NCLEX-RN Practice: Fundamental Skills

While assessing the pupils of a client, a health care professional notices pupillary dilatation. Which drug would have resulted in this condition? 1. Heroin 2. Atropine 3. Morphine 4. Pilocarpine

Atropine Note: The intake of eye medications such as atropine will cause dilatation of the pupils.

Reminiscence

recalling the past

Which psychosocial health concern involves accepting descriptive statements stated by a confused older client? 1. Validation Therapy 2. Reminiscence 3. Reality Orientation 4. Therapeutic Communication

Validation Therapy

Ectropion

a condition in which the eyelid is turned outward away from the eyeball.

Entropion

a malposition resulting in an inversion of the eyelid margin.

Objective data

observations or measurements of a client's health status. I.e. weight or height.

Which parts of the body assessed by the nurse would confirm a diagnosis of frostbite? Select all that apply. 1. Axilla 2. Fingers 3. Forehead 4. Ear lobes 5. Upper Thorax

Fingers and Ear lobes. Note:Areas particularly susceptible to frostbite are the fingers, toes, and earlobes. These parts of the body should be assessed to determine frostbite.

Which term refers to a blowing sound created by turbulence caused by narrowing of arteries while assessing for carotid pulse? 1. Bruit 2. Ectropion 3. Entropion 4. Borborygmi

Bruit

Which piece of equipment must the nurse ensure remains sterile during care of the client? 1. Bedpan 2. Stethoscope 3. Suction catheter 4. Blood pressure cuff

Suction catheter

Which intellectual factor would the nurse consider as a dimension when gathering data for a client's health history? 1. Attention Span 2. Primary Language 3. Coping Mechanism 4. Activity and Coordination

Attention Span Note:Attention span is an intellectual dimension used to gather data for a health history. The social dimension for gathering the health history includes primary language. A coping mechanism is considered to be a social subdimension used to gather a client's health history data. Physical and developmental subdimensions would include activities and coordination.

A client with a diagnosis of malabsorption syndrome exhibits a symptom of spastic muscle spasms. Which electrolyte is responsible for this symptom? 1. Sodium 2. Calcium 3. Potassium 4. Phosphorous

Calcium

Which factor would elevate the oxygen saturation during an assessment? 1. Nail Polish 2. Carbon Monoxide 3. Intravascular dyes 4. Skin pigmentation

Carbon monoxide Note:Carbon monoxide artificially elevates the oxygen saturation during assessment. Nail polishes interfere with the ability of the oximeter. Intravascular dyes will artificially lower the oxygen saturation. Skin pigmentation will overestimate the saturation.

Subjective data

information conveyed to the nurse by the client, such as the client's feelings, perceptions, and self-reporting of symptoms.

The nurse applies a cold pack to relieve musculoskeletal pain. Which rationale explains the analgesic properties of cold therapy? 1. Promoting analgesia and circulation 2. Numbing the nerves and dilating the blood vessels 3. Promoting circulation and reducing muscle spasms 4. Causing local vasoconstriction, preventing edema and muscle spasms

Causing local vasoconstriction, preventing edema and muscle spasms. Note: Cold causes the blood vessels to constrict, which reduces the leakage of fluid into the tissues and prevents swelling and muscle spasms. Cold therapy also may numb the nerves and surrounding tissues, thus reducing pain (analgesic).

The client reports difficulty in breathing. The nurse auscultates lung sounds and assesses the respiratory rate. Which is the purpose of the nurse's action? 1. Data Collection 2. Data Validation 3. Data Clustering 4. Data Interpretation

Data Collection Note: The nurse is gathering objective data during an assessment to support the subjective data reported by the client.

Which nonpharmacological nursing intervention is effective in helping relieve postoperative pain? 1. Ambulation 2. Repositioning 3. Purse-lipped breathing 4. Deep breathing and coughing

Repositioning Note: Acute postoperative pain always requires the use of analgesics, but nonpharmacological interventions such as repositioning the client can help relieve pain.

R. A. C. E.

Rescue: Remove patients from immediate danger Activate: Activate the fire alarm Contain: Confine the fire by closing doors and windows Extinguish: Put out the fire with an appropriate extinguisher

The nurse is assessing a client who had knee replacement surgery. Which assessment finding gathered by the nurse is an example of subjective data? 1. The client weighs 151 lbs (68.5 Kg). 2. The client's pain is 7 on a scale of 1 to 10. 3. The client's fasting blood sugar is 95 mg/dL. 4. The client's blood pressure is 140/90 mm Hg.

The client's pain is 7 on a scale of 1 to 10.

A client has been placing used insulin needles in a container sealed with heavy-duty tape. Where would the nurse tell the client to dispose of the container? 1. The local hazardous waste collection site 2. The regular household trash 3. The local health department for disposal 4. The Environmental Protection Agency (EPA) through the mail

The local hazardous waste collection site Note: Each state (province) has its own waste management guidelines for proper disposal of sharps containers, as well as hazardous waste collection sites.

Bruit

an audible vascular blowing sound associated with turbulent blood flow through a carotid artery

Therapeutic Communication

enables the nurse to perceive and respect the older client's uniqueness and health care expectations

Reality Orientation

helping a confused older client agree with the nurse's statements

Borborygmi

rumbling or gurgling noises made by the movement of fluid and gas in the intestines.

Validation Therapy

the psychosocial concern involved in accepting the descriptive statements made by a confused older client.

Which pulse site is used to perform Allen Test? 1. Ulnar 2. Brachial 3. Femoral 4. Dorsalis Pedis

ulnar