2016 NCLEX Practice Questions on Blood Infusion 81-85

81. A client is brought to the emergency department having experienced blood loss related to an arterial laceration. Fresh-frozen plasma is prescribed and transfused to replace fluid and blood loss. The nurse understands that which is the rationale for transfusing fresh-frozen plasma to this client?

a) To treat the loss of platelets
b) To promote rapid volume expansion
c) Because a transfusion must be done slowly
d) Because it will increase the hemoglobin and hematocrit levels

82. The nurse who is about to begin a blood transfusion knows that blood cells start to deteriorate after a certain period of time. Which item is important to check regarding the age of blood cells before the transfusion is begun?

a) Expiration date
b) Presence of clots
c) Blood group and type
d) Blood identification number

83. A client requiring surgery is anxious about the possible need for a blood transfusion during or after the procedure. The nurse suggests to the client to take which action(s) to reduce the risk of possible transfusion complications? Select all that apply.

a) Ask a family member to donate blood ahead of time.
b) Give an autologous blood donation before the surgery.
c) Take iron supplements before surgery to boost hemoglobin levels.
d) Request that any donated blood be screened twice by the blood bank.
e) Take adequate amounts of vitamin C several days prior to the surgery date.

84. A client with severe blood loss resulting from multiple trauma requires rapid transfusion of several units of blood. The nurse asks another health team member to obtain which device for use during the transfusion procedure to help reduce the risk of cardiac dysrhythmias?

a) Infusion pump
b) Pulse oximeter
c) Cardiac monitor
d) Blood-warming device

85. A client has a prescription to receive a unit of packed red blood cells. The nurse should obtain which intravenous (IV) solution from the IV storage area to hang with the blood product at the client’s bedside?

1. Lactated Ringer’s
2. 0.9% sodium chloride
3. 5% dextrose in 0.9% sodium chloride
4. 5% dextrose in 0.45% sodium chloride





NCLEX Practice Questions
Answers and Rationale

81) B
- Rationale: Fresh-frozen plasma is often used for volume expansion as a result of fluid and blood loss. It does not contain platelets, so it is not used to treat any type of low platelet count disorder. It is rich in clotting factors and can be thawed quickly and transfused quickly. It will not specifically increase the hemoglobin and hematocrit level.

- Test-Taking Strategy: Focus on the subject of the question, the purpose for transfusing fresh frozen plasma. Note the relationship between the words experienced blood loss and the correct option.

82) A
- Rationale: The nurse notes the expiration date on the unit of blood to ensure that the blood is fresh. Blood cells begin to deteriorate over time, so safe storage usually is limited to 35 days. Careful notation of the expiration date by the nurse is an essential part of the verification process before hanging a unit of blood. The nurse also notes the blood identification (unit) number, blood group and type, and client’s name. The nurse also inspects the unit of blood for leaks, abnormal color, clots, and bubbles and returns the unit to the blood bank if clots are noted.

Test-Taking Strategy: Focus on the subject , measures to verify prior to blood administration. Note the word deteriorate . To answer this question correctly, you must know which part of the pretransfusion verification procedure relates to the freshness of the unit of blood. Keeping this in mind should direct you to the correct option.

83) A, B
- Rationale: A donation of the client’s own blood before a scheduled procedure is autologous. Donating autologous blood to be reinfused as needed during or after surgery reduces the risk of disease transmission and potential transfusion complications. The next most effective way is to ask a family member to donate blood before surgery. Blood banks do not provide extra screening on request. Preoperative iron supplements are helpful for iron deficiency anemia but are not helpful in replacing blood lost during the surgery. Vitamin C enhances iron absorption, but also is not helpful in replacing blood lost during surgery.

- Test-Taking Strategy: Focus on the subject , reducing the risk of possible transfusion complications. Recalling that an autologous transfusion is the collection of the client’s own blood and also that family donation of blood is usually effective will direct you to the correct options.

84) D
- Rationale: If several units of blood are to be administered, a blood warmer should be used. Rapid transfusion of cool blood places the client at risk for cardiac dysrhythmias. To prevent this, the nurse warms the blood with a blood-warming device. Pulse oximetry and cardiac monitoring equipment are useful for the early assessment of complications but do not reduce the occurrence of cardiac dysrhythmias. Electronic infusion devices are not helpful in this case because the infusion must be rapid, and infusion devices generally are used to control the flow rate. In addition, not all infusion devices are made to handle blood or blood products.

- Test-Taking Strategy: Note the words rapid and reduce the risk . These words tell you that the infusions will infuse quickly and that the correct option is the one that will minimize the risk of cardiac dysrhythmias. Eliminate the pulse oximeter and cardiac monitor first because these items are comparable or alike and are used to assess for rather than reduce the risk of complications. From the remaining options, use knowledge related to the complications of transfusion therapy and note the relationship between the words several units of blood in the question and blood-warming device in the correct option.

85) B
- Rationale: Sodium chloride 0.9% (normal saline) is a standard isotonic solution used to precede and follow infusion of blood products. Dextrose is not used because it could result in clumping and subsequent hemolysis of red blood cells. Lactated Ringer’s is not the solution of choice with this procedure.

- Test-Taking Strategy: Eliminate options that contain dextrose first because they are comparable or alike . From the remaining options, remember that normal saline is an isotonic solution and the solution compatible with red blood cells.


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Parenteral Nutrition NCLEX Questions (Fundamentals 76-80)

76. The nurse is preparing to hang the first bag of parenteral nutrition (PN) solution via the central line of an assigned client. The nurse should obtain which most essential piece of equipment before hanging the solution?
a) Urine test strips
b) Blood glucose meter
c) Electronic infusion pump
d) Noninvasive blood pressure monitor

77. The nurse is making initial rounds at the beginning of the shift and notes that the parenteral nutrition (PN) bag of an assigned client is empty. Which solution readily available on the nursing unit should the nurse hang until another PN solution is mixed and delivered to the nursing unit?

a) 5% dextrose in water
b) 10% dextrose in water
c) 5% dextrose in Ringer’s lactate
d) 5% dextrose in 0.9% sodium chloride

78. The nurse is monitoring the status of a client’s fat emulsion (lipid) infusion and notes that the infusion is 1 hour behind. Which action should the nurse take?

a) Adjust the infusion rate to catch up over the next hour.
b) Increase the infusion rate to catch up over the next 2 hours.
c) Ensure that the fat emulsion infusion rate is infusing at the prescribed rate.
d) Adjust the infusion rate to run wide open until the solution is back on time.

79. A client receiving parenteral nutrition (PN) in the home setting has a weight gain of 5 lb in 1 week. The nurse should next assess the client for the presence of which condition?

a) Thirst
b) Polyuria
c) Decreased blood pressure
d) Crackles on auscultation of the lungs

80. The nurse is caring for a restless client who is beginning nutritional therapy with parenteral nutrition (PN). The nurse should plan to ensure that which action is taken to prevent the client from sustaining injury?

a) Calculate daily intake and output.
b) Monitor the temperature once daily.
c) Secure all connections in the PN system.
d) Monitor blood glucose levels every 12 hours.

81. A client receiving parenteral nutrition (PN) complains of a headache. The nurse notes that the client has an increased blood pressure, bounding pulse, jugular vein distention, and crackles bilaterally. The nurse determines that the client is experiencing which complication of PN therapy?

a) Sepsis
b) Air embolism
c) Hypervolemia
d) Hyperglycemia




Answers and Rationale

 76) C
- The nurse obtains an electronic infusion pump before hanging a PN solution. Because of the high glucose content, use of an infusion pump is necessary to ensure that the solution does not infuse too rapidly or fall behind. Because the client’s blood glucose level is monitored every 4 to 6 hours during administration of PN, a blood glucose meter also will be needed, but this is not the most essential item needed before hanging the solution. Urine test strips (to measure glucose) rarely are used because of the advent of blood glucose monitoring. Although the blood pressure will be monitored, a noninvasive blood pressure monitor is not the most essential piece of equipment needed for this procedure.

77) B
- The client is at risk for hypoglycemia; therefore the solution containing the highest amount of glucose should be hung until the new PN solution becomes available. Because PN solutions contain high glucose concentrations, the 10% dextrose in water solution is the best of the choices presented. The solution selected should be one that minimizes the risk of hypoglycemia. The remaining options will not be as effective in minimizing the risk of hypoglycemia.

78) C
- The nurse should not increase the rate of a fat emulsion to make up the difference if the infusion timing falls behind. Doing so could place the client at risk for fat overload. In addition, increasing the rate suddenly can cause fluid overload. The same principle (not increasing the rate) applies to PN or any intravenous (IV) infusion. Therefore the remaining options are incorrect.

79) D
- Optimal weight gain when the client is receiving PN is 1 to 2 lb/week. The client who has a weight gain of 5 lb/week while receiving PN is likely to have fluid retention. This can result in hypervolemia. Signs of hypervolemia include increased blood pressure, crackles on lung auscultation, a bounding pulse, jugular vein distention, headache, and weight gain more than desired. Thirst and polyuria are associated with hyperglycemia. A decreased blood pressure is likely to be noted in deficient fluid volume.

80) C
- The nurse should plan to secure all connections in the tubing (tape is used per agency protocol). This helps prevent the restless client from pulling the connections apart accidentally. The nurse should also monitor intake and output, but this does not relate specifically to a risk for injury as presented in the question. Also, monitoring the temperature and blood glucose levels does not relate to a risk for injury as presented in the question. In addition, the client’s temperature and blood glucose levels are monitored more frequently than the time frames identified in the options to detect signs of infection and hyperglycemia, respectively.

81) C
- Hypervolemia is a critical situation and occurs from excessive fluid administration or administration of fluid too rapidly. Clients with cardiac, renal, or hepatic dysfunction are also at increased risk. The client’s signs and symptoms presented in the question are consistent with hypervolemia. The increased intravascular volume increases the blood pressure, whereas the pulse rate increases as the heart tries to pump the extra fluid volume. The increased volume also causes neck vein distention and shifting of fluid into the alveoli, resulting in lung crackles. The signs and symptoms presented in the question do not indicate sepsis, air embolism, or hyperglycemia.


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Nursing Fundamentals Course (71-75)

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71. The nurse inserts an indwelling urinary catheter into a male client. As the catheter moves into the bladder, urine begins to flow into the tubing. Which should the nurse implement next?

a) inflate the balloon with water
b) insert the catheter 2.5 to 5 cm
c) measure the initial urine output
d) secure the catheter to the client

72. A nurse is collecting a sputum specimen for culture and sensitivity testing from a client who has a productive cough. The nurse plans to implement which intervention to obtain the specimen?

a) ask the client to obtain the specimen after breakfast
b) use a sterile plastic container for obtaining the specimen
c) provide tissues for expectoration and obtaining the specimen
d) ask the client to expectorate a small amount of sputum into the emesis basin

73. A client who is 40 years old has a severe mental impairment and is scheduled fro gallbladder surgery. Which should the nurse implement about the informed consent first to facilitate the scheduled surgery?

a) check for the identity of the client's legal guardian
b) inform the legal guardian about advanced directives
c) arrange fro the surgeon to provide informed consent
d) ensure that the legal guardian signed the informed consent

74. Which action does the nurse implement to obtain a urine specimen for a urinalysis from a female client with an indwelling urinary catheter?

a) detach the tubing of the drainage bag
b) use a sterile container for the specimen
c) cleanse the perineum from front to back
d) aspirate the urine from the drainage bag port

75. The nurse has given a subcutaneous injection to a client with acquired immunodeficiency syndrome (AIDS). The nurse disposes of the used needle and syringe by:

a) breaking the needle before discarding it
b) recapping the needle and discarding the syringe in a disposal unit
c) placing the uncapped needle and syringe in a labeled cardboard box
d) placing the uncapped needle and syringe in labeled, rigid plastic container







Nursing Fundamentals Course
Answers and Rationale

71) B

- The catheter's balloon is behind the opening at the insertion tip, so the nurse inserts the catheter 2.5 to 5 cm further after urine begins to flow in order to provide sufficient space to inflate the balloon. After the nurse secures the catheter to the client's leg, the nurse measures the initial urine output.

72) B

- Sputum specimens for culture and sensitivity testing need to be obtained using sterile techniques, because the test is done to determine the presence of organisms. If the procedure for obtaining the specimen is not sterile, then the specimen would be contaminated and the results of the test would be invalid. A first morning specimen is preferred because it represents overnight secretions of the tracheobronchial tree.

73) A

- The client is not competent to sign an informed consent, so the nurse verifies the identity of the client's legal guardian to fulfill part of the nurse's duty in informed consent. This helps avoid improperly signed documents and to direct the surgeon to the legal representatives of the client's interests. Most states require client notification of advanced directives at admission.

74) D

- A specimen for urinalysis does not need to be sterile; however, the system must remain sterile to reduce the risk of infection. Therefore, the nurse obtains the specimen using sterile technique and obtains a fresh specimen by aspirating urine from the drainage bag port after sanitizing the port and inserting a sterile needle. The nurse avoids breaking the integrity of the urinary collection system to prevent contamination. The nurse also avoids taking urine from the urinary drainage bag because the urine is less likely to reflect the current client status and because urine undergoes chemical changes and particulate matter settles over time. A sterile container is unnecessary for a urinalysis, and because the client has an indwelling catheter, perineal cleansing before obtaining a urine specimen is unnecessary.

75) D

- Standard precautions include specific guidelines for handling of needles. Needles should not be recapped, bent, broken, or cut after use. They should be disposed of in a labeled, impermeable container specific for this purpose. Needles should not be discarded in cardboard boxes, because these types of boxes are not impervious. Needles should never be left lying around after use.


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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)

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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.


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NCLEX Review - Fundamentals of Nursing 7th edition (46-50)

Welcome to NCLEX Review - 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

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46. A client is receiving nutrition by means of parenteral nutrition (PN). A nurse monitors the client for complications of  the therapy and assesses the client for which of the following signs of hyperglycemia?

a) fever, weak pulse, and thirst
b) nausea, vomiting, and oliguria
c) sweating, chills, and abdominal pain
d) weakness, thirst, and increased urine output


47. At 8 am, a nurse checks the amount of solution left in a parenteral nutrition (PN) infusion bag for an assigned client. It is a 3000 ml bag with 1000 ml remaining. The solution is running at a rate of 100 ml/hr. The bag was hung the previous day at noon. The nurse plans to change the infusion bag and tubing today at:

a) noon
b) 2 pm
c) 4 pm
d) 8 pm

48. A nurse is changing the central line dressing of a client receiving parenteral nutrition (PN) and notes that the catheter insertion site appears reddened. The nurse next assesses which of the following items?

a) client's temperature
b) expiration date on the bag
c) time of last dressing change
d) tightness of tubing connections

49. A nurse is preparing to hang fat emulsion (lipids) and notes that the fat globules are visible at the top of the solution. The nurse takes which of the following actions?

a) rolls the bottle of solution gently
b) obtains a different bottle of solution
c) shakes the bottle of solution vigorously
d) runs the bottle of solution under warm water

50. A nurse is preparing to change the total parenteral nutrition (TPN) solution bag and tubing. The client's central venous line is located in the right subclavian vein. The nurse asks the client to take which most essential action during the tubing change?

a) breathe normally
b) turn the head to the right
c) exhale slowly and evenly
d) take a deep breath, hold it, and bear down





Fundamentals of Nursing 7th edition:
ANSWERS AND RATIONALE

46) D

- The high glucose concentration in PN places the client at risk for hyperglycemia. Signs of hyperglycemia include excessive thirst, fatigue, restlessness, confusion, weakness, Kussmaul’s respirations, diuresis, and coma, when hyperglycemia is severe. If the client has these symptoms, the blood glucose level should be checked immediately. Options A, B, and C do not identify signs specific to hyperglycemia.

47) A

- Parenteral nutrition solution should be changed every 24 hours because the PN solution is a high-concentrate glucose solution and is a medium for bacterial growth. Infection control is also aided by use of aseptic technique with bag and tubing changes. Most agencies recommend that tubing be changed every 24 hours along with the bag, although some agencies recommend changing tubing every 48 to 72 hours. The nurse always should adhere to specific agency policies. Options B, C, and D identify insufficient time frames and present the risk for infection.

48) A

- Redness at the catheter insertion site is a possible indication of infection. The nurse would next assess for other signs of infection. Of the options given, the temperature is the next item to assess. The tightness of tubing connections should be assessed each time the PN is checked; loose connections would result in leakage, not skin redness. The expiration date on the bag is a viable option, but this also should be checked at the time the solution is hung and with each shift change. The time of the last dressing change should be checked with each shift change.

49) B

The nurse should examine the bottle of fat emulsion for separation of emulsion into layers or fat globules or for the accumulation of froth. The nurse should not hang a fat emulsion if any of these are observed and should return the solution to the pharmacy. Options A, C, and D are inappropriate actions.

50) D

- The client should be asked to perform the Valsalva maneuver during tubing changes. This helps avoid air embolism during tubing changes. The nurse asks the client to take a deep breath, hold it, and bear down. If the IV line is on the right, the client turns his or her head to the left. This position will increase intrathoracic pressure. Options A and C are inappropriate and could cause the potential for an air embolism during the tubing change.



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Fundamentals of Nursing 7th edition (1-5)

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Fundamentals of Nursing 7th edition (51-55)

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NCLEX Review - Fundamentals of Nursing 7th edition (41-45)

41. An adult female client has a hemoglobin level of 10.8 g/dL. The nurse interprets that this result is most likely caused by which of the following conditions noted in the client's history?

a) dehydration
b) heart failure
c) iron deficiency anemia
d) chronic obstructive pulmonary disease


42. The nurse is conducting a dietary assessment on a client who is on a vegan diet. The nurse plans to provide dietary teaching focusing on foods high in which vitamin that may be lacking in a vegan diet?

a) vitamin A
b) vitamin B12
c) vitamin C
d) vitamin E

43. A client is recovering from abdominal surgery and has a large abdominal wound. A nurse encourages the client to eat which food item that is naturally high in vitamin C to promote wound healing?

a) milk
b) oranges
c) bananas
d) chicken

44. A postoperative client has been placed on a clear liquid diet. Select the items that the client is allowed to consume on this diet. Select all that apply

a) broth
b) coffee
c) gelatin
d) pudding
e) vegetable juice
f) pureed vegetables


45. A nurse is preparing to care for a client who will receive parenteral nutrition (PN) support. The client is receiving dextrose, amino acids, and lipids all in one solution (total nutrient admixture). The nurse plans to do which of the following?

a) use a 1.2 um filter
b) use 0.22 um filter to ensure sterility
c) use a 0.10 um filter to ensure sterility
d) administer the solution without a filter





Fundamentals of Nursing 7th edition:
ANSWERS AND RATIONALE

41) C

- The normal hemoglobin level for an adult female client is 12 to 15 g/dL. Iron deficiency anemia can result in lower hemoglobin levels. Dehydration may increase the hemoglobin level by hemoconcentration. Heart failure and chronic obstructive pulmonary disease may increase the hemoglobin level as a result of the body’s need for more oxygen-carrying capacity.

42) B

- Vegans do not consume any animal products. Vitamin B12 is found in animal products and therefore would most likely be lacking in a vegan diet. Vitamins A, C, and E are found in fresh fruits and vegetables, which are consumed in a vegan diet.

43) B

- Citrus fruits and juices are especially high in vitamin C. Bananas are high in potassium. Meats and dairy products are two food groups that are high in the B vitamins.

44) A, B, C

- A clear liquid diet consists of foods that are relatively transparent to light and are clear and liquid at room and body temperature. These foods include items such as water, bouillon, clear broth, carbonated beverages, gelatin, hard candy, lemonade, Popsicles, and regular or decaffeinated coffee or tea. The incorrect food items are items that are allowed on a full liquid diet.

45) A

- A total nutrient admixture (TNA) is a solution that combines dextrose, amino acids, and lipids in one solution. A 1.2-µm filter or larger filter should be used because the lipid particles are too large to pass through a smaller (0.22- or 0.10-µm) filter. A 0.22-µm filter is used for 2-in-1 solutions containing only dextrose and amino acids. A 0.10-µm filter is smaller than a 1.2-µm filter. Administering the solution without using a filter is not an appropriate action.


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Fundamentals of Nursing Quiz (36-40)

Fundamentals of Nursing Quiz no. 36 - 40

36. A client is scheduled for blood to be drawn from the radial artery for an arterial blood gas determination. Before the blood is drawn, an Allen's test is performed to determined the adequacy of the:

a) ulnar circulation
b) carotid circulation
c) femoral circulation
d) popliteal circulation

37. A nurse is caring for a client with a nasogastric tube that is attached to low suction. The nurse monitors the client, knowing that he client is at risk for which acid-base disorder?

a) metabolic acidosis
b) metabolic alkalosis
c) respiratory acidosis
d) respiratory alkalosis

38. A nurse caring for a client with an ileostomy understands that he client is most at risk for developing which acid-base disorder?

a) metabolic acidosis
b) metabolic alkalosis
c) respiratory acidosis
d) respiratory alkalosis

39. A nurse is caring for a client with diabetic ketoacidosis and documents that the client is experiencing Kussmaul's respirations. Based on this documentation, which of the following did the nurse observe?

a) respirations that cease for several seconds
b) respirations that are regular but abnormally slow
c) respirations that are labored and increased in depth and rate
d) respirations that are abnormally deep, regular, and increased in rate

40. A client is brought to the emergency room stating that he has accidentally been taking two times his prescribed dose of warfarin (Coumadin) for the past week. After noting that the client has no evidence of obvious bleeding, the nurse plans to do which of the following next?

a) prepare to administer an antidote
b) draws a sample for type and crossmatch and transfuse the client
c) draws a sample for an activated partial thromboplastin time (aPTT)
d) draws a sample for prothrombin (PT) and international normalized ratio (INR) level






Fundamentals of Nursing Quiz:
ANSWERS AND RATIONALE

36) A

- Before radial puncture for obtaining an arterial specimen for arterial blood gases, you should perform an Allen’s test to determine adequate ulnar circulation. Failure to determine the presence of adequate collateral circulation could result in severe ischemic injury to the hand if damage to the radial artery occurs with arterial puncture. Options B, C, and D are incorrect options.

37) B

- Loss of gastric fluid via nasogastric suction or vomiting causes metabolic alkalosis as a result of the loss of hydrochloric acid. Options A, C, and D are incorrect.

38) A

- Intestinal secretions are high in bicarbonate and may be lost through enteric drainage tubes or an ileostomy, or with diarrhea. These conditions result in metabolic acidosis. Options B, C, and D are incorrect because they do not occur in the client with an ileostomy.

39) D

- Kussmaul’s respirations are abnormally deep, regular, and increased in rate. Apnea is described as respirations that cease for several seconds. In bradypnea, respirations are regular but abnormally slow. In hyperpnea, respirations are labored and increased in depth and rate.

40) D

- The next action is to draw a sample for PT and INR level to determine the client’s anticoagulation status and risk for bleeding. These results will provide information as to how to best treat this client if an antidote (vitamin K) or blood transfusion is needed. The aPTT monitors the effects of heparin therapy.


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Fundamentals Nursing Test Bank (31-35)

31. A nurse is caring for a client with a nasogastric tube. Nasogastric tube irrigation are prescribed to be performed once every shift. The client's serum electrolyte results indicate a potassium level of 4.5 mEq/L and a sodium level of 132 mEq/L. Based on these laboratory findings, the nurse selects which solution to use for the nasogastric tube irrigation?a) tap water
b) sterile water
c) sodium chloride
d) distilled water

32. A nurse is reviewing laboratory results and notes that a client's serum sodium level is 150 mEq/L. The nurse reports the serum sodium level to the physician and the physician prescribes dietary instructions based on the sodium level. Which food item does the nurse instruct the client to avoid?

a) peas
b) cauliflower
c) low-fat yogurt
d) processed oat cereals

33. A nurse is assessing a client with a suspected diagnosis of hypocalcemia. Which of the following clinical manifestations would the nurse expect to note in the client?

a) twitching
b) negative Trousseau's sign
c) hypoactive bowel sounds
d) hypoactive deep tendon reflexes

34. A nurse plans care for a client with chronic obstructive pulmonary disease, knowing that he client most likely to experience what type of acid-base imbalance?

a) metabolic acidosis
b) metabolic alkalosis
c) respiratory acidosis
d) respiratory alkalosis

35. A nurse is caring for a client who is on a mechanical ventilator. Blood gas results indicate a pH of 7.50 and a Pco2 of 30 mm Hg. The nurse has determined that the client is experiencing respiratory alkalosis. Which laboratory value would most likely be noted in this condition?

a) sodium level of 145 mEq/L
b) potassium level of 3.0 mEq/L
c) magnesium level of 2.0 mg/dL
d) phosporus level of 4.0 mg/dL





Fundamentals Nursing Test Bank:
ANSWERS AND RATIONALE

31) C

- A potassium level of 4.5 mEq/L is within normal range. A sodium level of 132 mEq/L is low, indicating hyponatremia. In clients with hyponatremia, sodium (isotonic) chloride should be used rather than water for gastrointestinal irrigations.

32) D

- The normal serum sodium level is 135 to 145 mEq/L. A serum sodium level of 150 mEq/L indicates hypernatremia. Based on this finding, the nurse would instruct the client to avoid foods high in sodium. Low-fat yogurt, cauliflower, and peas are good food sources of phosphorus. Processed foods are high in sodium content.

33) A

- Signs of hypocalcemia include paresthesias followed by numbness, hyperactive deep tendon reflexes, and a positive Trousseau’s or Chvostek’s sign. Additional signs of hypocalcemia include increased neuromuscular excitability, muscle cramps, twitching, tetany, seizures, irritability, and anxiety. Gastrointestinal symptoms include increased gastric motility, hyperactive bowel sounds, abdominal cramping, and diarrhea.

34) C

Respiratory acidosis is most often caused by hypoventilation. Chronic respiratory acidosis is most commonly caused by chronic obstructive pulmonary disease. In end-stage disease, pathological changes lead to airway collapse, air trapping, and disturbance of ventilation-perfusion relationships. Options A, B, and C are incorrect options.

35) B

- Clinical manifestations of respiratory alkalosis include headache, tachypnea, paresthesias, tetany, vertigo, convulsions, hypokalemia, and hypocalcemia. Options A, C, and D identify normal laboratory values. Option B identifies the presence of hypokalemia.


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NCLEX Review - Fundamentals of Nursing 7th edition (26-30)

NCLEX Review - Fundamentals of Nursing 7th edition

26. The nurse hears a client calling out for help, hurries down the hallway to the client's room, and finds a client lying on the floor. The nurse performs a thorough assessment, assists the client back to bed, notifies the physician of the incident, and completes an incident report. Which of the following should the nurse document on the incident report?

a) the client fell out of bed
b) the client climbed over the side rails
c) the client was found lying on the floor
d) the client became restless and tried to get out of bed

27. A client is brought to the emergency room by emergency medical services (EMS) after being hit by a car. The name of the client is not known and the client has sustained a severe head injury and multiple fractures, and unconscious. An emergency craniotomy is required. Regarding informed consent for the surgical procedure, which of the following is the best action?

a) obtain a court order for the surgical procedure
b) transport the victim to the operating room for surgery
c) call the police to identify the client and locate the family
d) ask the EMS team to sign the informed consent

28. A nurse is reading a physician's progress notes in the client's record and reads that the physician has documented "insensible fluid loss of approximately 800 ml daily." The nurse understands that this type of fluid loss can occur through:

a) the skin
b) urinary output
c) wound drainage
d) the gastrointestinal tract

29. A nurse instructs a client at risk for hypokalemia about the foods high in potassium that should be included in the daily diet. The nurse determines that the client understands the food sources of potassium if the client states that the food item lowest in potassium is:

a) apples
b) carrots
c) spinach
d) avocado

30. A nurse caring for a group of clients reviews the electrolyte laboratory results and notes a potassium level of 5.5 mEq/L on one client's laboratory report. The nurse understands that which client is at highest risk for the development of a potassium value at this level?

a) the client with colitis
b) the client with cushing's syndrome
c) the client who has been overusing laxatives
d) the client who has sustained a traumatic burn




Fundamentals of Nursing 7th edition:
ANSWERS AND RATIONALE

26) C

- The incident report should contain the client’s name, age, and diagnosis. The report should contain a factual description of the incident, any injuries experienced by those involved, and the outcome of the situation. Option 3 is the only option that describes the facts as observed by the nurse. Options A, B, and D are interpretations of the situation and are not factual information as observed by the nurse.

27) B

- Generally, there are two situations in which informed consent of an adult client is not needed. One is when an emergency is present and delaying treatment for the purpose of obtaining informed consent would result in injury or death to the client. The second is when the client waives the right to give informed consent. Option A will delay emergency treatment and option D is inappropriate. Although option C may be pursued, it is not the best action.

28) A

- Sensible losses are those of which the person is aware, such as through wound drainage, gastrointestinal tract losses, and urination. Insensible losses may occur without the person’s awareness. Insensible losses occur daily through the skin and the lungs.

29) A

- A medium apple provides about 159 mg of potassium. A large carrot provides 341 mg, spinach (3½ oz) provides 470 mg, and a medium avocado provides 1097 mg of potassium.

30) D

A serum potassium level higher than 5.1 mEq/L indicates hyperkalemia. Clients who experience cellular shifting of potassium in the early stages of massive cell destruction, such as with trauma, burns, sepsis, or metabolic or respiratory acidosis, are at risk for hyperkalemia. The client with Cushing’s syndrome or colitis and the client who has been overusing laxatives are at risk for hypokalemia.



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NCLEX Review - Fundamentals of Nursing 7th edition (21-25)

Fundamentals of Nursing 7th edition

21. A hospitalized client tells the nurse that a living will is being prepared and that the lawyer will be bringing the will to the hospital today for witness signatures. The client asks the nurse for assistance in obtaining a witness to the will. The appropriate response to the client is which of the following?

a) I will sign as a witness to your signature
b) you will need to find a witness on your own
c) whoever is available at the time will sign as a witness for you
d) I will call the nursing supervisor to seek assistance regarding your request


22. The nurse has made an error in documenting an assessment finding on a client and obtains the client's record to correct the error. The nurse corrects the error by:

a) documenting a late entry into the client's record
b) trying to erase the error for space to write in the correct data
c) using Wite-Out to delete the error to write in the correct data
d) drawing one line through the error, initiating and dating the line, and then documenting the correct information


23. The nurse employed in a hospital is waiting to receive a report from the laboratory via the fascimile (fax) machine. The fax machine activates and the nurse expects the report but instead receives a sexually oriented photograph. The appropriate initial nursing action is to:

a) call the police
b) cut up the photograph and throw it away
c) call the nursing supervisor and report the incident
d) call the laboratory and ask for the individual's name that sent the photograph

24. The nursing instructor provides a lecture to nursing students regarding the issue of client's rights and asks a nursing student to identify a situation that represents an example of invasion of client privacy. Which of the following, if identified by the student, indicates an understanding of a violation of this client right?

a) performing a procedure without consent
b) threatening to give a client a medication
c) telling the client that he or she cannot leave the hospital
d) observing care provided to the client without the client's permission

25. The nursing staff is sitting in the lounge taking their morning break. A nursing assistant tells the group that she thinks that he unit secretary has acquired immunodeficiency syndrome (AIDS) and proceeds to tell the nursing staff that the secretary probably contracted the disease from her husband, who is supposedly a drug addict. Which legal tort has the nursing assistant violated?

a) libel
b) slander
c) assault
d) negligence





Fundamentals of Nursing 7th edition:
ANSWERS AND RATIONALE

21) D

- Living wills are required to be in writing and signed by the client. The client’s signature must be witnessed by specified individuals or notarized. Many states prohibit any employee, including a nurse of a facility where the client is receiving care, from being a witness. Option B is nontherapeutic and not a helpful response. The nurse should seek the assistance of the nursing supervisor.

22) D

- If the nurse makes an error in documenting in the client’s record, the nurse should follow agency policies to correct the error. This includes drawing one line through the error, initialing and dating the line, and then documenting the correct information. A late entry is used to document additional information not remembered at the initial time of documentation. Erasing data from the client’s record and the use of Wite-Out are prohibited.

23) C

- Sexual harassment in the workplace is prohibited by state and federal laws. Sexually suggestive jokes, touching, pressuring a co-worker for a date, and open displays of or transmitting sexually oriented photographs or posters are examples of conduct that could be considered sexual harassment by another worker. If the nurse believes that he or she is being subjected to unwelcome sexual conduct, these concerns should be reported to the nursing supervisor immediately. Option A is unnecessary at this time. Options B and D are not appropriate initial actions.

24) D

- Invasion of privacy takes place with unreasonable intrusion into an individual’s private affairs. Performing a procedure without consent is an example of battery. Threatening to give a client a medication constitutes assault. Telling the client that the client cannot leave the hospital constitutes false imprisonment.

25) B

- Defamation is a false communication or a careless disregard for the truth that causes damage to someone’s reputation, either in writing (libel) or verbally (slander). An assault occurs when a person puts another person in fear of a harmful or an offensive contact. Negligence involves the actions of professionals that fall below the standard of care for a specific professional group.




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Fundamentals Nursing Test Bank (16-20)

Fundamentals Nursing Test Bank

16. The nurse calls the physician regarding a new medication order because the dosage prescribed is higher than the recommended dosage. Then nurse is unable to locate the physician and the medication is due to administered. Which action should the nurse take?

a) contact the nursing supervisor
b) administer the dose prescribed
c) hold the medication until the physician can be contacted
d) administer the recommended dose until the physician can be located

17. A nursing graduate is employed as a staff nurse in a local hospital. During orientation, the new graduate asks the nurse educator about the need to obtain professional liability insurance. The appropriate response by the nurse educator is:

a) it is very expensive and not necessary
b) the hospital's liability insurance will cover your actions
c) the majority of suits are filled against physicians and the hospital
d) nurses are encouraged to have their own professional insurance

18. The registered nurse arrives at work and is told to report (float) to the intensive care unit (ICU) for the day because the ICU is understaffed and needs additional nurses to care for the clients. The nurse has never worked in the ICU. The nurse should take which action first?

a) call the hospital lawyer
b) refuse to float to the ICU
c) call the nursing supervisor
d) report to the ICU and identify tasks that can be performed safely

19. The nurse gives an inaccurate dose of medication to a client. Following assessment of the client, the nurse completes an incident report. The nurse notifies the nursing supervisor of the medication error and calls the physician to report the occurrence. The nurse who administered the inaccurate medication dose understands that:

a) the error will result in suspension
b) the incident will be reported to the board of nursing
c) the incident will be documented in the personnel file
d) an incident report needs to be completed and is a method of promoting quality care and risk management

20. A nurse works on the night shift enters the medication room and finds a co-worker with a tourniquet wrapped around the upper arm. The co-worker is about to insert a needle, attached to a syringe containing a clear liquid, into the antecubital area. The appropriate initial action by the nurse is which of the following?

a)  call security
b) call the police
c) call the nursing supervisor
d) lock the co-worker in the medication room until help is obtained




Fundamentals Nursing Test Bank:
ANSWERS AND RATIONALE

16) A

- If the physician writes an order that requires clarification, the nurse’s responsibility is to contact the physician for clarification. If there is no resolution regarding the order because the physician cannot be located or because the order remains as it was written after talking with the physician, the nurse then should contact the nurse manager or nursing supervisor for further clarification as to what the next step should be. Under no circumstances should the nurse proceed to carry out the order until obtaining clarification.

17) D

- Nurses need their own professional liability insurance for protection against malpractice law suits. Nurses erroneously assume that they are protected by an agency’s professional liability policies. Usually, when a nurse is sued, the employer also is sued for the nurse’s actions or inactions. Even though this is the norm, nurses are encouraged to have their own professional liability insurance.

18) D

- Floating is an acceptable legal practice used by hospitals to solve their understaffing problems. Legally, a nurse cannot refuse to float unless a union contract guarantees that nurses can work only in a specified area or the nurse can prove the lack of knowledge for the performance of assigned tasks. When encountering this situation, the nurse should set priorities and identify potential areas of harm to the client. The nursing supervisor is called if the nurse is expected to perform tasks that he or she cannot safely perform. Calling the hospital lawyer is a premature action.

19) D

- Documentation of unusual occurrences, incidents, and accidents and of the nursing actions taken as a result of the occurrence is internal to the institution or agency and allows the nurse and administration to review the quality of care and determine any potential risks present. Based on the information provided in the question, the nurse’s error will not result in suspension,  nor will it be documented in the personnel file. The error and the situation presented in the question are not a reason for notifying the board of nursing.

20) C

- Nurse practice acts require reporting impaired nurses. The board of nursing has jurisdiction over the practice of nursing and may develop plans for treatment and supervision of the impaired nurse. This incident needs to be reported to the nursing supervisor, who will then report to the board of nursing and other authorities, such as the police, as required. The nurse may call security if a disturbance occurs, but no information in the question supports this need, and therefore this is not the initial action. Option D is an inappropriate and unsafe action.


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Fundamentals of Nursing Quiz (11-15)

Fundamentals of Nursing Quiz

11. An antihypertensive medication has been prescribed for a client with hypertension. The client tells the clinic nurse that she would like to take a herbal substance to help lower her blood pressure. The nurse should take which appropriate action?

a) tell the client that herbal substances are not safe and should never be used
b) advise the client to discuss the use of a herbal substance with the physician
c) teach the client how to take her blood pressure so that it can be monitored easily
d) tell the client that if she takes the herbal substance she will need to have her blood pressure checked frequently

12. A nurse educator is providing in-service education to the nursing staff regarding transcultural nursing care when a staff member asks the nurse educator to describe the concept of acculturation. The appropriate response is which of the following?

a) it is a subjective perspective of the person's heritage and a sense of belonging to a group
b) it is a group of individuals in a society who are culturally distinct and have a unique identity
c) it is a process of learning a different culture to adapt to a new or changing environment
d) it is a group that shares some of the characteristics of the larger population group of which it is a part

13. The nurse understands that which of the following statements regarding herbal therapies is true?

a) zinc is used for insomnia
b) ginger is used to improve memory
c) echinacea is used for erectile dysfunction
d) black cohosh produces estrogen-like effects

14. Which of the following are low-risk therapies? Select all that apply

a) herbs
b) prayer
c) touch
d) massage
e) relaxation
f) acupuncture

15. The nurse has just assisted a client back to bed after a fall. The nurse and physician have assessed the client, and have determined that he client is not injured. After completing the incident report, the nurse should take which action next?

a) reassess the client
b) conduct a staff meeting to describe the fall
c) document in the nurse's notes that an incident report was completed
d) contact the nursing supervisor to update information regarding the fall





Fundamentals of Nursing Quiz:
ANSWERS AND RATIONALE

11) B

- Although herbal substances may have some beneficial effects, not all herbs are safe to use. Clients who are being treated with conventional medication therapy should be advised to avoid herbal substances with similar pharmacological effects because the combination may lead to an excessive reaction or to unknown interaction effects. Therefore, the nurse would advise the client to discuss the use of the herbal substance with the physician. Options A, C, and D are inappropriate nursing actions.

12) C

- Acculturation is a process of learning a different culture to adapt to a new or changing environment. Option A describes ethnic identity. Option B describes an ethnic group. Option D describes a subculture.

13) D

- Black cohosh produces estrogen-like effects. Zinc stimulates the immune system and is used for its antiviral properties. Echinacea stimulates the immune system and ginger is used for nausea and vomiting.

14) B, C, D, E

- Low-risk therapies include meditation, relaxation techniques, imagery, music therapy, massage, touch, laughter and humor, and spiritual measures, such as prayer.  The other options are not considered low-risk therapies.

15) A

- The client’s fall should be treated as private information and shared on a “need to know” basis. Communication regarding the event should involve only those participating in the client’s care. An incident report is a problem-solving document; however, its completion is not documented in the nurse’s notes. If the nursing supervisor has been made aware of the incident, the supervisor will contact the nurse if status update is desired. After a client’s fall, the nurse must frequently reassess the client, because potential complications do not always appear immediately after the fall.


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• Fundamentals of Nursing  Concepts
• Medical-Surgical Concepts
• Maternal and Child Concepts

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NCLEX Review - Fundamentals of Nursing Study Guide (6-10)

Fundamentals of Nursing Study Guide

6.The role of the nurse regarding complementary and alternative medicine (CAM) should include:

a) recommending herbal remedies that the client should use
b) educating the client about "good" versus "bad" therapies
c) discouraging the client from using any alternative therapies
d) educating the client about therapies that he or she is using or is interested in using

7. A nursing student is discussing cultural diversity issues in a clinical conference when a nursing instructor asks the student to describe ethnocentrism. Which statement by the student indicates a lack of understanding of the issue of ethnocentrism?

a) it is a tendency to view one's own ways as best
b) it is acting in a manner that is superior to other cultures
c) it is imposing one's beliefs on individuals from another culture
d) it is believing that one's own way is the only acceptable way

8. When communicating with a cultural diverse client who speaks a different language, the best practice for the nurse is to:

a) speak loudly and slowly
b) stand close to the client and speak loudly
c) arrange for an interpreter when communicating with the client
d) speak to the client and family together to increase the chances that the topic will be understood

9. Which of the following clients has the lowest risk of obesity and diabetes mellitus?

a) a 45 year-old Native-American male
b) a 23 year-old Asian-American female
c) a 35 year-old Hispanic-American male
d) a 40 year-old African-American female

10. A nurse is bathing a hospitalized Native American client of the Navajo culture and notes that the client avoids eye contact during the procedure. The nurse makes which interpretation about the client's behavior?

a) the client is depressed
b) the client is displaying disrespectful mannerisms
c) the client is displaying behavior that is a common cultural action
d) the client is humiliated because of hte need to be cared for by someone else





Fundamentals of Nursing Study Guide:
ANSWERS AND RATIONALE:

6) C

- Complementary (alternative) therapies include a wide variety of treatment modalities that are used in addition to conventional therapy to treat a disease or illness. Educating the client about therapies that he or she uses or is interested in using is the nurse’s role. Options A, B, and C are all inappropriate actions for the nurse to take.

7) C

- Ethnocentrism is a tendency to view one’s own way of life as the most desirable, acceptable, or best and to act in a superior manner toward another culture. Cultural imposition is the tendency to impose one’s own beliefs, values, and patterns of behavior on individuals from another culture.

8) C

- Arranging for an interpreter would be the best practice when communicating with a client who speaks a different language. Options A and B are inappropriate and are ineffective ways in which to communicate. Option D is inappropriate because it violates privacy and does not ensure correct translation.

9) B

- Asian Americans have the lowest risk of obesity and diabetes mellitus from the options provided.  Native Americans, African Americans, and Hispanic Americans have a high risk of obesity and diabetes mellitus.

10) C

- Native American clients often avoid eye contact when being cared for by health care personnel. In this culture, eye contact is considered a sign of disrespect. Therefore, this client's action is culturally appropriate behavior. Options A, B, and D are inappropriate interpretations of the client's behavior.



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Related Topics:

• Fundamentals of Nursing  Concepts
• Medical-Surgical Concepts
• Maternal and Child Concepts

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