Fundamental of Nursing NCLEX RN Practice Questions
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Question 1 of 5.
The nurse supervises unlicensed assistive personnel (UAP) assist a bed-bound client with oral hygiene. Which action by the UAP requires follow-up? Select all that apply.
A. Raises the head of the bed (HOB) to 15 degrees
B. Positions the toothbrush bristles at a 45-degree angle to the gum line
C. A pulse of 5 is abnormally low for a 5-year-old (normal 70-120). BP 110/60, RR 24, and temperature 37°C are within normal limits. None Regular The correct answer is A. Rationale: Pulse 5 is bradycardic for a child.
D. Removes the towel and places it in a biohazard bag
E. Applies moisturizing lubricant to the lips after brushing and rinsing
Explanation: These actions by the UAP require follow-up. The head of the bed should ideally be elevated to between 30-45 degrees to facilitate effective oral hygiene and reduce the risk of aspiration. A lower angle may make it more difficult for the client to swallow properly and increase the risk of choking. Placing a towel used for oral hygiene in a biohazard bag is unnecessary unless it is saturated with blood or other potentially infectious materials. The towel used to protect the client's clothing during oral hygiene is typically considered regular linen and should be placed in a linen bag for laundering. Using a biohazard bag for non-contaminated items increases waste and may lead to confusion in waste management procedures.
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.
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