NCLEX Practice Exam for Foundation of Nursing

1. The most important nursing intervention to correct skin dryness is:

  1. Avoid bathing the patient until the condition is remedied, and notify the physician
  2. Ask the physician to refer the patient to a dermatologist, and suggest that the patient wear home-laundered sleepwear
  3. Consult the dietitian about increasing the patient’s fat intake, and take necessary measures to prevent infection
  4. Encourage the patient to increase his fluid intake, use nonirritating soap when bathing the patient, and apply lotion to the involved areas

2. When bathing a patient’s extremities, the nurse should use long, firm strokes from the distal to the proximal areas. This technique:

  1. Provides an opportunity for skin assessment
  2. Avoids undue strain on the nurse
  3. Increases venous blood return
  4. Causes vasoconstriction and increases circulation

3. Vivid dreaming occurs in which stage of sleep?

  1. Stage I non-REM
  2. Rapid eye movement (REM) stage
  3. Stage II non-REM
  4. Delta stage

4. The natural sedative in meat and milk products (especially warm milk) that can help induce sleep is:

  1. Flurazepam
  2. Temazepam
  3. Tryptophan
  4. Methotrimeprazine

5. Nursing interventions that can help the patient to relax and sleep restfully include all of the following except:

  1. Have the patient take a 30- to 60-minute nap in the afternoon
  2. Turn on the television in the patient’s room
  3. Provide quiet music and interesting reading material
  4. Massage the patient’s back with long strokes

6. Restraints can be used for all of the following purposes except to:

  1. Prevent a confused patient from removing tubes, such as feeding tubes, I.V. lines, and urinary catheters
  2. Prevent a patient from falling out of bed or a chair
  3. Discourage a patient from attempting to ambulate alone when he requires assistance for his safety
  4. Prevent a patient from becoming confused or disoriented

7. Which of the following is the nurse’s legal responsibility when applying restraints?

  1. Document the patient’s behavior
  2. Document the type of restraint used
  3. Obtain a written order from the physician except in an emergency, when the patient must be protected from injury to himself or others
  4. All of the above

8. Kubler-Ross’s five successive stages of death and dying are:

  1. Anger, bargaining, denial, depression, acceptance
  2. Denial, anger, depression, bargaining, acceptance
  3. Denial, anger, bargaining, depression acceptance
  4. Bargaining, denial, anger, depression, acceptance

9. A terminally ill patient usually experiences all of the following feelings during the anger stage except:

  1. Rage
  2. Envy
  3. Numbness
  4. Resentment

10. Nurses and other health care provides often have difficulty helping a terminally ill patient through the necessary stages leading to acceptance of death. Which of the following strategies is most helpful to the nurse in achieving this goal?

  1. Taking psychology courses related to gerontology
  2. Reading books and other literature on the subject of thanatology
  3. Reflecting on the significance of death
  4. Reviewing varying cultural beliefs and practices related to death

11. Which of the following symptoms is the best indicator of imminent death?

  1. A weak, slow pulse
  2. Increased muscle tone
  3. Fixed, dilated pupils
  4. Slow, shallow respirations

12. A nurse caring for a patient with an infectious disease who requires isolation should refers to guidelines published by the:

  1. National League for Nursing (NLN)
  2. Centers for Disease Control (CDC)
  3. American Medical Association (AMA)
  4. American Nurses Association (ANA)

13. To institute appropriate isolation precautions, the nurse must first know the:

  1. Organism’s mode of transmission
  2. Organism’s Gram-staining characteristics
  3. Organism’s susceptibility to antibiotics
  4. Patient’s susceptibility to the organism

14. Which is the correct procedure for collecting a sputum specimen for culture and sensitivity testing?

  1. Have the patient place the specimen in a container and enclose the container in a plastic bag
  2. Have the patient expectorate the sputum while the nurse holds the container
  3. Have the patient expectorate the sputum into a sterile container
  4. Offer the patient an antiseptic mouthwash just before he expectorate the sputum

15. An autoclave is used to sterilize hospital supplies because:

  1. More articles can be sterilized at a time
  2. Steam causes less damage to the materials
  3. A lower temperature can be obtained
  4. Pressurized steam penetrates the supplies better

16. The best way to decrease the risk of transferring pathogens to a patient when removing contaminated gloves is to:

  1. Wash the gloves before removing them
  2. Gently pull on the fingers of the gloves when removing them
  3. Gently pull just below the cuff and invert the gloves when removing them
  4. Remove the gloves and then turn them inside out

17. After having an I.V. line in place for 72 hours, a patient complains of tenderness, burning, and swelling. Assessment of the I.V. site reveals that it is warm and erythematons. This usually indicates:

  1. Infection
  2. Infiltration
  3. Phlebitis
  4. Bleeding

18. To ensure homogenization when diluting powdered medication in a vial, the nurse should:

  1. Shake the vial vigorously
  2. Roll the vial gently between the palms
  3. Invert the vial and let it stand for 1 minute
  4. Do nothing after adding the solution to the vial

19. The nurse is teaching a patient to prepare a syringe with 40 units of U-100 NPH insulin for self-injection. The patient’s first priority concerning self-injection in this situation is to:

  1. Assess the injection site
  2. Select the appropriate injection site
  3. Check the syringe to verify that the nurse has removed the prescribed insulin dose
  4. Clean the injection site in a circular manner with and alcohol sponge

20. The physician’s order reads “Administer 1 g cefazolin sodium (Ancef) in 150 ml of normal saline solution in 60 minutes.” What is the flow rate if the drop factor is 10 gtt = 1 ml?

  1. 25 gtt/minute
  2. 37 gtt/minute
  3. 50 gtt/minute
  4. 60 gtt/minute

21. A patient must receive 50 units of Humulin regular insulin. The label reads 100 units = 1 ml. How many milliliters should the nurse administer?

  1. 0.5 ml
  2. 0.75 ml
  3. 1 ml
  4. 2 ml

22. How should the nurse prepare an injection for a patient who takes both regular and NPH insulin?

  1. Draw up the NPH insulin, then the regular insulin, in the same syringe
  2. Draw up the regular insulin, then the NPH insulin, in the same syringe
  3. Use two separate syringe
  4. Check with the physician

23. A patient has just received 30 mg of codeine by mouth for pain. Five minutes later he vomits. What should the nurse do first?

  1. Call the physician
  2. Remedicate the patient
  3. Observe the emesis
  4. Explain to the patient that she can do nothing to help him

24. A patient is characterized with a #16 indwelling urinary (Foley) catheter to determine if:

  1. Trauma has occurred
  2. His 24-hour output is adequate
  3. He has a urinary tract infection
  4. Residual urine remains in the bladder after voiding

25. A staff nurse who is promoted to assistant nurse manager may feel uncomfortable initially when supervising her former peers. She can best decrease this discomfort by:

  1. Writing down all assignments
  2. Making changes after evaluating the situation and having discussions with the staff.
  3. Telling the staff nurses that she is making changes to benefit their performance
  4. Evaluating the clinical performance of each staff nurse in a private conference
Answers and Rationales
  1. Answer – D. Dry skin will eventually crack, ranking the patient more prone to infection. To prevent this, the nurse should provide adequate hydration through fluid intake, use nonirritating soaps or no soap when bathing the patient, and lubricate the patient’s skin with lotion. Bathing may be limited but need not be avoided entirely. The attending physician and dietitian may be consulted for treatment, but home-laundered items usually are not necessary.
  2. Answer – C. Washing from distal to proximal areas stimulates venous blood flow, thereby preventing venous stasis. It improves circulation but does not result in vasoconstriction. The nurse can assess the patient’s condition throughout the bath, regardless of washing technique, and should feel no strain while bathing the patient.
  3. Answer – B. Other characteristics of rapid eye movement (REM) sleep are deep sleep (the patient cannot be awakened easily), depressed muscle tone, and possibly irregular heart and respiratory rates. Non-REM sleep is a deep, restful sleep without dreaming. Delta stage, or slow-wave sleep, occurs during non-REM Stages III and IV and is often equated with quiet sleep.
  4. Answer – C. Tryptophan is a natural sedative; flurazepam (Dalmane), temazepam (Restoril), and methotrimeprazine (Levoprome) are hypnotic sedatives.
  5. Answer – A. Napping in the afternoon is not conductive to nighttime sleeping. Quiet music, watching television, reading, and massage usually will relax the patient, helping him to fall asleep.
  6. Answer – D. By restricting a patient’s movements, restraints may increase stress and lead to confusion, rather than prevent it. The other choices are valid reasons for using restraints.
  7. Answer – D. When applying restraints, the nurse must document the type of behavior that prompted her to use them, document the type of restraints used, and obtain a physician’s written order for the restraints.
  8. Answer – C. Kubler-Ross’s five successive stages of death and dying are denial, anger, bargaining, depression, and acceptance. The patient may move back and forth through the different stages as he and his family members react to the process of dying, but he usually goes through all of these stages to reach acceptance.
  9. Answer – C. Numbness is typical of the depression stage, when the patient feels a great sense of loss. The anger stage includes such feelings as rage, envy, resentment, and the patient’s questioning “Why me?”
  10. Answer – C. According to thanatologists, reflecting on the significance of death helps to reduce the fear of death and enables the health care provider to better understand the terminally ill patient’s feelings. It also helps to overcome the belief that medical and nursing measures have failed, when a patient cannot be cured.
  11. Answer – C. Fixed, dilated pupils are sign of imminent death. Pulse becomes weak but rapid, muscles become weak and atonic, and periods of apnea occur during respiration.
  12. Answer – B. The Center of Disease Control (CDC) publishes and frequently updates guidelines on caring for patients who require isolation. The National League of Nursing’s (NLN’s) major function is accrediting nursing education programs in the
    United States. The American Medical Association (AMA) is a national organization of physicians. The American Nurses’ Association (ANA) is a national organization of registered nurses.
  13. Answer – A. Before instituting isolation precaution, the nurse must first determine the organism’s mode of transmission. For example, an organism transmitted through nasal secretions requires that the patient be kept in respiratory isolation, which involves keeping the patient in a private room with the door closed and wearing a mask, a grown, and gloves when coming in direct contact with the patient. The organism’s Gram-straining characteristics reveal whether the organism is gram-negative or gram-positive, an important criterion in the physician’s choice for drug therapy and the nurse’s development of an effective plan of care. The nurse also needs to know whether the organism is susceptible to antibiotics, but this could take several days to determine; if she waits for the results before instituting isolation precautions, the organism could be transmitted in the meantime. The patient’s susceptibility to the organism has already been established. The nurse would not be instituting isolation precautions for a noninfected patient.
  14. Answer – C. Placing the specimen in a sterile container ensures that it will not become contaminated. The other answers are incorrect because they do not mention sterility and because antiseptic mouthwash could destroy the organism to be cultured (before sputum collection, the patient may use only tap water for nursing the mouth).
  15. Answer – D. An autoclave, an apparatus that sterilizes equipment by means of high-temperature pressured steam, is used because it can destroy all forms of microorganisms, including spores.
  16. Answer – C. Turning the gloves inside out while removing them keeps all contaminants inside the gloves. They should than be placed in a plastic bag with soiled dressings and discarded in a soiled utility room garbage pail (double bagged). The other choices can spread pathogens within the environment.
  17. Answer – C. Tenderness, warmth, swelling, and, in some instances, a burning sensation are signs and symptoms of phlebitis. Infection is less likely because no drainage or fever is present. Infiltration would result in swelling and pallor, not erythema, near the insertion site. The patient has no evidence of bleeding.
  18. Answer – B. Gently rolling a sealed vial between the palms produces sufficient heat to enhance dissolution of a powdered medication. Shaking the vial vigorously can break down the medication and alter its pharmacologic action. Inverting the vial or leaving it alone does not ensure thorough homogenization of the powder and the solvent.
  19. Answer – C. When the nurse teaches the patient to prepare an insulin injection, the patient’s first priority is to validate the dose accuracy. The next steps are to select the site, assess the site, and clean the site with alcohol before injecting the insulin.
  20. Answer – A. 25 gtt/minute
  21. Answer – A. 0.5 ml
  22. Answer – B. Drugs that are compatible may be mixed together in one syringe. In the case of insulin, the shorter-acting, clear insulin (regular) should be drawn up before the longer-acting, cloudy insulin (NPH) to ensure accurate measurements.
  23. Answer – C. After a patient has vomited, the nurse must inspect the emesis to document color, consistency, and amount. In this situation, the patient recently ingested medication, so the nurse needs to check for remnants of the medication to help determine whether the patient retained enough of it to be effective. The nurse must then notify the physician, who will decide whether to repeat the dose or prescribe an antiemetic.
  24. Answer – B. A 24-hour urine output of less than 500 ml in an adult is considered inadequate and may indicate kidney failure. This must be corrected while the patient is in the acute state so that appropriate fluids, electrolytes, and medications can be administered and excreted. Indwelling catheterization is not needed to diagnose trauma, urinary tract infection, or residual urine.
  25. Answer – B. A new assistant nurse manger should not make changes until she has had a chance to evaluate staff members, patients, and physicians. Changes must be planned thoroughly and should be based on a need to improve conditions, not just for the sake of change. Written assignments allow all staff members to know their own and others responsibilities and serve as a checklist for the manager, enabling her to gauge whether the unit is being run effectively and whether patients are receiving appropriate care. Telling the staff nurses that she is making changes to benefit their performance should occur only after the nurse has made a thorough evaluation. Evaluations are usually done on a yearly basis or as needed.