Fundamental of Nursing NCLEX RN Practice Questions
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Question 1 of 5.
Extract:The following scenario applies to the next 6 items The home health nurse is caring for a 67-year-old female client with progressive multiple sclerosis. Item 1 of 6 Nurses' Note Current Medications 1349: Initial home visit performed. The client was hospitalized last week for four days following a ground-level fall, delirium, and cystitis. The client is alert and fully oriented. Clear lung sounds bilaterally. Peripheral pulses 2+. Her muscle movements were uncoordinated as she missed grabbing the television remote and a can of cola. Speech was intelligible with some pauses. When ambulating to the bathroom, she used scattered furniture as assistive devices. Skin is warm, dry, and normal for ethnicity. She reports significant fatigue throughout the day. She states that during the day, the heat bothers her, so she is reluctant to go to the mailbox. She is also tired while cooking and cleaning in the evening hours. Since discharge, the client reports that she sleeps 7-8 hours, but does not feel rested in the morning. She reports that her urine is clear and without odor, but she has an urgency when going to the bathroom. She reports numbness and tingling in the lower extremities that last all day. She does report her legs 'stiffening up' intermittently throughout the day. She reports that she is taking the prescribed antibiotic when she remembers. Denies any loss of appetite and has increased her fluids with cola and sweet tea since discharge.
Select the three (3) client findings that require immediate follow-up for a 67-year-old female client with progressive multiple sclerosis.
A. reports of fatigue
B. heat sensitivity
C. activity intolerance
D. medication adherence
E. ambulation assistance
F. muscle incoordination
G. characteristics of pain
Explanation: Medication adherence (incomplete antibiotic course) risks recurrent cystitis, ambulation assistance (using furniture) indicates fall risk, and muscle incoordination increases injury risk, requiring immediate intervention.
Question 2 of 5.
The nurse recognizes which of the following would contraindicate the use of electronic blood pressure monitoring?
A. Coarse tremors
B. Intrajugular central vascular access device
C. Wearing a wrist watch
D. Cardiac pacemaker
Explanation: Coarse tremors can interfere with accurate electronic blood pressure readings. Intrajugular devices, wrist watches, and pacemakers do not typically contraindicate use.
Question 3 of 5.
The nurse observes a client perform isometric exercises. It would indicate effective understanding if the client
A. Exercises both extremities simultaneously.
B. Knows their heart rate should be monitored while exercising.
C. Practices forced resistance against stable objects.
D. Swings their limbs through the full range of motion.
Explanation: Isometric exercises involve static muscle contraction against resistance, like pushing against a stable object. Simultaneous exercise, heart rate monitoring, and full range of motion are not specific to isometrics.
Question 4 of 5.
The nurse is teaching a client about ambulating with a cane. It would indicate effective teaching if the nurse observes the client
A. Position the cane on their weaker side.
B. Advances their weaker leg first, then the cane.
C. Measures the height of the cane from their wrist crease.
D. Advances the cane 12-16 inches with each step.
Explanation: Advancing the cane 12-16 inches ensures stability. The cane is held on the stronger side, stronger leg moves first, and height is measured to the greater trochanter.
Question 5 of 5.
The nurse is teaching a client about a vegetarian diet. Which of the following foods should the nurse recommend for this diet? Select all that apply.
A. Legumes
B. Almond butter
C. Grilled chicken
D. Apricots
E. Baked fish
F. Seafood salad
Explanation: Vegetarian diets exclude meat, so legumes, almond butter, and apricots are suitable. Chicken, fish, and seafood are not vegetarian.