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NCLEX Practice Exam for Fundamentals of Nursing 1 (PM)
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Question 1
Before administering the evening dose of a prescribed medication, the nurse on the evening shift finds an unlabeled, filled syringe in the patient’s medication drawer. What should the nurse in charge do?
A
Use the syringe because it looks like it contains the same medication the nurse was prepared to give
B
Call the day nurse to verify the contents of the syringe
C
Discard the syringe to avoid a medication error
D
Obtain a label for the syringe from the pharmacy
Question 1 Explanation:
As a safety precaution, the nurse should discard an unlabeled syringe that contains medication. The other options are considered unsafe because they promote error.
Question 2
The nurse is assessing a postoperative adult patient. Which of the following should the nurse document as subjective data?
A
Patient’s description of pain
B
Electrocardiographic (ECG) waveforms
C
Laboratory test result
D
Vital signs
Question 2 Explanation:
Subjective data come directly from the patient and usually are recorded as direct quotations that reflect the patient’s opinions or feelings about a situation. Vital signs, laboratory test result, and ECG waveforms are examples of objective data.
Question 3
The doctor orders dextrose 5% in water, 1,000 ml to be infused over 8 hours. The I.V. tubing delivers 15 drops per milliliter. The nurse in charge should run the I.V. infusion at a rate of:
A
21 drop per minute
B
15 drop per minute
C
32 drop per minute
D
125 drops per minute
Question 3 Explanation:
Giving 1,000 ml over 8 hours is the same as giving 125 ml over 1 hour (60 minutes) to find the number of milliliters per minute:
125/60 min = X/1 minute
60X = 125X = 2.1 ml/minute
To find the number of drops/minute:
2.1 ml/X gtts = 1 ml/15 gtts
X = 32 gtts/minute, or 32 drops/minute
Question 4
A female patient exhibits signs of heightened anxiety. Which response by the nurse is most likely to reduce the patient’s anxiety?
A
“Let’s talk about what’s bothering you.”
B
“Read this manual and then ask me any questions you may have.”
C
“Everything will be fine. Don’t worry.”
D
“Why don’t you listen to the radio?”
Question 4 Explanation:
Anxiety may result from feeling of helplessness, isolation, or insecurity. This response helps reduce anxiety by encouraging the patient to express feelings. The nurse should be supportive and develop goals together with the patient to give the patient some control over an anxiety-inducing situation. Because the other options ignore the patient’s feeling and block communication, they would not reduce anxiety.
Question 5
When administering drug therapy to a male geriatric patient, the nurse must stay especially alert for adverse effects. Which factor makes geriatric patients to adverse drug effects?
A
Increased amount of neurons
B
Aging-related physiological changes
C
Enhanced blood flow to the GI tract
D
Faster drug clearance
Question 5 Explanation:
Aging-related physiological changes account for the increased frequency of adverse drug reactions in geriatric patients. Renal and hepatic changes cause drugs to clear more slowly in these patients. With increasing age, neurons are lost and blood flow to the GI tract decreases.
Question 6
A male patient is to be discharged with a prescription for an analgesic that is a controlled substance. During discharge teaching, the nurse should explain that the patient must fill this prescription how soon after the date on which it was written?
A
Within 12 months
B
Within 1 month
C
Within 6 months
D
Within 3 months
Question 6 Explanation:
In most cases, an outpatient must fill a prescription for a controlled substance within 6 months of the date on which the prescription was written.
Question 7
The physician orders heparin, 7,500 units, to be administered subcutaneously every 6 hours. The vial reads 10,000 units per milliliter. The nurse should
anticipate giving how much heparin for each dose?
A
½ ml
B
¾ ml
C
1 ¼ ml
D
¼ ml
Question 7 Explanation:
The nurse solves the problem as follows:
10,000 units/7,500 units = 1 ml/X
10,000 X = 7,500
X= 7,500/10,000 or ¾ ml
Question 8
Which human element considered by the nurse in charge during assessment can affect drug administration?
A
The patient’s occupational hazards
B
The patient’s socioeconomic status
C
The patient’s ability to recover
D
The patient’s cognitive abilities
Question 8 Explanation:
The nurse must consider the patient’s cognitive abilities to understand drug instructions. If not, the nurse must find a family member or significant other to take on the responsibility of administering medications in the home setting. The patient’s ability to recover, occupational hazards, and socioeconomic status do not affect drug administration
Question 9
The physician prescribes 250 mg of a drug. The drug vial reads 500 mg/ml. how much of the drug should the nurse give?
A
1 ml
B
½ ml
C
¼ ml
D
2 ml
Question 9 Explanation:
The nurse should give ½ ml of the drug. The dosage is calculated as follows:
250 mg/X=500 mg/1 ml
500x=250
X=1/2 ml
Question 10
Which nursing action is essential when providing continuous enteral feeding?
A
Warming the formula before administering it
B
Positioning the patient on the left side
C
Hanging a full day’s worth of formula at one time
D
Elevating the head of the bed
Question 10 Explanation:
Elevating the head of the bed during enteral feeding minimizes the risk of aspiration and allows the formula to flow in the patient’s intestines. When such elevation is contraindicated, the patient should be positioned on the right side. The nurse should give enteral feeding at room temperature to minimize GI distress. To limit microbial growth, the nurse should hang only the amount of formula that can be infused in 3 hours.
Question 11
What does the nurse in charge do when making a surgical bed?
A
Rolls the patient to the far side of the bed
B
Leaves the bed in the high position when finished
C
Places the pillow at the head of the bed
D
Tucks the top sheet and blanket under the bottom of the bed
Question 11 Explanation:
When making a surgical bed, the nurse leaves the bed in the high position when finished. After placing the top linens on the bed without pouching them, the nurse fanfolds these linens to the side opposite from where the patient will enter and places the pillow on the bedside chair. All these actions promote transfer of the postoperative patient from the stretcher to the bed. When making an occupied bed or unoccupied bed, the nurse places the pillow at the head of the bed and tucks the top sheet and blanket under the bottom of the bed. When making an occupied bed, the nurse rolls the patient to the far side of the bed.
Question 12
A patient is in the bathroom when the nurse enters to give a prescribed medication. What should the nurse in charge do?
A
Return shortly to the patient’s room and remain there until the patient takes the medication
B
Leave the medication at the patient’s bedside
C
Wait for the patient to return to bed, and then leave the medication at the bedside
D
Tell the patient to be sure to take the medication. And then leave it at the bedside
Question 12 Explanation:
The nurse should return shortly to the patient’s room and remain there until the patient takes the medication to verify that it was taken as directed. The nurse should never leave medication at the patient’s bedside unless specifically requested to do so.
Question 13
The nurse in charge is transferring a patient from the bed to a chair. Which action does the nurse take during this patient transfer?
A
Stands behind the patient
B
Places the chair facing away from the bed
C
Position the head of the bed flat
D
Helps the patient dangle the legs
Question 13 Explanation:
After placing the patient in high Fowler’s position and moving the patient to the side of the bed, the nurse helps the patient sit on the edge of the bed and dangle the legs; the nurse then faces the patient and places the chair next to and facing the head of the bed.
Question 14
When examining a patient with abdominal pain the nurse in charge should assess:
A
Any quadrant first
B
The symptomatic quadrant either second or third
C
The symptomatic quadrant last
D
The symptomatic quadrant first
Question 14 Explanation:
The nurse should systematically assess all areas of the abdomen, if time and the patient’s condition permit, concluding with the symptomatic area. Otherwise, the nurse may elicit pain in the symptomatic area, causing the muscles in other areas to tighten. This would interfere with further assessment.
Question 15
A male patient has a soft wrist-safety device. Which assessment finding should the nurse consider abnormal?
A
Cool, pale fingers
B
A palpable radial pulse
C
A palpable ulnar pulse
D
Pink nail beds
Question 15 Explanation:
A safety device on the wrist may impair circulation and restrict blood supply to body tissues. Therefore, the nurse should assess the patient for signs of impaired circulation, such as cool, pale fingers. A palpable radial or lunar pulse and pink nail beds are normal findings.
Question 16
Which action by the nurse in charge is essential when cleaning the area around a Jackson-Pratt wound drain?
A
Cleaning from the center outward in a circular motion
B
Wearing sterile gloves and a mask
C
Cleaning briskly around the site with alcohol
D
Removing the drain before cleaning the skin
Question 16 Explanation:
The nurse always should clean around a wound drain, moving from center outward in ever-larger circles, because the skin near the drain site is more contaminated than the site itself. The nurse should never remove the drain before cleaning the skin. Alcohol should never be used to clean around a drain; it may irritate the skin and has no lasting effect on bacteria because it evaporates. The nurse should wear sterile gloves to prevent contamination, but a mask is not necessary.
Question 17
Nurse Brenda is teaching a patient about a newly prescribed drug. What could cause a geriatric patient to have difficulty retaining knowledge about prescribed medications?
A
History of Tourette syndrome
B
Lack of family support
C
Decreased plasma drug levels
D
Sensory deficits
Question 17 Explanation:
Sensory deficits could cause a geriatric patient to have difficulty retaining knowledge about prescribed medications. Decreased plasma drug levels do not alter the patient’s knowledge about the drug. A lack of family support may affect compliance, not knowledge retention. Toilette syndrome is unrelated to knowledge retention.
Question 18
A male patient undergoes a total abdominal hysterectomy. When assessing the patient 10 hours later, the nurse identifies which finding as an early sign of shock?
A
Pale, warm, dry skin
B
Heart rate of 110 beats/minute
C
Urine output of 30 ml/hour
D
Restlessness
Question 18 Explanation:
Early in shock, hyperactivity of the sympathetic nervous system causes increased epinephrine secretion, which typically makes the patient restless, anxious, nervous, and irritable. It also decreases tissue perfusion to the skin, causing pale, cool clammy skin. An above-normal heart rate is a late sign of shock. A urine output of 30 ml/hour is within normal limits.
Question 19
The nurse uses a stethoscope to auscultate a male patient’s chest. Which statement about a stethoscope with a bell and diaphragm is true?
A
The bell detects high-pitched sounds best
B
The diaphragm detects high-pitched sounds best
C
The bell detects thrills best
D
The diaphragm detects low-pitched sounds best
Question 19 Explanation:
The diaphragm of a stethoscope detects high-pitched sound best; the bell detects low pitched sounds best. Palpation detects thrills best.
Question 20
An employer establishes a physical exercise area in the workplace and encourages all employees to use it. This is an example of which level of health promotion?
A
Secondary prevention
B
Tertiary prevention
C
Passive prevention
D
Primary prevention
Question 20 Explanation:
Primary prevention precedes disease and applies to health patients. Secondary prevention focuses on patients who have health problems and are at risk for developing complications. Tertiary prevention enables patients to gain health from others’ activities without doing anything themselves
Question 21
Which of the following planes divides the body longitudinally into anterior and posterior regions?
A
Sagittal plane
B
Frontal plane
C
Midsagittal plane
D
Transverse plane
Question 21 Explanation:
Frontal or coronal plane runs longitudinally at a right angle to a sagittal plane dividing the body in anterior and posterior regions. A sagittal plane runs longitudinally dividing the body into right and left regions; if exactly midline, it is called a midsagittal plane. A transverse plane runs horizontally at a right angle to the vertical axis, dividing the structure into superior and inferior regions.
Question 22
The nurse in charge measures a patient’s temperature at 102 degrees F. what is the equivalent Centigrade temperature?
A
39 degrees C
B
40.1 degrees C
C
47 degrees C
D
38.9 degrees C
Question 22 Explanation:
To convert Fahrenheit degrees to centigrade, use this formula:
C degrees = (F degrees – 32) x 5/9
C degrees = (102 – 32) 5/9
+ 70 x 5/9
38.9 degrees C
Question 23
Nurse Mackey is monitoring a patient for adverse reactions during barbiturate therapy. What is the major disadvantage of barbiturate use?
A
Prolonged half-life
B
Potential for drug dependence
C
Poor absorption
D
Potential for hepatotoxicity
Question 23 Explanation:
Patients can become dependent on barbiturates, especially with prolonged use. Because of the rapid distribution of some barbiturates, no correlation exists between duration of action and half-life. Barbiturates are absorbed well and do not cause hepatotoxicity, although existing hepatic damage does require cautions use of the drug because barbiturates are metabolized in the liver.
Question 24
A scrub nurse in the operating room has which responsibility?
A
Assisting with gowning and gloving
B
Positioning the patient
C
Applying surgical drapes
D
Handling surgical instruments to the surgeon
Question 24 Explanation:
The scrub nurse assist the surgeon by providing appropriate surgical instruments and supplies, maintaining strict surgical asepsis and, with the circulating nurse, accounting for all gauze, sponges, needles, and instruments. The circulating nurse assists the surgeon and scrub nurse, positions the patient, applies appropriate equipment and surgical drapes, assists with gowning and gloving, and provides the surgeon and scrub nurse with supplies.
Question 25
Which pulse should the nurse palpate during rapid assessment of an unconscious male adult?
A
Carotid
B
Brachial
C
Femoral
D
Radial
Question 25 Explanation:
During a rapid assessment, the nurse’s first priority is to check the patient’s vital functions by assessing his airway, breathing, and circulation. To check a patient’s circulation, the nurse must assess his heart and vascular network function. This is done by checking his skin color, temperature, mental status and, most importantly, his pulse. The nurse should use the carotid artery to check a patient’s circulation. In a patient with a circulatory problems or a history of compromised circulation, the radial pulse may not be palpable. The brachial pulse is palpated during rapid assessment of an infant.
Question 26
A female patient is being discharged after cataract surgery. After providing medication teaching, the nurse asks the patient to repeat the instructions. The nurse is performing which professional role?
A
Manager
B
Educator
C
Patient advocate
D
Caregiver
Question 26 Explanation:
When teaching a patient about medications before discharge, the nurse is acting as an educator. The nurse acts as a manager when performing such activities as scheduling and making patient care assignments. The nurse performs the care giving role when providing direct care, including bathing patients and administering medications and prescribed treatments. The nurse acts as a patient advocate when making the patient’s wishes known to the doctor.
Question 27
A female patient who speaks a little English has emergency gallbladder surgery, during discharge preparation, which nursing action would best help this patient understand wound care instruction?
A
Writing out the instructions and having a family member read them to the patient
B
Asking an interpreter to replay the instructions to the patient.
C
Demonstrating the procedure and having the patient return the demonstration
D
Asking frequently if the patient understands the instruction
Question 27 Explanation:
Demonstrating by the nurse with a return demonstration by the patient ensures that the patient can perform wound care correctly. Patients may claim to understand discharge instruction when they do not. An interpreter of family member may communicate verbal or written instructions inaccurately.
Question 28
A female patient with a terminal illness is in denial. Indicators of denial include:
A
Preparatory grief
B
Numbness
C
Shock dismay
D
Stoicism
Question 28 Explanation:
Shock and dismay are early signs of denial-the first stage of grief. The other options are associated with depression—a later stage of grief.
Question 29
To evaluate a patient for hypoxia, the physician is most likely to order which laboratory test?
A
Sputum culture
B
Total hemoglobin
C
Arterial blood gas (ABG) analysis
D
Red blood cell count
Question 29 Explanation:
All of these test help evaluate a patient with respiratory problems. However, ABG analysis is the only test evaluates gas exchange in the lungs, providing information about patient’s oxygenation status.
Question 30
When teaching a female patient how to take a sublingual tablet, the nurse should instruct the patient to place the table on the:
A
Inside of the cheek
B
Roof of the mouth
C
Floor of the mouth
D
Top of the tongue
Question 30 Explanation:
The nurse should instruct the patient to touch the tip of the tongue to the roof of the mouth and then place the sublingual tablet on the floor of the mouth. Sublingual medications are absorbed directly into the bloodstream form the oral mucosa, bypassing the GI and hepatic systems. No drug is administered on top of the tongue or on the roof of the mouth. With the buccal route, the tablet is placed between the gum and the cheek.
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NCLEX Practice Exam for Fundamentals of Nursing 1 (EM)
Choose the letter of the correct answer. You got 30 minutes to finish the exam .Good luck!
Start
Congratulations - you have completed NCLEX Practice Exam for Fundamentals of Nursing 1 (EM).
You scored %%SCORE%% out of %%TOTAL%%.
Your performance has been rated as %%RATING%%
Your answers are highlighted below.
Question 1
When administering drug therapy to a male geriatric patient, the nurse must stay especially alert for adverse effects. Which factor makes geriatric patients to adverse drug effects?
A
Increased amount of neurons
B
Faster drug clearance
C
Aging-related physiological changes
D
Enhanced blood flow to the GI tract
Question 1 Explanation:
Aging-related physiological changes account for the increased frequency of adverse drug reactions in geriatric patients. Renal and hepatic changes cause drugs to clear more slowly in these patients. With increasing age, neurons are lost and blood flow to the GI tract decreases.
Question 2
An employer establishes a physical exercise area in the workplace and encourages all employees to use it. This is an example of which level of health promotion?
A
Primary prevention
B
Passive prevention
C
Secondary prevention
D
Tertiary prevention
Question 2 Explanation:
Primary prevention precedes disease and applies to health patients. Secondary prevention focuses on patients who have health problems and are at risk for developing complications. Tertiary prevention enables patients to gain health from others’ activities without doing anything themselves
Question 3
Nurse Brenda is teaching a patient about a newly prescribed drug. What could cause a geriatric patient to have difficulty retaining knowledge about prescribed medications?
A
History of Tourette syndrome
B
Lack of family support
C
Sensory deficits
D
Decreased plasma drug levels
Question 3 Explanation:
Sensory deficits could cause a geriatric patient to have difficulty retaining knowledge about prescribed medications. Decreased plasma drug levels do not alter the patient’s knowledge about the drug. A lack of family support may affect compliance, not knowledge retention. Toilette syndrome is unrelated to knowledge retention.
Question 4
The nurse in charge is transferring a patient from the bed to a chair. Which action does the nurse take during this patient transfer?
A
Places the chair facing away from the bed
B
Position the head of the bed flat
C
Stands behind the patient
D
Helps the patient dangle the legs
Question 4 Explanation:
After placing the patient in high Fowler’s position and moving the patient to the side of the bed, the nurse helps the patient sit on the edge of the bed and dangle the legs; the nurse then faces the patient and places the chair next to and facing the head of the bed.
Question 5
The nurse uses a stethoscope to auscultate a male patient’s chest. Which statement about a stethoscope with a bell and diaphragm is true?
A
The bell detects thrills best
B
The diaphragm detects high-pitched sounds best
C
The diaphragm detects low-pitched sounds best
D
The bell detects high-pitched sounds best
Question 5 Explanation:
The diaphragm of a stethoscope detects high-pitched sound best; the bell detects low pitched sounds best. Palpation detects thrills best.
Question 6
Before administering the evening dose of a prescribed medication, the nurse on the evening shift finds an unlabeled, filled syringe in the patient’s medication drawer. What should the nurse in charge do?
A
Use the syringe because it looks like it contains the same medication the nurse was prepared to give
B
Discard the syringe to avoid a medication error
C
Call the day nurse to verify the contents of the syringe
D
Obtain a label for the syringe from the pharmacy
Question 6 Explanation:
As a safety precaution, the nurse should discard an unlabeled syringe that contains medication. The other options are considered unsafe because they promote error.
Question 7
Which human element considered by the nurse in charge during assessment can affect drug administration?
A
The patient’s socioeconomic status
B
The patient’s occupational hazards
C
The patient’s cognitive abilities
D
The patient’s ability to recover
Question 7 Explanation:
The nurse must consider the patient’s cognitive abilities to understand drug instructions. If not, the nurse must find a family member or significant other to take on the responsibility of administering medications in the home setting. The patient’s ability to recover, occupational hazards, and socioeconomic status do not affect drug administration
Question 8
A patient is in the bathroom when the nurse enters to give a prescribed medication. What should the nurse in charge do?
A
Wait for the patient to return to bed, and then leave the medication at the bedside
B
Tell the patient to be sure to take the medication. And then leave it at the bedside
C
Leave the medication at the patient’s bedside
D
Return shortly to the patient’s room and remain there until the patient takes the medication
Question 8 Explanation:
The nurse should return shortly to the patient’s room and remain there until the patient takes the medication to verify that it was taken as directed. The nurse should never leave medication at the patient’s bedside unless specifically requested to do so.
Question 9
A female patient who speaks a little English has emergency gallbladder surgery, during discharge preparation, which nursing action would best help this patient understand wound care instruction?
A
Demonstrating the procedure and having the patient return the demonstration
B
Writing out the instructions and having a family member read them to the patient
C
Asking frequently if the patient understands the instruction
D
Asking an interpreter to replay the instructions to the patient.
Question 9 Explanation:
Demonstrating by the nurse with a return demonstration by the patient ensures that the patient can perform wound care correctly. Patients may claim to understand discharge instruction when they do not. An interpreter of family member may communicate verbal or written instructions inaccurately.
Question 10
When examining a patient with abdominal pain the nurse in charge should assess:
A
The symptomatic quadrant first
B
The symptomatic quadrant last
C
Any quadrant first
D
The symptomatic quadrant either second or third
Question 10 Explanation:
The nurse should systematically assess all areas of the abdomen, if time and the patient’s condition permit, concluding with the symptomatic area. Otherwise, the nurse may elicit pain in the symptomatic area, causing the muscles in other areas to tighten. This would interfere with further assessment.
Question 11
The nurse is assessing a postoperative adult patient. Which of the following should the nurse document as subjective data?
A
Laboratory test result
B
Patient’s description of pain
C
Electrocardiographic (ECG) waveforms
D
Vital signs
Question 11 Explanation:
Subjective data come directly from the patient and usually are recorded as direct quotations that reflect the patient’s opinions or feelings about a situation. Vital signs, laboratory test result, and ECG waveforms are examples of objective data.
Question 12
The physician prescribes 250 mg of a drug. The drug vial reads 500 mg/ml. how much of the drug should the nurse give?
A
½ ml
B
¼ ml
C
2 ml
D
1 ml
Question 12 Explanation:
The nurse should give ½ ml of the drug. The dosage is calculated as follows:
250 mg/X=500 mg/1 ml
500x=250
X=1/2 ml
Question 13
Which of the following planes divides the body longitudinally into anterior and posterior regions?
A
Frontal plane
B
Midsagittal plane
C
Transverse plane
D
Sagittal plane
Question 13 Explanation:
Frontal or coronal plane runs longitudinally at a right angle to a sagittal plane dividing the body in anterior and posterior regions. A sagittal plane runs longitudinally dividing the body into right and left regions; if exactly midline, it is called a midsagittal plane. A transverse plane runs horizontally at a right angle to the vertical axis, dividing the structure into superior and inferior regions.
Question 14
Which nursing action is essential when providing continuous enteral feeding?
A
Elevating the head of the bed
B
Warming the formula before administering it
C
Positioning the patient on the left side
D
Hanging a full day’s worth of formula at one time
Question 14 Explanation:
Elevating the head of the bed during enteral feeding minimizes the risk of aspiration and allows the formula to flow in the patient’s intestines. When such elevation is contraindicated, the patient should be positioned on the right side. The nurse should give enteral feeding at room temperature to minimize GI distress. To limit microbial growth, the nurse should hang only the amount of formula that can be infused in 3 hours.
Question 15
What does the nurse in charge do when making a surgical bed?
A
Leaves the bed in the high position when finished
B
Tucks the top sheet and blanket under the bottom of the bed
C
Rolls the patient to the far side of the bed
D
Places the pillow at the head of the bed
Question 15 Explanation:
When making a surgical bed, the nurse leaves the bed in the high position when finished. After placing the top linens on the bed without pouching them, the nurse fanfolds these linens to the side opposite from where the patient will enter and places the pillow on the bedside chair. All these actions promote transfer of the postoperative patient from the stretcher to the bed. When making an occupied bed or unoccupied bed, the nurse places the pillow at the head of the bed and tucks the top sheet and blanket under the bottom of the bed. When making an occupied bed, the nurse rolls the patient to the far side of the bed.
Question 16
The physician orders heparin, 7,500 units, to be administered subcutaneously every 6 hours. The vial reads 10,000 units per milliliter. The nurse should
anticipate giving how much heparin for each dose?
A
½ ml
B
1 ¼ ml
C
¾ ml
D
¼ ml
Question 16 Explanation:
The nurse solves the problem as follows:
10,000 units/7,500 units = 1 ml/X
10,000 X = 7,500
X= 7,500/10,000 or ¾ ml
Question 17
Nurse Mackey is monitoring a patient for adverse reactions during barbiturate therapy. What is the major disadvantage of barbiturate use?
A
Potential for hepatotoxicity
B
Prolonged half-life
C
Potential for drug dependence
D
Poor absorption
Question 17 Explanation:
Patients can become dependent on barbiturates, especially with prolonged use. Because of the rapid distribution of some barbiturates, no correlation exists between duration of action and half-life. Barbiturates are absorbed well and do not cause hepatotoxicity, although existing hepatic damage does require cautions use of the drug because barbiturates are metabolized in the liver.
Question 18
A scrub nurse in the operating room has which responsibility?
A
Assisting with gowning and gloving
B
Positioning the patient
C
Applying surgical drapes
D
Handling surgical instruments to the surgeon
Question 18 Explanation:
The scrub nurse assist the surgeon by providing appropriate surgical instruments and supplies, maintaining strict surgical asepsis and, with the circulating nurse, accounting for all gauze, sponges, needles, and instruments. The circulating nurse assists the surgeon and scrub nurse, positions the patient, applies appropriate equipment and surgical drapes, assists with gowning and gloving, and provides the surgeon and scrub nurse with supplies.
Question 19
A female patient is being discharged after cataract surgery. After providing medication teaching, the nurse asks the patient to repeat the instructions. The nurse is performing which professional role?
A
Patient advocate
B
Caregiver
C
Educator
D
Manager
Question 19 Explanation:
When teaching a patient about medications before discharge, the nurse is acting as an educator. The nurse acts as a manager when performing such activities as scheduling and making patient care assignments. The nurse performs the care giving role when providing direct care, including bathing patients and administering medications and prescribed treatments. The nurse acts as a patient advocate when making the patient’s wishes known to the doctor.
Question 20
The doctor orders dextrose 5% in water, 1,000 ml to be infused over 8 hours. The I.V. tubing delivers 15 drops per milliliter. The nurse in charge should run the I.V. infusion at a rate of:
A
21 drop per minute
B
125 drops per minute
C
15 drop per minute
D
32 drop per minute
Question 20 Explanation:
Giving 1,000 ml over 8 hours is the same as giving 125 ml over 1 hour (60 minutes) to find the number of milliliters per minute:
125/60 min = X/1 minute
60X = 125X = 2.1 ml/minute
To find the number of drops/minute:
2.1 ml/X gtts = 1 ml/15 gtts
X = 32 gtts/minute, or 32 drops/minute
Question 21
Which pulse should the nurse palpate during rapid assessment of an unconscious male adult?
A
Radial
B
Brachial
C
Carotid
D
Femoral
Question 21 Explanation:
During a rapid assessment, the nurse’s first priority is to check the patient’s vital functions by assessing his airway, breathing, and circulation. To check a patient’s circulation, the nurse must assess his heart and vascular network function. This is done by checking his skin color, temperature, mental status and, most importantly, his pulse. The nurse should use the carotid artery to check a patient’s circulation. In a patient with a circulatory problems or a history of compromised circulation, the radial pulse may not be palpable. The brachial pulse is palpated during rapid assessment of an infant.
Question 22
A female patient with a terminal illness is in denial. Indicators of denial include:
A
Stoicism
B
Shock dismay
C
Numbness
D
Preparatory grief
Question 22 Explanation:
Shock and dismay are early signs of denial-the first stage of grief. The other options are associated with depression—a later stage of grief.
Question 23
A male patient is to be discharged with a prescription for an analgesic that is a controlled substance. During discharge teaching, the nurse should explain that the patient must fill this prescription how soon after the date on which it was written?
A
Within 12 months
B
Within 3 months
C
Within 1 month
D
Within 6 months
Question 23 Explanation:
In most cases, an outpatient must fill a prescription for a controlled substance within 6 months of the date on which the prescription was written.
Question 24
A male patient undergoes a total abdominal hysterectomy. When assessing the patient 10 hours later, the nurse identifies which finding as an early sign of shock?
A
Restlessness
B
Urine output of 30 ml/hour
C
Pale, warm, dry skin
D
Heart rate of 110 beats/minute
Question 24 Explanation:
Early in shock, hyperactivity of the sympathetic nervous system causes increased epinephrine secretion, which typically makes the patient restless, anxious, nervous, and irritable. It also decreases tissue perfusion to the skin, causing pale, cool clammy skin. An above-normal heart rate is a late sign of shock. A urine output of 30 ml/hour is within normal limits.
Question 25
Which action by the nurse in charge is essential when cleaning the area around a Jackson-Pratt wound drain?
A
Cleaning from the center outward in a circular motion
B
Cleaning briskly around the site with alcohol
C
Removing the drain before cleaning the skin
D
Wearing sterile gloves and a mask
Question 25 Explanation:
The nurse always should clean around a wound drain, moving from center outward in ever-larger circles, because the skin near the drain site is more contaminated than the site itself. The nurse should never remove the drain before cleaning the skin. Alcohol should never be used to clean around a drain; it may irritate the skin and has no lasting effect on bacteria because it evaporates. The nurse should wear sterile gloves to prevent contamination, but a mask is not necessary.
Question 26
A female patient exhibits signs of heightened anxiety. Which response by the nurse is most likely to reduce the patient’s anxiety?
A
“Why don’t you listen to the radio?”
B
“Read this manual and then ask me any questions you may have.”
C
“Let’s talk about what’s bothering you.”
D
“Everything will be fine. Don’t worry.”
Question 26 Explanation:
Anxiety may result from feeling of helplessness, isolation, or insecurity. This response helps reduce anxiety by encouraging the patient to express feelings. The nurse should be supportive and develop goals together with the patient to give the patient some control over an anxiety-inducing situation. Because the other options ignore the patient’s feeling and block communication, they would not reduce anxiety.
Question 27
When teaching a female patient how to take a sublingual tablet, the nurse should instruct the patient to place the table on the:
A
Inside of the cheek
B
Top of the tongue
C
Floor of the mouth
D
Roof of the mouth
Question 27 Explanation:
The nurse should instruct the patient to touch the tip of the tongue to the roof of the mouth and then place the sublingual tablet on the floor of the mouth. Sublingual medications are absorbed directly into the bloodstream form the oral mucosa, bypassing the GI and hepatic systems. No drug is administered on top of the tongue or on the roof of the mouth. With the buccal route, the tablet is placed between the gum and the cheek.
Question 28
The nurse in charge measures a patient’s temperature at 102 degrees F. what is the equivalent Centigrade temperature?
A
38.9 degrees C
B
40.1 degrees C
C
39 degrees C
D
47 degrees C
Question 28 Explanation:
To convert Fahrenheit degrees to centigrade, use this formula:
C degrees = (F degrees – 32) x 5/9
C degrees = (102 – 32) 5/9
+ 70 x 5/9
38.9 degrees C
Question 29
A male patient has a soft wrist-safety device. Which assessment finding should the nurse consider abnormal?
A
A palpable radial pulse
B
Pink nail beds
C
Cool, pale fingers
D
A palpable ulnar pulse
Question 29 Explanation:
A safety device on the wrist may impair circulation and restrict blood supply to body tissues. Therefore, the nurse should assess the patient for signs of impaired circulation, such as cool, pale fingers. A palpable radial or lunar pulse and pink nail beds are normal findings.
Question 30
To evaluate a patient for hypoxia, the physician is most likely to order which laboratory test?
A
Red blood cell count
B
Total hemoglobin
C
Sputum culture
D
Arterial blood gas (ABG) analysis
Question 30 Explanation:
All of these test help evaluate a patient with respiratory problems. However, ABG analysis is the only test evaluates gas exchange in the lungs, providing information about patient’s oxygenation status.
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1. Nurse Brenda is teaching a patient about a newly prescribed drug. What could cause a geriatric patient to have difficulty retaining knowledge about prescribed medications?
Decreased plasma drug levels
Sensory deficits
Lack of family support
History of Tourette syndrome
2. When examining a patient with abdominal pain the nurse in charge should assess:
Any quadrant first
The symptomatic quadrant first
The symptomatic quadrant last
The symptomatic quadrant either second or third
3. The nurse is assessing a postoperative adult patient. Which of the following should the nurse document as subjective data?
Vital signs
Laboratory test result
Patient’s description of pain
Electrocardiographic (ECG) waveforms
4. A male patient has a soft wrist-safety device. Which assessment finding should the nurse consider abnormal?
A palpable radial pulse
A palpable ulnar pulse
Cool, pale fingers
Pink nail beds
5. Which of the following planes divides the body longitudinally into anterior and posterior regions?
Frontal plane
Sagittal plane
Midsagittal plane
Transverse plane
6. A female patient with a terminal illness is in denial. Indicators of denial include:
Shock dismay
Numbness
Stoicism
Preparatory grief
7. The nurse in charge is transferring a patient from the bed to a chair. Which action does the nurse take during this patient transfer?
Position the head of the bed flat
Helps the patient dangle the legs
Stands behind the patient
Places the chair facing away from the bed
8. A female patient who speaks a little English has emergency gallbladder surgery, during discharge preparation, which nursing action would best help this patient understand wound care instruction?
Asking frequently if the patient understands the instruction
Asking an interpreter to replay the instructions to the patient.
Writing out the instructions and having a family member read them to the patient
Demonstrating the procedure and having the patient return the demonstration
9. Before administering the evening dose of a prescribed medication, the nurse on the evening shift finds an unlabeled, filled syringe in the patient’s medication drawer. What should the nurse in charge do?
Discard the syringe to avoid a medication error
Obtain a label for the syringe from the pharmacy
Use the syringe because it looks like it contains the same medication the nurse was prepared to give
Call the day nurse to verify the contents of the syringe
10. When administering drug therapy to a male geriatric patient, the nurse must stay especially alert for adverse effects. Which factor makes geriatric patients to adverse drug effects?
Faster drug clearance
Aging-related physiological changes
Increased amount of neurons
Enhanced blood flow to the GI tract
11. A female patient is being discharged after cataract surgery. After providing medication teaching, the nurse asks the patient to repeat the instructions. The nurse is performing which professional role?
Manager
Educator
Caregiver
Patient advocate
12. A female patient exhibits signs of heightened anxiety. Which response by the nurse is most likely to reduce the patient’s anxiety?
“Everything will be fine. Don’t worry.”
“Read this manual and then ask me any questions you may have.”
“Why don’t you listen to the radio?”
“Let’s talk about what’s bothering you.”
13. A scrub nurse in the operating room has which responsibility?
Positioning the patient
Assisting with gowning and gloving
Handling surgical instruments to the surgeon
Applying surgical drapes
14. A patient is in the bathroom when the nurse enters to give a prescribed medication. What should the nurse in charge do?
Leave the medication at the patient’s bedside
Tell the patient to be sure to take the medication. And then leave it at the bedside
Return shortly to the patient’s room and remain there until the patient takes the medication
Wait for the patient to return to bed, and then leave the medication at the bedside
15. The physician orders heparin, 7,500 units, to be administered subcutaneously every 6 hours. The vial reads 10,000 units per milliliter. The nurse should
anticipate giving how much heparin for each dose?
¼ ml
½ ml
¾ ml
1 ¼ ml
16. The nurse in charge measures a patient’s temperature at 102 degrees F. what is the equivalent Centigrade temperature?
39 degrees C
47 degrees C
38.9 degrees C
40.1 degrees C
17. To evaluate a patient for hypoxia, the physician is most likely to order which laboratory test?
Red blood cell count
Sputum culture
Total hemoglobin
Arterial blood gas (ABG) analysis
18. The nurse uses a stethoscope to auscultate a male patient’s chest. Which statement about a stethoscope with a bell and diaphragm is true?
The bell detects high-pitched sounds best
The diaphragm detects high-pitched sounds best
The bell detects thrills best
The diaphragm detects low-pitched sounds best
19. A male patient is to be discharged with a prescription for an analgesic that is a controlled substance. During discharge teaching, the nurse should explain that the patient must fill this prescription how soon after the date on which it was written?
Within 1 month
Within 3 months
Within 6 months
Within 12 months
20. Which human element considered by the nurse in charge during assessment can affect drug administration?
The patient’s ability to recover
The patient’s occupational hazards
The patient’s socioeconomic status
The patient’s cognitive abilities
21. An employer establishes a physical exercise area in the workplace and encourages all employees to use it. This is an example of which level of health promotion?
Primary prevention
Secondary prevention
Tertiary prevention
Passive prevention
22. What does the nurse in charge do when making a surgical bed?
Leaves the bed in the high position when finished
Places the pillow at the head of the bed
Rolls the patient to the far side of the bed
Tucks the top sheet and blanket under the bottom of the bed
23. The physician prescribes 250 mg of a drug. The drug vial reads 500 mg/ml. how much of the drug should the nurse give?
2 ml
1 ml
½ ml
¼ ml
24. Nurse Mackey is monitoring a patient for adverse reactions during barbiturate therapy. What is the major disadvantage of barbiturate use?
Prolonged half-life
Poor absorption
Potential for drug dependence
Potential for hepatotoxicity
25. Which nursing action is essential when providing continuous enteral feeding?
Elevating the head of the bed
Positioning the patient on the left side
Warming the formula before administering it
Hanging a full day’s worth of formula at one time
26. When teaching a female patient how to take a sublingual tablet, the nurse should instruct the patient to place the table on the:
Top of the tongue
Roof of the mouth
Floor of the mouth
Inside of the cheek
27. Which action by the nurse in charge is essential when cleaning the area around a Jackson-Pratt wound drain?
Cleaning from the center outward in a circular motion
Removing the drain before cleaning the skin
Cleaning briskly around the site with alcohol
Wearing sterile gloves and a mask
28. The doctor orders dextrose 5% in water, 1,000 ml to be infused over 8 hours. The I.V. tubing delivers 15 drops per milliliter. The nurse in charge should run the I.V. infusion at a rate of:
15 drop per minute
21 drop per minute
32 drop per minute
125 drops per minute
29. A male patient undergoes a total abdominal hysterectomy. When assessing the patient 10 hours later, the nurse identifies which finding as an early sign of shock?
Restlessness
Pale, warm, dry skin
Heart rate of 110 beats/minute
Urine output of 30 ml/hour
30. Which pulse should the nurse palpate during rapid assessment of an unconscious male adult?
Radial
Brachial
Femoral
Carotid
Answers and Rationales
Answer B. Sensory deficits could cause a geriatric patient to have difficulty retaining knowledge about prescribed medications. Decreased plasma drug levels do not alter the patient’s knowledge about the drug. A lack of family support may affect compliance, not knowledge retention. Toilette syndrome is unrelated to knowledge retention.
Answer C. The nurse should systematically assess all areas of the abdomen, if time and the patient’s condition permit, concluding with the symptomatic area. Otherwise, the nurse may elicit pain in the symptomatic area, causing the muscles in other areas to tighten. This would interfere with further assessment.
Answer C. Subjective data come directly from the patient and usually are recorded as direct quotations that reflect the patient’s opinions or feelings about a situation. Vital signs, laboratory test result, and ECG waveforms are examples of objective data.
Answer C. A safety device on the wrist may impair circulation and restrict blood supply to body tissues. Therefore, the nurse should assess the patient for signs of impaired circulation, such as cool, pale fingers. A palpable radial or lunar pulse and pink nail beds are normal findings.
Answer A. Frontal or coronal plane runs longitudinally at a right angle to a sagittal plane dividing the body in anterior and posterior regions. A sagittal plane runs longitudinally dividing the body into right and left regions; if exactly midline, it is called a midsagittal plane. A transverse plane runs horizontally at a right angle to the vertical axis, dividing the structure into superior and inferior regions.
Answer A. Shock and dismay are early signs of denial-the first stage of grief. The other options are associated with depression—a later stage of grief.
Answer B. After placing the patient in high Fowler’s position and moving the patient to the side of the bed, the nurse helps the patient sit on the edge of the bed and dangle the legs; the nurse then faces the patient and places the chair next to and facing the head of the bed.
Answer D. Demonstrating by the nurse with a return demonstration by the patient ensures that the patient can perform wound care correctly. Patients may claim to understand discharge instruction when they do not. An interpreter of family member may communicate verbal or written instructions inaccurately.
Answer A. As a safety precaution, the nurse should discard an unlabeled syringe that contains medication. The other options are considered unsafe because they promote error.
Answer B. Aging-related physiological changes account for the increased frequency of adverse drug reactions in geriatric patients. Renal and hepatic changes cause drugs to clear more slowly in these patients. With increasing age, neurons are lost and blood flow to the GI tract decreases.
Answer B. When teaching a patient about medications before discharge, the nurse is acting as an educator. The nurse acts as a manager when performing such activities as scheduling and making patient care assignments. The nurse performs the care giving role when providing direct care, including bathing patients and administering medications and prescribed treatments. The nurse acts as a patient advocate when making the patient’s wishes known to the doctor.
Answer D. Anxiety may result from feeling of helplessness, isolation, or insecurity. This response helps reduce anxiety by encouraging the patient to express feelings. The nurse should be supportive and develop goals together with the patient to give the patient some control over an anxiety-inducing situation. Because the other options ignore the patient’s feeling and block communication, they would not reduce anxiety.
Answer C. The scrub nurse assist the surgeon by providing appropriate surgical instruments and supplies, maintaining strict surgical asepsis and, with the circulating nurse, accounting for all gauze, sponges, needles, and instruments. The circulating nurse assists the surgeon and scrub nurse, positions the patient, applies appropriate equipment and surgical drapes, assists with gowning and gloving, and provides the surgeon and scrub nurse with supplies.
Answer C. The nurse should return shortly to the patient’s room and remain there until the patient takes the medication to verify that it was taken as directed. The nurse should never leave medication at the patient’s bedside unless specifically requested to do so.
Answer C. The nurse solves the problem as follows:
10,000 units/7,500 units = 1 ml/X
10,000 X = 7,500
X= 7,500/10,000 or ¾ ml
Answer C. To convert Fahrenheit degrees to centigrade, use this formula:
C degrees = (F degrees – 32) x 5/9
C degrees = (102 – 32) 5/9
70 x 5/9 = 38.9 degrees C
Answer D. All of these test help evaluate a patient with respiratory problems. However, ABG analysis is the only test evaluates gas exchange in the lungs, providing information about patient’s oxygenation status.
Answer B. The diaphragm of a stethoscope detects high-pitched sound best; the bell detects low pitched sounds best. Palpation detects thrills best.
Answer C. In most cases, an outpatient must fill a prescription for a controlled substance within 6 months of the date on which the prescription was written.
Answer D. The nurse must consider the patient’s cognitive abilities to understand drug instructions. If not, the nurse must find a family member or significant other to take on the responsibility of administering medications in the home setting. The patient’s ability to recover, occupational hazards, and socioeconomic status do not affect drug administration.
Answer A. Primary prevention precedes disease and applies to health patients. Secondary prevention focuses on patients who have health problems and are at risk for developing complications. Tertiary prevention enables patients to gain health from others’ activities without doing anything themselves.
Answer A. When making a surgical bed, the nurse leaves the bed in the high position when finished. After placing the top linens on the bed without pouching them, the nurse fanfolds these linens to the side opposite from where the patient will enter and places the pillow on the bedside chair. All these actions promote transfer of the postoperative patient from the stretcher to the bed. When making an occupied bed or unoccupied bed, the nurse places the pillow at the head of the bed and tucks the top sheet and blanket under the bottom of the bed. When making an occupied bed, the nurse rolls the patient to the far side of the bed.
Answer C. The nurse should give ½ ml of the drug. The dosage is calculated as follows:
250 mg/X=500 mg/1 ml
500x=250
X=1/2 ml
Answer C. Patients can become dependent on barbiturates, especially with prolonged use. Because of the rapid distribution of some barbiturates, no correlation exists between duration of action and half-life. Barbiturates are absorbed well and do not cause hepatotoxicity, although existing hepatic damage does require cautions use of the drug because barbiturates are metabolized in the liver.
Answer A. Elevating the head of the bed during enteral feeding minimizes the risk of aspiration and allows the formula to flow in the patient’s intestines. When such elevation is contraindicated, the patient should be positioned on the right side. The nurse should give enteral feeding at room temperature to minimize GI distress. To limit microbial growth, the nurse should hang only the amount of formula that can be infused in 3 hours.
Answer C. The nurse should instruct the patient to touch the tip of the tongue to the roof of the mouth and then place the sublingual tablet on the floor of the mouth. Sublingual medications are absorbed directly into the bloodstream form the oral mucosa, bypassing the GI and hepatic systems. No drug is administered on top of the tongue or on the roof of the mouth. With the buccal route, the tablet is placed between the gum and the cheek.
Answer A. The nurse always should clean around a wound drain, moving from center outward in ever-larger circles, because the skin near the drain site is more contaminated than the site itself. The nurse should never remove the drain before cleaning the skin. Alcohol should never be used to clean around a drain; it may irritate the skin and has no lasting effect on bacteria because it evaporates. The nurse should wear sterile gloves to prevent contamination, but a mask is not necessary.
Answer C. Giving 1,000 ml over 8 hours is the same as giving 125 ml over 1 hour (60 minutes) to find the number of milliliters per minute:
125/60 min = X/1 minute
60X = 125X = 2.1 ml/minute
To find the number of drops/minute:
2.1 ml/X gtts = 1 ml/15 gtts
X = 32 gtts/minute, or 32 drops/minute
Answer A. Early in shock, hyperactivity of the sympathetic nervous system causes increased epinephrine secretion, which typically makes the patient restless, anxious, nervous, and irritable. It also decreases tissue perfusion to the skin, causing pale, cool clammy skin. An above-normal heart rate is a late sign of shock. A urine output of 30 ml/hour is within normal limits.
Answer D. During a rapid assessment, the nurse’s first priority is to check the patient’s vital functions by assessing his airway, breathing, and circulation. To check a patient’s circulation, the nurse must assess his heart and vascular network function. This is done by checking his skin color, temperature, mental status and, most importantly, his pulse. The nurse should use the carotid artery to check a patient’s circulation. In a patient with a circulatory problems or a history of compromised circulation, the radial pulse may not be palpable. The brachial pulse is palpated during rapid assessment of an infant.
