Fundamentals NCLEX 4 Questions

An assistive personnel (AP) is caring for a client who has an indwelling urinary catheter. Which action by the AP would indicate the need for further instruction in the care of the client?

Allowed the drainage tubing to rest under the leg

The nurse is caring for a client with acute viral hepatitis A who resides in a group home. Which outcome indicates that the most important goal has been achieved?

Avoids transmitting the virus to others in the group home

The nurse identifies a potential for infection in a patient with partial-thickness (second-degree) and full-thickness (third-degree) burns. What intervention has the highest priority in decreasing the client's risk of infection?

Careful hand washing technique (B) is the single most effective intervention for the prevention of contamination to all clients. (A) reverses the hypovolemia that initially accompanies burn trauma but is not related to decreasing the proliferation of infective organisms. (C and D) are recommended by various burn centers as possible ways to reduce the chance of infection. (B) is a proven technique to prevent infection.

The nurse is preparing an intravenous (IV) solution and tubing for a client who requires IV fluids. While preparing to prime the tubing, the tubing drops and hits the top of the medication cart. The nurse should plan to take which action?

Change the IV tubing. Rationale: The nurse should change the IV tubing. The tubing has become contaminated, and, if used, it could result in a systemic infection in the client. Wiping or scrubbing the tubing is insufficient to prevent systemic infection.

A 20-year-old female client with a noticeable body odor has refused to shower for the last 3 days. She states, "I have been told that it is harmful to bathe during my period." Which action should the nurse take first?

Teach the importance of personal hygiene during menstruation with the client.

The nurse is providing care to clients at a day treatment center. One of the clients who is usually talkative and eats well is now confused and did not eat lunch. The nurse learns these are new findings as of today. What are the next nursing actions?

Assess for the initiation of any new medications Obtain an oxygen saturation Take the client's vital signs Obtain a clean catch urine sample

When performing sterile wound care in the acute care setting, the nurse obtains a bottle of normal saline from the bedside table that is labeled "opened" and dated 48 hours prior to the current date. Which is the best action for the nurse to take?

Discard the saline solution and obtain a new unopened bottle

The nurse is working with one LPN and two aides on a 20-bed unit. Which are the appropriate tasks to delegate to the appropriate person?

Feeding an elderly and confused client to the aide Reinforcing the discharge teaching instructions to the LPN Administering a PO pain medication to the LPN Performing the routine dressing change 5 days after surgery to the LPN There are 5 rights of delegation: the right task, circumstances, person, direction, and supervision. The aide can perform routine tasks, the LPN can deliver skilled care, the RN performs the assessment and does the teaching. Toileting the client for the first time requires the assessment of the RN. The bathroom supplies can be delegated to the aide. The remaining selections are appropriate. The LPN can reinforce teaching; the initial teaching must be done by the RN.

The nurse is preparing a plan of care for a client with a diagnosis of agranulocytosis who is being admitted to the hospital. The nurse determines that which is the priority when formulating the client's plan of care?

Potential for infection Agranulocytosis is characterized by a reduced number of leukocytes (leukopenia) and neutrophils (neutropenia) in the blood. The client is at high risk for infection because of the decreased body defenses against microorganisms. Insufficient knowledge related to the nature of the disorder and the prevention of complications may be appropriate, but it is not the priority. Similarly, fatigue and constipation may be a concern for the client with agranulocytosis, but the priority problem relates specifically to infection.

The nurse is planning discharge teaching for a client newly diagnosed with chronic kidney disease (CKD). Which factor will enhance the educational process?

Presence of family

The nurse is setting up a sterile field for a chest tube insertion. What is an important intervention in maintaining sterile asepsis with the field?

Prevent moisture from clean area coming in contact with the sterile field because it will carry organisms into the sterile field

The nurse observes a nursing assistant using antiseptic hand rub and rubbing the hands vigorously after leaving the room of a client diagnosed with Clostridium difficile. Which action is most appropriate by the nurse?

Require the nursing assistant to wash hands again with soap and water

A client becomes angry while waiting for a supervised break to smoke a cigarette outside and states, "I want to go outside now and smoke. It takes forever to get anything done here!" Which nursing action is best for this client?

Review the schedule of outdoor breaks with the client

The nurse is evaluating measures implemented for the non-responsive client. Which findings indicate the effectiveness of the care delivered?

Skin intact on the back Heals without redness bilaterally Elbow joint fully flexes and extends Ankle joint rotates 360 degrees freely The footboard helps prevent foot drop, but does not measure the effectiveness of the treatment. The sheepskin booties are in place to protect the heal, but they do not demonstrate the effectiveness. The remaining are assessments that demonstrate the interventions are effective.

1. The home health nurse is watching the caregiver change the sternotomy dressing on the postoperative client. Which action by the caregiver identifies correct principles of infection control?

The caregiver washes hands before removal of the soiled dressing and again before applying the clean dressing.

The nurse notes that an older client with dementia is unable to care for self to bathe and perform other activities of daily living (ADL). Which is an appropriate goal for this client?

The client will function at the highest level of independence possible

A client with tuberculosis (TB) asks the nurse about precautions to take after discharge to prevent infection of others. The nurse develops a response to the client's question based on which correct understanding of TB transmission?

The disease is transmitted by droplet nuclei

The nurse is giving a bed bath to a client and discovers that an additional washcloth and towel are needed. Which is the most appropriate action to take to obtain the needed items?

Wash hands, leave the client's room, and obtain the needed items.

An older adult who recently began self-administration of insulin calls the nurse daily to review the steps that should be taken when giving an injection. The nurse has assessed the client's skills during two previous office visits and knows that the client safely administered the injections. What is the nurse's best response?

When I watched you give yourself the injection, you did it correctly."

The nurse provides home care instructions to a client with hepatitis B. Which statement made by the client indicates the best understanding of how to prevent transmission of the disease?

Wife should get the vaccine