Fundamentals Nyclex Lessons 7

Question 1

Patient is developing shock. Which action should the nurse take?

1. Elevate the victim’s head
2. Elevate the victim’s legs and feet
3. Elevate the victim’s upper body
4. Leave the victim in a flat position

Answer 1

elevate the victim’s legs and feet

Question 2

Nurse finds a client in a burning car.
Client is breathing with fractured arm and lacerations that are bleeding profusely. what action should the nurse take first?

1. Splint the fractured arm
2. get the client out of the car
3. give mouth to mouth resuscitation
4. stop the bleeding

Answer 2

get the client out of the car

Question 3

A neighbor tells the nurse that her 12 y/o son has been burned with scalding water. The arm is red and starting to blister. In addition to advising her to see a hip, what will the nurse tell the neighbor to apply to the burn?

1. hydrogen peroxide
2. petroleum jelly
3. cool compresses
4. salt water compress

Answer 3

cool compress

Question 4

Nurse comes across a one-car auto accident. the driver of the car is walking around with a dazed look on his face. he states that he was wearing his seatbelt but is unsure of what happened exactly.
He has no visible injury. In checking his vitals, the nurse finds his blood pressure is 84/56, P 110, and R 32. Another bystander says that ambo is enroute. Nurse initial action?

1. complete neuro assessment
2. instruct him to get back in the car and rest
3. position him on his back on the ground with legs and feet elevated
4. assess for any wounds that may be contributing to his memory loss.

Answer 4

Position him on his back on the ground with legs elevated

Question 5

the nurse is told in report that one of the patients been depressed lately. on checking the unit, nurse finds the patient in bathroom with one wrist bleeding profusely. The patient states that he broke a glass and used it to cut his wrist in a suicide attempt. what should the nurse do after sending someone to call for help?

1. attempt to find out what has been causing her depression
2. apply a tourniquet above the injury
3. use 4x4 gauze pads to apply direct pressure
4. Thoroughly wash the wound

Answer 5

use a 4x4 to apply direct pressure

Question 6

neighbor tells the nurse that her 5 y/o son has ingested one of her liquid cleaning supplies. the child is in no distress at this time. the mother shows the nurse the bottle, the nurse is unfamiliar wit the ingredients. which action by the nurse is appropriate?

1. give syrup of ipecac to induce vomitting
2. give milk to neutralize any acids
3. give water to dilute the poison
4. call the poison control center

Answer 6

call the poison control center

Question 7

the nurse comes upon a victim who is unconscious. place in order the interventions that the nurse should take.

1. admin 30 chest compressions
2. give 2 mouth to mouth breaths
3. check the carotid pulse
4. activate the EMS
5. Open airway

Answer 7

open airway
activate EMS
check carotid pulse
admin 30 chest compressions
give 2 mouth to mouth breaths

Question 8

Nurse is in the park and witnesses a child getting stung by a wasp. what action should the nurse implement 1st?

1. Cleanse the site with soap and water
2. remove the stinger with a scraping motion’
3. apply ice to the stung area
4. determine whether the child has any allergy to wasp

Answer 8

remove the stinger with a scraping motion

Question 9

Nurse is assessing an adult patient who has been brought to the hospital with 3rd degree burns covering his head, right arm, and right leg. The nurse demonstrates accurate assessment skills by determining what to be the extent of the patient’s burns?

1. 27%
2. 36%
3. 45%
4. 54%

Answer 9

27%

The front and back of the head and neck = 9%
The front and back of each arm and hand = 9%

Question 10

A man suffers heat exhaustion while mowing the grass. the man’s wife demonstrates knowledge of proper care of her husband with which action? SATA

1. The wife calls 911 immediately
2. the wife encourages her husband to sit in a tub of cold water
3. the wife gives her husband cold water and a sports drink
4. the wife carefully monitors her husband while he finished mowing
5. the wife loosens her husband’s clothing.

Answer 10

The wife looses her husband’s clothing
911
cold water and sports drink

Question 11

How to treat frostbite. What statement indicates the need for further teaching?

1. “I should place the frozen body part in hot water around 110-114F”
2. I can wrap a frozen body part in a warm moist towel”
3. “I should avoid vigorous rubbing the frozen body part”
4. “After the frozen part is warmed, I should wrap it in clean material and elevate it”

Answer 11

I should avoid vigorous rubbing the frozen body part

Question 12

Patient comes to the sport medical center after twisting his ankle. the hcp determine he has a sprain. what discharge instructions will the nurse include in discharge summary for the patient? SATA

1. apply ice to the sprained area for 1 hour, then off for 1 hour.
2. wrap your ankle with an ACE bandage each morning
3. elevate your leg as much as possible to prevent further swelling
4. exercise your ankles as soon as you get home to prevent stiffness
5. You will use warm compresses to increase blood flow to the area after removing the ice.

which numbers are correct?

Answer 12

2,3,5

Question 13

Patient suffered a fracture of the tibia after crashing his motorcycle. he tells the nurse that his hcp told him he shattered his tibia in 3 places and will need surgery. The nurse is aware that the patient has which type of fracture?

1. greenstick
2. spiral’
3. comminuted
4. compound

Answer 13

comminuted

Question 14

Several high school teachers completed a CPR class. which comment by one of the teachers demonstrates knowledge of proper CPR? SATA

1. chest compressions should be at least 100 per min’
2. a jaw thrust maneuver should be used on all patients with an open airway
3. the proper sequence for CPR is circulation , airway and breathing
4. I should look, listen and feel for breathing for no more than 10 seconds
5. the adult chest should be compressed at least 2 inches during compressions

which numbers are correct?

Answer 14

1, 3, 5

Question 15

When the nurse is caring for a person who has developed a nosebleed, which nursing action is appropriate ?

1. apply steady pressure to the bridge of the nose for 5 mins
2. remind the victim to try to breathe though the nose
3. avoid using ice over the nose
4. keep the victims head tilted slightly forward

Answer 15

keep the victim head tilted slightly forward

other interventions include:

apply pressure to bridge of nose for 10-15 mins
apply ice compress over nose
check the back of throat for bleeding
seek care if bleeding continues despite Interventions

Question 16

After surgery for a total knee replacement, a patient was given an epidural catheter for fentanyl epidural analgesia. What is the most important nursing intervention?

1. Admin additional analgesic meds as needed
2. change the epidural dressing every shift
3. assess respiratory rate
4. encourage ambulation

Answer 16

assess respiratory rate

Question 17

A 52 y/o patient admitted for deep vein thrombosis of the left iliac vein c/o excruciating pain in his left leg . What is the most appropriate response by the nurse?

1. “Pain is what you say it is; I will assist you in whatever way I can”
2. “Your pain is an unpleasant sensation cause by inflammation if the vein and difficult to control”
3. “Your pain is one of the cardinal signs of inflammation.”
4. ” I know you are in pain, but it is important that we guard against possible addiction to opioids.”

Answer 17

Pain is what you say it is, I will assist you in whatever way I can

Question 18

A 63 y/o patient underwent a lower anterior bowel resection yesterday. What common central nervous system analgesic is prescribed often for pain?

1. Aspirin
2. Acetaminophen (Tylenol)
3. Morphine
4. Ibuprofen (Motrin)

Answer 18

Acetaminophen (Tylenol)

Question 19

What delivery system is used to control pain vi a portable computerized pump with a chamber for a syringe?

1. Patient controlled analgesia (PCA)
2. Transcutaneous electric nerve stimulation
3. A venous access device
   4 an intraecal delivery system

Answer 19

Patient controlled anaglesia

Question 20

The nursing student is discussing the gate control theory of pain. Which statement by the student indicates the need for further instruction? SATA

1. The gate of the pain pathways can be opened with therapeutic massage and heat treatments
2. pain has exclusive use of the pathways ahead of other stimuli according to the theory
3. Distraction is beneficial in pain management according to the theory
4. pain is a manifestation of an intricate chain of electrochemical events
5. Memories and feelings may alter gating mechanisms

Answer 20

Distracton is beneficial in pain management according to the theory

pain is a manifestation of an intricate chain of electrochemical events

memories and feelings may alter gating mechanisms

Question 21

Patient admitted with severe cellulitis of the left breast states “I have a severe burning pain and it feel like my breast is on fire”. she rates her pain as 7 on the 0-10 pain assessment scale. How would this collection of data by the nurse in assessing the patient’s pain be classified.

1. Deductive
2. speculative
3. Objective
4. Subjective

Answer 21

Subjective

Question 22

The nurse listens attentively while the patient describes her angina pectoris pain as radiating down her inner arm to the little finger and upward to the jaw and shoulder. What term is used to classify this type of pain?

1. precisely localized
2. referred
3. intermittent
4. chronic

Answer 22

Referred

Question 23

Nurse is assessing the patient’s description of his back pain. He states that it is immobilizing , intense, on a scale of 0-10 it is an 8. What type of pain assessment scale is this patient using.

1. Visual
2. Category
3. functional
4. Numeric

Answer 23

Numeric

Question 24

Nurse is caring for two patients with similar injuries. One patient expresses severe pain, and the other reports feeling fine with low levels of pain. Which statement is most correct?

1. The patient having more intense reports of pain has dysfunctional endorphins
2. The patient having lesser levels of pain has a higher level of endorphins
3. The patient experiencing intense pain has lower levels of endorphins
4. the patient having elevated levels of pain has a alteration I recognition of endorphins by the hypothalamus

Answer 24

The patient having lesser amount of pain, have higher amount of endophins

Question 25

Patient admitted to the orthopedic section for acute back pain. the hcp is planning to use cutaneous stimulation management. Which is an example of this pain control method?

1. epidural analgesia
2. Transcutaneous electric nerve stimulation (TENS)
3. Nonsteroidal antiinflammatory drugs (NSAIDS)
4. Patient controlled analgesia

Answer 25

Tanscutaneous electric nerve stimulation (TENS)

Question 26

What statement is correct concerning unrelieved pain?

1. Unrelieved pain is a normal expectation after major surgery
2. patients with cancer diagnosis can expect to experience unrelieved pain
3. physiologic and psychological complications can result from unrelieved pain.
4. Although unrelieved pain is stressful and annoying, it is not as important as other physical care needs

Answer 26

Physiologic and psychological complications can result from unrelieved pain

Question 27

What us the priority responsibility of the nurse related to pain?

1. leave the patient alone to rest
2. help the patient appear to not be in pain
3. Believe what the patient says about pain
4. assume responsibility for eliminating the patients’s pain

Answer 27

Believe what the patient says about pain

Question 28

Research indicates that the risk of clinically significant opioid-induced respiratory depression is

1. less than 1%
2. 5%
3. 20%
4. 30%

Answer 28

less than 1%

Question 29

Which route is most appropriate for treating rapidly escalating severe pain?

1. Oral
2. Intramuscular (IM)
   3.Intravenous (IV)
3. Transdermal

Answer 29

Intravenous

Question 30

Which opioid is no longer a drug of choice for managing pain because of its toxic complications such as causing seizures?

1. Codeine
2. Morphine
3. Meperidine
4. Fentanyl

Answer 30

Meperidine

Question 31

Nurse has recommended the patient consider music therapy to manage pain after an upcoming surgery. What info should be provided to the patient ? SATA

1. Music therapy works best when selections are instrumental instead of songs containing words.
2. Music therapy is successful for at least 50% of people who try it.
3. Music therapy promotes relaxation and takes the focus away from the pain being experienced.
4. Music therapy is easily a self directed means of pain management
5. Music therapy’s success is limited to postoperative pain.

Answer 31

Music therapy is successful for at least 50% of people who try it

Music therapy promotes relaxation and takes the focus away from the pain being experienced

Music therapy is easily a self directed means of pain management

Question 32

Patient prescribed acetaminophen to manage pain after a sports injury. What information can be included in the discussion about this medication with the patient? SATA

1. This medication is limited to the management of mild pain
2. The dosage of acetaminophen should be limited to 4000 mg (4g) in a 24hour period
3. Acetaminophen is associated with gastrointestinal upset
4. Excessive dosages are associated with hepatoxicity
5. Acetaminophen works by blocking pain impulses

Answer 32

The dosage of acetaminophen should be should be limited to 4000 mg (4g) in a 24 hour period

Excessive dosages are associated with hepatotoxicity

Acetaminophen works by blocking pain impulses

Question 33

Among alternative therapies, acupressure may be most effective with effective with which patient?

1. A patient who is restless and anxious
2. a patient in whom ulcerative colitis has been diagnosed
3. a pregnant patient
4. a patient with mental health concerns

Answer 33

a patient who is restless and anxious

Question 34

The nurse is preparing a presentation on alternative therapies for a community group. Which statement should be included in the presentation?

1. Herbal therapies are approved by the US Food and Drug Admin under the food, drug and cosmetic act
2. Herbal therapies are sold as medicines in most stores because they lack major side effects
3. Herbal therapies may be packaged as dietary supplements if they are without health claims
4. Herbal therapies are consistent in their standards for concentrations

Answer 34

Herbal therapies may be packaged as dietary supplements if they are without health claims

Question 35

Patient asks about different herbal therapies that may promote physical endurance and reduce stress. Which herb promotes physical endurance and reduces stress?

1. Ginseng
2. Ginger
3. Echinacea
4. Chamomile

Answer 35

Ginseng

Question 36

When assessing a patient’s use of alternative therapies, the nurse should ask which question?

1. “what herbal supplements have you taken?”
2. “Have you ever used relaxation therapy?”
3. “What types of activities or remedies do you use when you dont not feel well?”
4. Do you take holistic treatments?

Answer 36

what types of activities or remedies do you use when you dont feel well?

Question 37

A patient questions the nurse about the use of complementary and alternative medicine. Which statement made by the nurse is correct regarding complementary and alternative medicine?

1. 1/3 of the US population uses one or more forms of alternative therapy
2. decreasing amounts of insurance coverage are avail to meet the needs of alternative therapies
3. Discussion of alternative is still not provided in traditional medical journals
4. integration of alternative therapies is regulated by state and national agencies.

Answer 37

1/2 of US population uses one or more forms of alternative therapy

Question 38

A patient receiving chemotherapy is implementing relaxation therapy in conjunction with medical protocol. Which benefit can this patient gain from relaxation therapy?

1. Decreased receptivity
2. Decreased peripheral skin temperature
3. decreased oxygen consumption
4. decreased a-wave brain activity

Answer 38

decreased oxygen consumption

Question 39

the nurse is preparing to administer medications to a patient taking several herbal preparations. which factor makes accurate administration of precise dosages of herbs difficult?

1. the fact that multiple clinical trials are under way
2. Availability in many different forms
3. Infrequent usage by consumers
4. excessive standardization by international organizations

Answer 39

Availability in many different forms

Question 40

Nurse is educating patients at a health care clinic about the use of herbs as a complementary therapy. which instruction should be included in education about safe herbal product usage? SATA

1. Combine several herbs to maximize the benefits
2. believe all claims made by the manufacturer
3. discontinue using herbs if side effects develop
4. Inform your primary care provider of all herbal products that you use.
5. Drug interactions may exist with anti platelet meds

Answer 40

Discontinue using herbs if side effects develop

inform your pap of all herbal products that you use

drug interactions may exist with anti platelet meds

Question 41

Patients at an integrative health care center are learning about various types of complementary and alternative health care methods. What is a method of stimulating certain points on the body by insertion of special needles to modify the perception of pain, normalize physiologic functions or treat or prevent disease?

1. Acupressure
2. Magnet therapy
3. Acupunture
4. Chiropractic therapy

Answer 41

Acupuncture

Question 42

Patient reported to the ambulatory care clinic. During the collection of data, the patient reports using reflexology on a weekly basis. What is a contraindication to use of reflexology? SATA

1. Taking chemotherapy for cancer
2. History of hypertension
3. Pregnancy
4. Epilepsy
5. History of cardiac disease

Answer 42

history of hypertension
epilepsy
history of cardiac disease

Question 43

The patient reports a reduction in pain and spasms since taking marijuana daily for her multiple sclerosis. What side effect is the nurse most likely to assess?

1. Decrease respiratory rate
2. increased appetite
3. Nausea
4. Rash

Answer 43

nausea

Question 44

_____________ Nursing addresses and treats the mind, body and spirit.

Answer 44

Holistic

Question 45

Which statement about complementary and alternative medicine (CAM) therapies is most correct?

1. The patient is actively involved in the treatment
2. The patient becomes a total believer in what is being taught
3. The patient becomes increasingly submissive to the practitioner
4. The patient becomes less competent in his or her own care.

Answer 45

The patient is actively involved in the treatment

Question 46

A patient is taking the herb comfrey on a daily basis for its wound-healing properties. What information is important for the nurse to tell this patient?

1. Comfrey should be taken internally
2. Comfrey may cause cancer
3. Comfrey can be used only externally
4. Comfrey is a known antiseptic

Answer 46

Comfrey can be used only externally

Question 47

When the nurse reviews the patient’s medical Diagnoses, which condition would be a cause for concern with regard to chiropractor treatments? SATA

1. Acute myelopathy
2. Vertigo
3. Osteoporosis
4. Hypertension
5. Rheumatoid arthritis

Answer 47

Acute myelopathy
Osteoporosis
Rheumatoid Arthritis

Question 48

The nurse is caring for an patient on the acute care unit. The patient reports that he takes St. John’s wort for mild depression. When the nurse reviews the patient’s dietary selections, which choice indicates the need for further teaching? SATA

1. Foods high in salt or sodium
2. Milk products
3. Anything containing barley, such as beer
4. aged cheese
5. red wine

Answer 48

anything containing barley , such as beer
aged cheese
red wine