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

Welcome to Fundamentals of Nursing 7th edition. 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 :

Complete NCLEX Study Materials

Enjoy answering and I hope that NCLEX Review and Secrets can somehow help you in your future examination. Good Luck.



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.


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

Fundamentals of Nursing 7th edition (1-5)


Or proceed to the next set of questions:

Fundamentals of Nursing 7th edition (71-75)