Nurse Test (Foundation of Nursing)
1. The most important nursing intervention to correct skin dryness is:
a. Avoid bathing the patient until the condition is remedied, and notify the physician
b. Ask the physician to refer the patient to a dermatologist, and suggest that the patient wear home-laundered sleepwear
c. Consult the dietitian about increasing the patient’s fat intake, and take necessary measures to prevent infection
d. Encourage the patient to increase his fluid intake, use nonirritating soap when bathing the patient, and apply lotion to the involved areas
2. When bathing a patient’s extremities, the nurse should use long, firm strokes from the distal to the proximal areas. This technique:
a. Provides an opportunity for skin assessment
b. Avoids undue strain on the nurse
c. Increases venous blood return
d. Causes vasoconstriction and increases circulation
3. Vivid dreaming occurs in which stage of sleep?
a. Stage I non-REM
b. Rapid eye movement (REM) stage
c. Stage II non-REM
d. Delta stage
4. The natural sedative in meat and milk products (especially warm milk) that can help induce sleep is:
a. Flurazepam
b. Temazepam
c. Tryptophan
d. Methotrimeprazine
5. Nursing interventions that can help the patient to relax and sleep restfully include all of the following except:
a. Have the patient take a 30- to 60-minute nap in the afternoon
b. Turn on the television in the patient’s room
c. Provide quiet music and interesting reading material
d. Massage the patient’s back with long strokes
6. Restraints can be used for all of the following purposes except to:
a. Prevent a confused patient from removing tubes, such as feeding tubes, I.V. lines, and urinary catheters
b. Prevent a patient from falling out of bed or a chair
c. Discourage a patient from attempting to ambulate alone when he requires assistance for his safety
d. Prevent a patient from becoming confused or disoriented
7. Which of the following is the nurse’s legal responsibility when applying restraints?
a. Document the patient’s behavior
b. Document the type of restraint used
c. Obtain a written order from the physician except in an emergency, when the patient must be protected from injury to himself or others
d. All of the above
8. Kubler-Ross’s five successive stages of death and dying are:
a. Anger, bargaining, denial, depression, acceptance
b. Denial, anger, depression, bargaining, acceptance
c. Denial, anger, bargaining, depression acceptance
d. Bargaining, denial, anger, depression, acceptance
9. A terminally ill patient usually experiences all of the following feelings during the anger stage except:
a. Rage
b. Envy
c. Numbness
d. Resentment
10. Nurses and other health care provides often have difficulty helping a terminally ill patient through the necessary stages leading to acceptance of death. Which of the following strategies is most helpful to the nurse in achieving this goal?
a. Taking psychology courses related to gerontology
b. Reading books and other literature on the subject of thanatology
c. Reflecting on the significance of death
d. Reviewing varying cultural beliefs and practices related to death
11. Which of the following symptoms is the best indicator of imminent death?
a. A weak, slow pulse
b. Increased muscle tone
c. Fixed, dilated pupils
d. Slow, shallow respirations
12. A nurse caring for a patient with an infectious disease who requires isolation should refers to guidelines published by the:
a. National League for Nursing (NLN)
b. Centers for Disease Control (CDC)
c. American Medical Association (AMA)
d. American Nurses Association (ANA)
13. To institute appropriate isolation precautions, the nurse must first know the:
a. Organism’s mode of transmission
b. Organism’s Gram-staining characteristics
c. Organism’s susceptibility to antibiotics
d. Patient’s susceptibility to the organism
14. Which is the correct procedure for collecting a sputum specimen for culture and sensitivity testing?
a. Have the patient place the specimen in a container and enclose the container in a plastic bag
b. Have the patient expectorate the sputum while the nurse holds the container
c. Have the patient expectorate the sputum into a sterile container
d. Offer the patient an antiseptic mouthwash just before he expectorate the sputum
15. An autoclave is used to sterilize hospital supplies because:
a. More articles can be sterilized at a time
b. Steam causes less damage to the materials
c. A lower temperature can be obtained
d. Pressurized steam penetrates the supplies better
16. The best way to decrease the risk of transferring pathogens to a patient when removing contaminated gloves is to:
a. Wash the gloves before removing them
b. Gently pull on the fingers of the gloves when removing them
c. Gently pull just below the cuff and invert the gloves when removing them
d. Remove the gloves and then turn them inside out
17. After having an I.V. line in place for 72 hours, a patient complains of tenderness, burning, and swelling. Assessment of the I.V. site reveals that it is warm and erythematons. This usually indicates:
a. Infection
b. Infiltration
c. Phlebitis
d. Bleeding
18. To ensure homogenization when diluting powdered medication in a vial, the nurse should:
a. Shake the vial vigorously
b. Roll the vial gently between the palms
c. Invert the vial and let it stand for 1 minute
d. Do nothing after adding the solution to the vial
19. The nurse is teaching a patient to prepare a syringe with 40 units of U-100 NPH insulin for self-injection. The patient’s first priority concerning self-injection in this situation is to:
a. Assess the injection site
b. Select the appropriate injection site
c. Check the syringe to verify that the nurse has removed the prescribed insulin dose
d. Clean the injection site in a circular manner with and alcohol sponge
20. The physician’s order reads “Administer 1 g cefazolin sodium (Ancef) in 150 ml of normal saline solution in 60 minutes.” What is the flow rate if the drop factor is 10 gtt = 1 ml?
a. 25 gtt/minute
b. 37 gtt/minute
c. 50 gtt/minute
d. 60 gtt/minute
21. A patient must receive 50 units of Humulin regular insulin. The label reads 100 units = 1 ml. How many milliliters should the nurse administer?
a. 0.5 ml
b. 0.75 ml
c. 1 ml
d. 2 ml
22. How should the nurse prepare an injection for a patient who takes both regular and NPH insulin?
a. Draw up the NPH insulin, then the regular insulin, in the same syringe
b. Draw up the regular insulin, then the NPH insulin, in the same syringe
c. Use two separate syringe
d. Check with the physician
23. A patient has just received 30 mg of codeine by mouth for pain. Five minutes later he vomits. What should the nurse do first?
a. Call the physician
b. Remedicate the patient
c. Observe the emesis
d. Explain to the patient that she can do nothing to help him
24. A patient is characterized with a #16 indwelling urinary (Foley) catheter to determine if:
a. Trauma has occurred
b. His 24-hour output is adequate
c. He has a urinary tract infection
d. Residual urine remains in the bladder after voiding
25. A staff nurse who is promoted to assistant nurse manager may feel uncomfortable initially when supervising her former peers. She can best decrease this discomfort by:
a. Writing down all assignments
b. Making changes after evaluating the situation and having discussions with the staff.
c. Telling the staff nurses that she is making changes to benefit their performance
d. Evaluating the clinical performance of each staff nurse in a private conference
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is this da actual nclex tests?
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