Fundamentals NCLEX RN Questions
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Question 1 of 5.
Extract:Nurses' Notes 1930 – Assessment completed Peripheral pulses were all palpable. S1/S2 heart tones auscultated. No peripheral edema. Lung sounds were clear in all fields. Client denied any cough or dyspnea. Respirations were regular and unlabored. Bowel sounds were active in all quadrants, with no abdominal distention noted. Client only reports nausea after her prescribed acetaminophen-oxycodone. Surgical incisions appeared approximated, reddened, and the surrounding area was hot to touch. Small amount of foul-smelling, purulent type of drainage was noted. The gauze dressing was changed, and a new gauze dressing was applied. Client reported intermittent incisional pain of 3/10 described as ‘sore'. Vital Signs: Oral Temperature 100.4° F (38° C) Pulse 93/minute Respirations 18/minute Blood pressure 111/69 mm Hg O2 saturation 95% on room air
The nurse performs a physical assessment for a client three days post-operative following a radical hysterectomy.Select three (3) assessment and vital sign findings that are highly concerning.
A. Incisional pain
B. Approximated wounds
C. Pulse rate
D. Foul smelling drainage
E. Nausea after pain medication
F. Oral temperature
G. Purulent wound drainage
Explanation: This client is demonstrating signs and symptoms of a surgical site infection. The findings requiring follow-up include the foul-smelling drainage that is purulent. Further, this client also has a concern for their oral temperature as it is a clinical fever. Findings that are not highly concerning include the client's incisional pain which is described as sore and is intermittent. This is an expected finding following surgery. The wounds being approximated is an optimal finding. The client's pulse is within normal limits. Finally, nausea after pain medication is a common side-effect.
Question 2 of 5.
Which of the following responses should the nurse avoid when communicating with a client who has just received a poor prognosis? Select all that apply.
A. My mother has the same thing.
B. I'll sit with you for a while.
C. I think you should try having surgery.
D. Don't cry, everything is going to be okay.
E. Do you have any questions for me right now?
Explanation: Avoid personal anecdotes, medical advice, or minimizing emotions, as they dismiss the client's feelings. Offering presence and open-ended questions are therapeutic.
Question 3 of 5.
The nurse is ambulating a client who is wearing a gait belt. The client begins to fall. The nurse should take which appropriate action to minimize injury?
A. Hold the gait belt, extend one leg, let the client slide against the leg, and lower the client to the floor.
B. Let go of the gait belt, grab the client under each arm, and gently lower the client to the floor.
C. Grasp the gait belt, and instruct the client to fall gently down to the floor in a side-lying position.
D. Hold the gait belt, and lower the client to the floor by using a narrow base of support.
Explanation: Using the gait belt to guide the client against the nurse's leg minimizes injury. Letting go, instructing a side-lying fall, or using a narrow base increases risk.
Question 4 of 5.
The nurse is teaching a client about a vegan diet. Which of the following foods should the nurse recommend for this diet? Select all that apply.
A. Legumes
B. Tofu
C. Almonds
D. Prunes
E. Baked fish
F. Grapefruit
Explanation: Vegan diets exclude animal products, so legumes, tofu, almonds, prunes, and grapefruit are suitable. Baked fish is not vegan.
Question 5 of 5.
Which of the following clients would most likely benefit from contralateral stimulation as a nonpharmacological comfort intervention to decrease pain?
A. A 36-year-old client with abdominal pain
B. A 56-year-old client with a below-the-knee amputation and phantom limb pain
C. A 76-year-old client with terminal cancer
D. An 84-year-old client with severe arthritis
Explanation: Contralateral stimulation, rubbing the opposite limb, is effective for phantom limb pain by altering pain perception. It is less effective for visceral, cancer, or arthritic pain.
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