shift and as needed. 3 Ensure that the knots in the rope are tied to the pulley. 4 Perform range of motion to joints proximal and distal to the fracture at least once a day.

2 Assess the pin sites at least every shift and as needed. Nursing care for a client in skeletal traction may include assessing pin sites every shift and as needed. - The needed weight for a client in skeletal traction is prescribed by the physician, not as desired by the client. - The nurse also should ensure that the knots are not tied to the pulley and move freely. - The performance of range of motion is indicated for all joints except the ones proximal and distal to the fracture because this area is immobilized by the skeletal traction to promote healing and prevent further injury and pain.

A client is hospitalized for treatment of severe hypertension. Captopril and alprazolam are prescribed. Shortly after admission, the client says, "I don't think any of you know what you are doing. You are just guessing what I need." What does the nurse determine as the probable cause of this behavior? 1 Denial of illness 2 Fear of the health problem 3 Response to cerebral anoxia 4 Reaction to the antihypertensive drug

2 Fear of the health problem Clients adapting to illness frequently feel afraid and helpless and strike out at health team members as a way of maintaining control or denying their fear. There is no evidence that the client denies the existence of the health problem. Although disorders such as brain attacks and atherosclerosis, which are associated with hypertension, may lead to cerebral anoxia, there is insufficient evidence to support this conclusion. Captopril (an antihypertensive) is a renin-angiotensin antagonist that reduces blood pressure and does not cause behavioral changes; alprazolam is prescribed to reduce anxiety.

The nurse assessing an adult understands that the client is experiencing a midlife crisis. Which factor should the nurse attribute to this condition? 1 The client is seeking an occupational direction. 2 The client is examining life goals and relationships. 3 The client is directing energy towards achievements. 4 The client is sharing responsibilities in a two-career family.

2 The client is examining life goals and relationships. Individuals between the age of 35 and 43 are vigorously examining their life goals and relationships. These individuals often experience stress or a midlife crisis during this reexamination, which may lead to changes in personal, social, and occupational areas.

A client injured in a motor vehicle accident was brought to the emergency and taken immediately for a scan. The client's family arrives later and asks about the client's health. What should the nurse tell the client's family? 1 "Please do not worry, everything will be alright." 2 "I am sorry; I do not have any information about the client." 3 "You will have to wait for the primary healthcare provider." 4 "Please wait; I will update you as soon as I have any information."

4 "Please wait; I will update you as soon as I have any information." The nurse should update the client's relatives once he or she receives relevant information. This action helps the nurse to maintain the nurse-client relationship. - The nurse must not provide false reassurances because this action affects the family's ability to adjust to any bad news. - If the nurse does not have any information about the client, the nurse must find out details and inform the client's family. - The nurse should not avoid the situation by asking the relatives to speak to the primary healthcare provider.

The registered nurse instructed the nursing student to care for a client who suffers from depression. During a follow up visit, the registered nurse finds that the client's symptoms have not improved. Which activity of the nursing student would the registered nurse relate this to? 1 Modifying the environment 2 Limiting the client's choices of diet and clothing 3 Encouraging fluid intake 4 Discouraging social interaction to avoid the client's distraction from outside environment

4 Discouraging social interaction to avoid the client's distraction from outside environment The nursing student's act of discouraging interactions due to fear of the client's distraction may result in a lack of improvement. Social interactions should be encouraged instead. - Modifying the environment may help to provide better healthcare. - The nurse should limit the client's choices of food and clothing to relieve any decision-making stress. - The nurse should also encourage fluid intake.

The spouse of a comatose client who has severe internal bleeding refuses to allow transfusions of whole blood because they are Jehovah's Witnesses. The client does not have a Durable Power of Attorney for Healthcare. What action should the nurse take? 1 Institute the prescribed blood transfusion because the client's survival depends on volume replacement. 2 Clarify the reason why the transfusion is necessary and explain the implications if there is no transfusion. 3 Phone the primary healthcare provider for an administrative prescription to give the transfusion under these circumstances. 4 Give the spouse a treatment refusal form to sign and notify the primary healthcare provider that a court order now can be sought.

4 Give the spouse a treatment refusal form to sign and notify the primary healthcare provider that a court order now can be sought. The client is unconscious. Although the spouse can give consent, there is no legal power to refuse a treatment for the client unless previously authorized to do so by a power of attorney or a healthcare proxy; the court can make a decision for the client. Explanations will not be effective at this time and will not meet the client's needs. Instituting the prescribed blood transfusion and phoning the primary healthcare provider for an administrative prescription are without legal basis, and the nurse may be held liable.

Which nursing action indicates that the nurse is actively listening to the client? 1 The nurse states his or her own opinions when the client is speaking. 2 The nurse refrains from telling his or her own story to the client. 3 The nurse reads the client's health record during the conversation. 4 The nurse interprets what the client is saying and reiterates in his or her own words.

4 The nurse interprets what the client is saying and reiterates in his or her own words. The nurse is listening actively if he or she is able to take in what the client says. A nurse who is listens attentively interprets and reiterates what the client is saying in his or her own words.

A nurse is assessing a child who is accompanied by a parent. The parent has remarried and has another child from the second marriage. What kind of a family does this child belong to? 1 Blended family 2 Extended family 3 Alternative family 4 Single-parent family

1 Blended family The child belongs to a blended family. Such a family is formed when parents bring unrelated children from prior relationships into a new, joint living situation. - Extended family comprises the husband, wife, children, uncles, aunts, cousins, and grandparents. - An alternative family may have grandparents caring for grandchildren. It may also be a multi-adult household with cohabiting partners or homosexual couples. - A single-parent family is formed when one parent cares for the children following the death, divorce, or desertion of the other parent. A single person may also decide to have or adopt a child.

Which action made by the client indicates that they are in the precontemplation stage of Transtheoretical Model of Change? 1 Refuses to think about changing 2 Intends to change in the next 60 days 3 Sustains the changed action for 6 months 4 Recognizes the advantages of the change

1 Refuses to think about changing

A client is to receive a transfusion of packed red blood cells (PRBCs). The nurse should prepare for the transfusion by priming the blood IV tubing with which solution? 1 Lactated Ringer solution 2 5% dextrose and water 3 0.9% normal saline 4 0.45% normal saline

3 0/9% normal saline Blood and blood products for transfusion should be infused/diluted only with 0.9% normal saline solution. Solutions other than normal saline are incompatible and may cause RBC destruction by hemolysis.

While assessing an older adult, the nurse observes visual impairment in the client. Which technique should the nurse use to communicate? 1 Face the caregiver while speaking 2 Provide bright, diffuse, glare lighting 3 Stand or sit far away from the client while remaining in the client's full view 4 Encourage the older adult to use assistive devices such as glasses

4 Encourage the older adult to use assistive devices such as glasses If an older adult has visual impairment, the nurse should encourage the older adult to use assistive devices such as glasses. The nurse should face the older adult while speaking and should not cover his or her mouth. The light should be bright and non-glaring so that the older adult can see properly. The nurse should stand or sit closely in front of the client in full view so that the client is able to identify.

A nurse is reviewing the laboratory report of a client with kidney problems. When ammonia is excreted by healthy kidneys, what mechanism usually is maintained? 1 Osmotic pressure of the blood 2 Acid-base balance of the body 3 Low bacterial levels in the urine 4 Normal red blood cell production

2 Acid-base balance of the body The excreted ammonia combines with hydrogen ions in the glomerular filtrate to form ammonium ions, which are excreted from the body. This mechanism helps rid the body of excess hydrogen, maintaining acid-base balance. - Osmotic pressure of the blood and normal red blood cell production are not affected by excretion of ammonia. - Ammonia is formed by the decomposition of bacteria in the urine; ammonia excretion is not related to the process and does not control bacterial levels

What is a characteristic of the primary nursing model? 1 Care can be delegated. 2 Care is provided by the registered nurse to the client during a stay in a facility. 3 The registered nurse is responsible for all aspects of care for one or more clients during a shift of care. 4 The registered nurse leads a team of other registered nurses, practical nurses, and unlicensed assistive personnel.

2 Care is provided by the registered nurse to the client during a stay in a facility.

What would be the behavioral characteristic of a slow-to-warm up child according to the theory related to temperament? 1 Highly active 2 Irritable and irregular in habits 3 Negative reaction to new stimuli 4 A positive mild-to-moderately intense mood

3 Negative reaction to new stimuli

Nursing actions for an older adult should include health education and promotion of self-care. Which is most important when working with an older adult client? 1 Encouraging frequent naps 2 Strengthening the concept of ageism 3 Reinforcing the client's strengths and promoting reminiscing 4 Teaching the client to increase calories and focusing on a high-carbohydrate diet

3 Reinforcing the client's strengths and promoting reminiscing Reinforcing strengths promotes self-esteem; reminiscing is a therapeutic tool that provides a life review that assists adaptation and helps achieve the task of integrity associated with older adulthood. - Frequent naps may interfere with adequate sleep at night. - Reinforcing ageism may enhance devaluation of the older adult. - A well-balanced diet that includes protein and fiber should be encouraged; increasing calories may cause obesity.

The nurse is teaching a client about safe insulin administration. Which statement made by the client indicates the need for further education? 1 "I should see whether the insulin is expired." 2 "I should keep a daily logbook of times of insulin injection." 3 "I should keep my medication in its original labeled container." 4 "I should administer insulin only if there are any symptoms."

4 "I should administer insulin only if there are any symptoms."

A client is undergoing radiation therapy. The nurse reassures the client and stays with the client throughout the therapy. Which caring behavior does this nursing action reflect? 1 Touch 2 Spiritual caring 3 Knowing the client 4 Providing presence

4 Providing presence The nursing action of providing reassurance and being with the client reflects the caring behavior "providing presence." Providing presence conveys closeness and a sense of caring.

Which nursing activities are examples of primary prevention? Select all that apply. 1 Preventing disabilities 2 Correcting dietary deficiencies 3 Establishing goals for rehabilitation 4 Assisting with immunization programs 5 Facilitating a program about dangers of smoking

4, 5 Assisting with immunization programs Facilitating a program about dangers of smoking - Preventing disabilities - tertiary - Correcting dietary deficiencies - secondary - Establishing goals for rehabilitation - tertiary

On the second day of hospitalization a client is discussing with the nurse concerns about unhealthy family relationships. During the nurse-client interaction the client begins to talk about a job problem. The nurse's response is, "Let's go back to what we were just talking about." What therapeutic communication technique did the nurse use? 1 Focusing 2 Restating 3 Exploring 4 Accepting

1 Focusing Focusing is a technique that directs a client back to the original topic of discussion. - Restating the main idea of what the client has said encourages the client to continue speaking or clarifies what has been said. - Exploring permits the nurse to delve deeper into the subject when the client tends to stay on a superficial level. - Accepting is a technique used to understand and demonstrate regard for what the client stated.

Which physiologic changes may occur during the first trimester of pregnancy? Select all that apply. 1 Fatigue 2 Increased libido 3 Morning sickness 4 Breast enlargement 5 Braxton Hicks contractions

1, 3, 4 Fatigue, morning sickness, and breast enlargement are observed during the first trimester of pregnancy. - Increased libido is observed during the second trimester of pregnancy. - Braxton Hicks contractions are observed during the third trimester of pregnancy.

A nurse provides discharge teaching related to intermittent urinary self-catheterization to a client with a new spinal cord injury. Which instruction is most important for the nurse to include? 1 "Wear sterile gloves when doing the procedure." 2 "Wash your hands before performing the procedure." 3 "Perform the self-catheterization every 12 hours." 4 "Dispose of the catheter after you have catheterized yourself."

2 "Wash your hands before performing the procedure." To prevent transferring organisms to the urinary system, the client is taught to wash his or her hands thoroughly with soap and water before inserting a clean catheter. - Sterile gloves are not required for this procedure in the home care setting. - Every 12 hours is too long of a time frame between catheterizations. The client should be taught to recognize when self-catheterization is needed and develop a 2- to 3-hour catheterization schedule. - Some home care settings may require the client to clean and re-use catheters.

A client has a right-above-the-knee amputation after trauma sustained in a work-related accident. Upon awakening from surgery, the client states, "What happened to me? I don't remember a thing." What is the nurse's best response? 1 "Tell me what you think happened." 2 "You will remember more as you get better." 3 "You were in a work-related accident this morning." 4 "It was necessary to amputate your leg after the accident."

3 "You were in a work-related accident this morning."

A nurse reviews the medical record of a client with ascites. Which client condition may be contributing to the development of ascites? 1 Portal hypotension 2 Kidney malfunction 3 Diminished plasma protein level 4 Decreased production of potassium

3 Diminished plasma protein level The liver manufactures albumin, the major plasma protein. A deficiency of this protein lowers the osmotic (oncotic) pressure in the intravascular space, leading to a fluid shift. -An enlarged liver compresses the portal system, causing increased, rather than decreased, pressure. - The kidneys are not the primary source of the pathologic condition. - It is the liver's ability to manufacture albumin that maintains the colloid oncotic pressure. - Potassium is not produced by the body, nor is its major function the maintenance of fluid balance.

Which action of the nurse would be most important to convey interest in starting a conversation with a client who has hearing loss? 1 Smiling while seeing the client 2 Nodding head in front of the client 3 Making eye contact with the client 4 Leaning forward towards the client

3 Making eye contact with the client The nurse should make eye contact with the client to show interest in starting a conversation with a client with hearing loss. - Smiling while seeing the client would help to build a positive relationship. - Nodding in front of the client helps to regulate the conversation. - Leaning forward towards the client shows attention and awareness.

A weak, dyspneic, terminally ill client is visited frequently by the spouse and teenage children. What should the client's plan of care include? 1 Foster self-activity whenever possible. 2 Plan care to be completed at one time followed by a long rest. 3 Teach family members how to assist with the client's basic care. 4 Limit visiting to evening hours before the client goes to sleep.

3 Teach family members how to assist with the client's basic care.

The nurse receives information about a client through another nurse. The nurse then finds that information has some missing facts. Which critical thinking attitude would the nurse use to clarify the information after talking to the client directly? 1 Fairness 2 Humility 3 Discipline 4 Perseverance

4 Perserverance Perseverance requires the nurse to be cautious of an easy answer. If the nurse clarifies some information after talking to the client directly, he or she demonstrates perseverance. - Fairness requires the nurse to listen to both the sides in any discussion. - Humility is associated with recognizing the need for more information for making a decision. - When the nurse is thoroughly aware of what is required and manages his or her time effectively, he or she uses discipline.