Foundation of Nursing NCLEX Test Review 1 Answers and Rationale

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1.    Answer D.  Administering eye drops should be done in the lower conjunctival sac to ensure that the medication gets to eye. Option A is not done since some medications can irritate the cornea when placed directly in to it. Options B and C are not practiced because doing so cannot hold the medication into the eye. Its tendency would be, the medication would run out or flow out of the eyes.
2.    Answer A. Infiltration happens when the intravenous fluid does not enter the veins, instead it is diffused in the areas outside the vein which explains why the area is swollen and cool to touch. Option B happens when there is there is an inflammation of the vein in the site. It is characterized by pain, swelling, redness and it is warm to touch. Option C is manifested by pain, swelling, warm to touch, redness and fever is present in the client. Option D is expected when the client complains of feeling pain in the IV site and that you can see in the IV tubing that it is filled with air.
3.    Answer B. It is a priority nursing action to first assess the client’s IV site before doing anything. Once there is a report of pain in the site, plus edema and erythema, we check for the patency of the IV site, if it is not patent, then we discontinue the IV and apply warm compress to the IV site to lessen swelling. Options A and D are incorrect because such actions will not relieve the client from pain, edema and erythema. Option C is not indicated because there is no accurate indication that there is a bacterial infection in the site.
4.    Answer B. Quantity= desired dose/ available dose       0.125/ 0.25 = 0.5 tab. The nurse should dispense ½ tablet of Digoxin. Options A, C and D are all incorrect answer.
5.    Answer B. 41.66 or 42 gtts/min           
6.    Answer D. When a nurse is caring for quite a number of patients, to prevent the spread of infections among patients, she should know who are the possible carrier of infections and those who are at risk of acquiring one. Options A, B and C are inappropriate infection preventions that are indicated in this situation.
7.    Answer A. Stool for ova and parasites does not require a sterile technique because we are after for the presence of ova and parasites. And if we are looking for the presence of bacteria in the stool, sterile technique is not still utilized because normally there will be a lot of bacteria in the stool. Options B, C and D require a sterile technique in order to identify what bacterial growth is present in the specimen.
8.    Answer C. The patient is at greater risk of wound infection when he is punctured by a nail in the foot. He is at risk for acquiring tetanus infection once he is not given with tetanus toxoid immunization. The wound the nail creates is quite deep thus there is a great risk for infection. In the case of Option A, patients with colostomy is often given with antibiotics. Options B and D are incorrect because the wound created is not quite deep.
9.    Answer C. The skin is the first line of defense of the body against the infections. In cases of burns more than 20% of the body, this defense is weakened thus the person is greatly predisposed to developing different kinds of infection. Burns does not only affect the ability of the skin to defend the body but it also alters the immunity of the body. Options A, B and D may predispose a patient from the development of infections but cannot be considered as great as compared to burns.
10.    Answer C. Heat loss is achieved through different methods. Conduction happens when there is a direct contact of a material in the skin to achieve heat loss. In this case heat loss is achieved with the use of cooling blanket. Option A is achieved when body heat is diffused away from the body into the air via skin. Option B is achieved by moving air away from the body to replace the warmth the body has with the use of a fan. Option D is achieved with the use of water such as in tepid sponge baths.
11.    Answer C. The stages of grief includes: Denial, Anger, Bargaining, Depression and Acceptance. The stage of denial is when the patient is unable to acknowledge the existence of the diagnosis. In this stage, the patient would seek more opinions from other doctors because she cannot accept the fact of her diagnosis. Options A and D are an example of the stage anger, in which she asks a lot of questions regarding the reason of her sickness. Option D shows the acceptance of the patient.
12.    Answer A. Touching to provide support is a form of therapeutic communication. The use of touch reinforces caring feelings. Option B is non therapeutic. Option C is incorrect because the nurse is not in the position to tell the patient’s family of her prognosis. It is only done by the patient or when the patient requests the nurse to do so. Option D may correct but is not the best answer indicated in this situation.
13.    Answer C. Mrs. Estrada is undergoing the process of depression which is a normal in coping with the grief process. In order to be therapeutic for this patient, the nurse should accept this behavioural adaptation of the patient, since it is just normal. Options A, B and D are non therapeutic because this conditions do not allow the normal process of grieving.
14.    Answer C. The patient is experiencing fear because she herself has seen how her father died in the same age as she has in the present. Options A, B and D may be correct but are not indicated in the situation presented.
15.    Answer B. Bargaining is the stage when the patient tries new things in order for her to lengthen her life. She is willing to try therapies ranging from the conventional to non conventional methods of treating her cancer. Other options do not describe the grieving stage that Mrs. Estrada is experiencing.
16.    Answer B. The Licensure of Registered Professional Nurses protects its main consumers which are the patients. Other options are not the reason as to why nurses undergo licensing.
17.    Answer C. Incident reports are filled out in order to record details of unusual events occurring in the hospital and care of patients. In this case, the incident report is filled out in order to have an available data for quality control analysis and in the future when dealing with legal liabilities. Options A, B and D are incorrect because these are not the reason as to why nurses fill out incident reports.
18.    Answer A. Assault is threatening or attempting to inflict injuries to the patient. The verbalization of the nurse clearly shows that it is a case of an assault. Option B is touching the patient without consent. This is done by pinching or slapping the patient. Options C and D are forms of violations that the nurse can commit to a patient in line with the patients profession.
19.    Answer B. This is a case where the nurse committed an assault as manifested by the threatening behaviour of the nurse. Option A is achieved when you speak ill of a person. Option B is putting the threatening behaviour into action. Option D is committed when one talks ill of another through writing it in a published form.
20.    Answer C. Living will is a legal document that an individual uses to make known his wishes to prolong his life. It is also known as advanced directives. In this case, a living will gives consent to perform life sustaining medical intervention to prolong life in cases of emergency. Other options presented are incorrect because they do not describe what a living will is all about.
21.    Answer C. Consents allow the physician to do the medical procedures indicated for the patient. Prior to procedure, it is the doctor’s responsibility to obtain the patient’s consent and it is the responsibility of the nurse to let the patient sign the consent prior to the surgical procedure. Consent unsigned is like consent not given so it is a must that the nurse should tell the situation to the doctor performing the surgery. Options A, B and D are incorrect because they violate the legalities of the consent.
22.    Answer B. The owner of the chart is the patient himself so it is a must that before authorizing any individual to view the chart, authorization should secured and have someone review the chart with the patient’s physician cousin. Options A, C and D are the incorrect way of dealing such situations involving the patient’s chart.
23.    Answer C. When restraints are applied, it is a must for the nurse to assess the quality of the patient’s skin where the restraint is applied. The priority assessment should be done by assessing the patient’s capillary refill so as to ensure circulation of the extremity. Capillary refill of less than two seconds shows that there is a good circulation in that area. Options A, B and D are signs that the restraints applied are having negative effects to the patient’s extremity.
24.    Answer A. It is the preferred answer because right there in then you will be able to stop the discussion of the patient’s case in front of a lot of people. Option B may be correct because you are saving from humiliation the nursing assistance but it is not the preferred answer because doing so will allow further discussion of the case and more harm will be committed. Option C may be correct because in the first place you are not their immediate superior but not appropriate in this situation because it will further the discussion of the case thus allowing a lot of people to overhear it. Option D is the worst thing to do since you will not do anything to prevent it from happening.
25.    Answer A.Good Samaritan Act protects those who choose to lend a hand during emergency situations. In this act, the nurse is not liable to any laws once she helps an injured individual during this emergency. Options B, C and D are incorrect because these do not explain what the act is all about.

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