NCLEX Review - Fundamentals of Nursing 7th edition (66-70)

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66. A nurse has administered an injection to a client. After the injection, the nurse accidentally drops the syringe on the floor. Which nursing action is appropriate in this situation?

a) obtain a dust pan and mop to sweep up the syringe
b) call the housekeeping department to pick up the syringe
c) carefully pick up the syringe from the floor and gently recap the needle
d) carefully pick up the syringe from the floor and dispose of it in a sharps container

67. A nurse is observing a client using a walker. The nurse determines that the client is using the walker correctly if the client:

a) puts weight on the hand pieces, moves the walker forward, and then walks into it
b) puts weight on the hand pieces, slides the walker forward, and then walks into it
c) puts all four points of the walker flat on the floor, puts weight on the hand pieces, and then walks into it
d) walks into the walker, puts weight on the hand pieces, and then puts all four points the walker flat on the floor

68. The nurse observes clients to evaluate for the correct height of crutches. Which client is correctly fitted with crutches?

a) the client stands with the axillae on the top of the crutches
b) a pencil can slide between the client's axillae and the top of the crutches
c) the client keeps the arms straight when standing with crutches
d) two fingers fit between the client's axillae ad the top of the crutches


69. A client is at risk for infection following a radical vulvectomy. Which does the nurse implement when giving perineal care to this client?


a) provides a sitz bath
b) provides care twice a day
c) applies a fresh sterile dressing
d) cleanses using warm tap water

70. A nurse prepares to assist postoperative client to progress from a lying to sitting position to prepare for ambulation. Which nursing action is appropriate to maintain the safety on the client?

a) assess the client for signs of dizziness and hypotension
b) allow the client to rise from the bed to a standing position unassisted
c) elevate the head of the bed quickly to assist the client to a sitting position
d) assist the client to move quickly from the lying position to to the sitting position








Fundamentals of Nursing 7th edition
Answers and Rationale

66) D

- Syringes should never be recapped, in any circumstances, because of the risk of getting pricked with a contaminated needle. Used syringes should always be placed in a sharps container immediately after use to avoid individuals from becoming injured. A syringe should not be swept up, because this action poses an additional risk for getting pricked. It is not the responsibility of the housekeeping department to pick up the syringe.

67) C

When the client uses a walker, the nurse stands adjacent to the affected side. The client is instructed to put all four points of the walker 2 feet forward flat on the floor before putting weight on the hand pieces. This will ensure client safety and prevent stress cracks in the walker. The client is then instructed to move the walker forward and walk into it.

68) D

With the client's elbows flexed 20 to 30 degrees, the shoulders in a relaxed position, and the crutches placed approximately 15 cm (6 inches) anterolateral from the toes, the nurse should be able to place two fingers comfortably between the client's axillae and the axillary bars. The crutches are adjusted if there is too much or too little space at the axillary area. The client is advised to avoid resting the axillae on the axillary bars because this could injure the brachial plexus (the nerves in the axillae that supply the arm and shoulder area). The nurse should terminate ambulation and recheck the crutch height if the client complains of numbness or tingling in the hands or arms.

69) A

The nurse provides a sitz bath to soothe tissues and to stimulate healing by increasing the regional blood flow. Perineal care is provided at least twice a day and after each voiding and bowel movement. A dressing is not used for a vulvectomy. Sterile solutions are used for perineal care using a sterile syringe or water pick.

70) A

- Early ambulation should not exceed the client's tolerance. The client should be assessed before sitting. The client is assisted to rise from the lying position to the sitting position gradually until any evidence of dizziness, if present, has subsided. This position can be achieved by raising the head of the bed slowly. After sitting, the client may be assisted to a standing position. The nurse should be at the client's side to provide physical support and encouragement.


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Fundamentals Nursing Test Bank (61-65)

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61. After receiving detailed information about a colonoscopy from the provider, the nurse asks the client to sign the informed consent form and discovers that the client cannot write. Which is the best intervention for the nurse to implement?

a) contact the provider to obtain informed consent
b) obtain a verbal informed consent from the client
c) have two nurses witness the client sign with an X
d) clarify information to the client with another nurse

62. The nurse documents an entry regarding client care in the client's medical record. When checking the entry, the nurse notices some incorrect information. Which should the nurse implement?

a) obliterate the incorrect information with a black marker
b) use correction fluid to cover up the incorrect information
c) erase the error completely and write in the correct information
d) draw a line through the incorrect information and initial the change

63. The nurse prepares to suction a client through a tracheostomy tube. Which should the nurse wear to perform this procedure?

a) mask, gown, and a cap
b) mask, sterile gloves, and a cap
c) gown, mask, and sterile gloves
d) goggles, mask, and sterile gloves

64. The nurse instructs a client how to use crutches safely for ambulating at home. Which instruction should the nurse recommend to minimize the risk of falls?

a) remove all area rugs
b) wear soft, slip-on shoes
c) use the bathtub's grab bars
d) remove pets from the home

65. The nurse observes than an older postoperative client has episodes of extreme agitation. Which is the best nursing measure to implement to help avoid episodes of agitation?

a) gently hold the client's hand while speaking
b) wait until the client's agitation has subsided
c) speak while moving slowly toward the client
d) speak to the client from the entrance to the room





Fundamentals Nursing Test Bank
Answers and Rationale

61) C

- Nurses are responsible to make sure the signed informed consent form is in the client's medical record prior to a procedure and for clarifying facts presented by the provider. Nonetheless, the person performing the procedure obtains informed consent and provides the explanations to the client. Informed consent can be obtained verbally, but that is also the responsibility of the provider. Clients who cannot write may sign an informed consent with an X in the presence of two witnesses. Nurses can serve as a witness to the client's signature but not to the fact that the client is informed.

62) D

- To correct an error documented in a medical record, the nurse draws one line through the incorrect information and then initials the error. The information remains visible and properly labeled as incorrect. Errors are never erased, and correction fluid or black markers are never used on a legal document such as the medical record.

63) D

- The nurse should wear a mask and goggles when suctioning the client. Sterile gloves are also worn unless suctioning is performed using a closed suctioning system. A mask offers full protection of the nurse's nose and mouth, and goggles protect the nurse's eyes from getting splashed with sputum. A gown protects the nurse's uniform, and a cap protects the nurse's hair, but these items are not required for suctioning a client.

64) A

- To reduce the risk of falls, the nurse recommends the removal of all obstacles and trip hazards from the home. Tie-on shoes with nonslip soles should be worn while crutch walking. Grab bars in the bath tub or shower will not necessarily assist the client while walking with crutches. Not all pets are trip hazards (e.g., fish, birds, guinea pigs).

65) C

- Speaking and moving slowly toward the client will prevent the client from becoming further agitated, because any sudden moves or speaking too quickly may cause the client to have a violent episode. Holding the client's hand can be misinterpreted by a client to mean restraint. If the client's agitation is not addressed, it is likely to increase; therefore, waiting for the agitation to subside is not a suitable option. Remaining at the entrance of the room can make the client feel alienated.


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Fundamentals of Nursing Quiz (56-60)

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56. A client receives cardiopulmonary resuscitation in the emergency department, but it is unsuccessful. The wife of the client indicates that the client is an organ donor and that they want to donate the client's eyes. Which should the nurse implement first to promote organ transplantation?

a) confirm that the client is a valid donor with an organ registry
b) cover the eyes with wet saline gauze pads and small ice packs
c) place the client in a supine position with the head on one pillow
d) ask the wife to produce the legal documents supporting the donation

57. The nurse prepares a client for discharge who needs intermittent antibiotic infusions through a peripherally inserted central catheter (PICC) line. Which should the nurse include in client teaching about daily infusion care in the home?

a) keep the affected arm immobilized
b) aspirate 3 ml of blood from the PICC line
c) maintain a continuous intravenous infusion
d) check the insertion site for redness and swelling

58. The nurse is in orientation for a full-time position as a case manager. Which should the nurse implement related to professional liability insurance?

a) obtain his own malpractice insurance
b) wait for six months to a year to decide
c) rely on the agency for liability insurance
d) discontinue his own malpractice insurance

59. In the role of a caregiver, the nurse's primary responsibility is to assess the client's ability to:

a) protect self
b) set own goals
c) decide the best approach(es) for care
d) restore physical, emotional, and social well-being

60. The nurse prepares a client who has a right pleural effusion for a thoracentesis; however, the client experiences severe dizziness when sitting upright, into which alternate position does the nurse assist the client to maintain safety during the procedure?

a) right side-lying with the head of the bed flat
b) prone with the head turned toward the affected side
c) sim's position with the head of the bed elevated 45 degrees
d) left side-lying with the head of the bed elevated 45 degrees








Fundamentals of Nursing Quiz
Answers and Rationale

56) B

- When a corneal donor dies, the eyes are closed, covered with sterile gauze pads wet with saline, and cooled with small ice packs. Within 2 to 4 hours the eyes are harvested, and the cornea is usually transplanted within 24 to 48 hours after harvesting. The head of the bed is elevated 30 to 45 degrees to prevent edema and tissue damage. Calling an organ registry and asking the wife to produce documents does not promote organ transplantation.

57) D

- A PICC is designed for long-term intravenous infusions and, usually, is inserted into the median cubital vein with the terminal end of the catheter in the superior vena cava. Although the risk of infection is less with a PICC line than with a central venous catheter, it is possible for phlebitis or infection to develop. Clients must inspect the insertion site and affected arm daily and report any discharge, redness, swelling, or pain to the nurse or provider immediately. A PICC line does not require the affected arm to be immobilized and can be used for intermittent or continuous fluid infusion. Although a PICC line can be used to obtain a blood specimen, the risk of occlusion from aspirating blood as part of the related daily care is greater than any potential benefit.

58) A

- Nurses need individual liability insurance policies for protection against malpractice lawsuits beginning on the first day of employment. Many agencies discourage nurses from obtaining professional malpractice insurance because, if a plaintiff brings a suit against the nurse or the hospital, the agency prefers to have their attorneys in control. However, this may not be in the best interests of an individual nurse, and, if the nurse breached any agency policy, the hospital can deny legal protection to the nurse. Still, nurses should be aware that carrying malpractice insurance increases the likelihood of being named in a suit at the onset of the case, especially when the plaintiff is seeking monetary compensation.

59) D

- A primary role of the caregiver is to assess the client's ability to restore well-being. Options A, B, and C identify the nurse's role as a client advocate.

60) D

- Positioning can help isolate the fluid in a pleural effusion; generally, the client sits at the edge of the bed, leaning over the bedside table, allowing the fluid to collect in a dependent body area. If the client is unable to sit up, the nurse turns the client to the unaffected side and elevates the head of the bed 30 to 45 degrees. Turning to the affected side, the prone, and the Sims' positions are unsuitable positions for this procedure because these do not facilitate fluid removal.


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NCLEX Review - Fundamentals of Nursing Study Guide (51-55)

Welcome to NCLEX Review - Fundamentals of Nursing Study Guide. Before you begin answering the questions, you may first want to take a peek about the material that will surely help you the pass the NCLEX examination :

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51. A registered nurse (RN) is providing postmortem care for a deceased client whose eyes will be donated. Which nursing action is required to provide sound care of the client's body?

a) close the eyes and places the bed flat
b) maintains the client in a supine position
c) irrigates the client's eyes with normal saline
d) places wet saline gauze pads on the eyelids and a small ice pack on the gauze pads

52. A nurse is caring for a client receiving parenteral nutrition (PN). Which does the nurse implement to decrease the risk of infection?

a) assesses vital signs at 4-hour intervals
b) administers prophylactic antimicrobial agents
c) checks the solution's label against the prescription
d) uses aseptic technique in handling the PH solution

53. The home care nurse provides medication instructions to a male client. To ensure that the client self-administers his medications safely in the home, the nurse:

a) performs a pill count of each prescription bottle at every home visit
b) instructs the client to double up on a medication when a dose is missed
c) demonstrates the proper procedure for self-administration of medications
d) asks the client to explain and demonstrate self-administration procedures

54. A client asks the home care nurse to witness the client's signature in a living will with the client's attorney in attendance. Which should the nurse implement?

a) decline to witness the signature on the wall
b) sign the will as a witness to the signature only
c) notify the supervisor that a living will is being witnessed
d) sign the will with identifying credentials and employment agency

55. The nurse notes old and new ecchymotic areas on an older client's arms and buttocks upon admission. The client tells the nurse in confidence that her daughter frequently hits her. Which statement should the nurse use in response?

a) I have a legal obligation to report this type of abuse
b) let's get these treated and I will maintain the confidence
c) if this happens again, you must call the emergency department
d) let's talk about ways to prevent your daughter from hitting you






Fundamentals of Nursing Study Guide
Answers and Rationale

51) D

- When a corneal donor dies, the eyes are closed and sterile gauze pads wet with saline are placed over them with a small ice pack. Within 2 to 4 hours the eyes are enucleated, and the corneas are usually transplanted within 24 to 48 hours. The head of the bed should be elevated. With the head of the bed elevated, the eyes will likely remain closed. Eye irrigations, if indicated, would be prescribed by the transplant surgeon.

52) D

- Clients receiving PN are at high risk for developing infection because the concentrated glucose solutions are an excellent medium for bacterial growth. The nurse reduces the client's risk of infection by using aseptic technique when handling all equipment and solutions related to the PN infusion. Option A is a reasonable intervention for early detection of infection but does not prevent infection. Prophylactic antibiotics are not indicated for PN infusions and can contribute to the development of secondary infections. The nurse implements option C to ensure that the client receives the correct infusion.

53) D

- To ensure safe administration of medication, the nurse asks the client to explain and demonstrate correct self-administration of medication procedures because demonstrating the proper procedure for the client does not ensure that the client can safely perform any procedure. Usually, it is not acceptable to double up on missed medication, and conducting a pill count on each visit is unrealistic and disrespectful.

54) A

- Living wills must be written documents and signed by the client. The client's signature either must be witnessed by nonagency individuals or notarized, thus the nurse should decline to sign the will to avoid a conflict of interest. The nurse's signature on the living will testifies to the validity of the client's signature. If the nurse contacts the supervisor, the supervisor should advise the nurse to decline.

55) A

- The nurse should inform the client that nurses cannot maintain confidences about alleged abusive behavior and that the nurse must report situations related to abuse. The nurse avoids bargaining with the client about treatment to maintain a confidence that the nurse is legally bound to report. Options C and D delay protective action and place the client at risk for future abuse.


After you reviewed your answers through its rationale, you can also go back to the first page to start from the beginning:

NCLEX Review - Fundamentals of Nursing Study Guide (1-5)


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NCLEX Review - Fundamentals of Nursing Study Guide (56-60)

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