Fundamental of Nursing NCLEX RN Practice Questions
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Question 1 of 5.
Extract:Item 1 of 1 • Nurses' Notes 0920: Client presents for a follow-up visit. Client reports increased difficulty with activities of daily living because of dyspnea. Reports pain and swelling in both lower extremities that increases with movement. "Washing my hair now takes me an hour instead of fifteen minutes." Transverse surgical incision was pink, approximated, and crusted—9 inches in length. Two Jackson-Pratt drains contained a total of 15 mL of serumlike drainage. Incisional pain reported at a '4' on the Numerical Rating Scale. Endorses increased incisional pain while coughing. The client reports full adherence to postoperative enoxaparin self-injections. She reports ejecting the air bubble prior to injection. Reports relief with prescribed oxycodone-acetaminophen but experiences generalized itching and drowsiness after. • Medical History • gastric bypass surgery performed two years ago • dyslipidemia • diabetes mellitus (type two) • Vital Signs • T 99.0°F (37.2°C); HR 90 beats/min; RR 18 breaths/min; BP 119/67 mm Hg; Pulse oximetry 96% on room air.
The nurse in the medical office is caring for a 41-year-old client who is 2-week postoperative abdominoplasty. Which of the following assessment findings require immediate follow-up? Select all that apply.
A. wound assessment findings
B. tolerance with activities of daily living
C. pain in lower extremities
D. enoxaparin self-injections
E. pulse, respirations, and blood pressure
Explanation: Tolerance with activities of daily living. The client reports increased difficulty with activities of daily living (ADLs) due to dyspnea, which could indicate a significant complication, such as pulmonary embolism (PE). Dyspnea, especially in the postoperative period, should always be investigated promptly, as it could be a sign of a PE, which is a life-threatening emergency. Immediate follow-up is necessary to rule out PE or other respiratory or circulatory issues. Pain in lower extremities. Pain and swelling in the lower extremities that increase with movement could suggest deep vein thrombosis (DVT). This complication is especially concerning in a postoperative patient on anticoagulation therapy (enoxaparin). DVT can lead to pulmonary embolism if the clot dislodges, which could cause dyspnea. This requires immediate follow-up to assess for DVT and initiate treatment if necessary. The client reports full adherence to postoperative enoxaparin self-injections and mentions ejecting the air bubble before injection. This is an incorrect technique; ejecting the air bubble can result in an underdose of the medication, potentially leading to ineffective anticoagulation. This can increase the risk of complications like DVT or VTE. Correct technique is crucial to ensure proper dosing. Immediate follow-up is required to educate the client about appropriate injection techniques (not ejecting the air bubble) to prevent these risks.Wound assessment findings. The transverse surgical incision is described as pink, approximated, and crusted, which are normal findings in the early postoperative period. These findings suggest no signs of infection or delayed wound healing. Therefore, no immediate follow-up is required for this finding.Incision pain level and characteristics. The client reports incisional pain at a level of 4 on the Numerical Rating Scale and increased pain when coughing. This level of pain is within a manageable range for a postoperative patient. The description of the pain as incisional and aggravated by coughing is consistent with expected postoperative discomfort. The pain level is manageable, and this is not a priority concern for immediate follow-up unless it becomes severe or is associated with other complications (e.g., infection or dehiscence).
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.