Fundamentals of Nursing NCLEX Practice Questions Quiz #4 | 75 Questions

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Fundamentals of Nursing NCLEX Practice Questions Quiz #5 | 75 Questions

FNDNRS-05-001

Once a nurse assesses a client’s condition and identifies appropriate nursing diagnoses, a:

A. Plan is developed for nursing care.
B. Physical assessment begins.
C. List of priorities is determined.
D. Review of the assessment is conducted with other team members.

Correct Answer: A. Plan is developed for nursing care.

Option B: Assessment is the first step and involves critical thinking skills and data collection; subjective and objective. Subjective data involves verbal statements from the patient or caregiver. Objective data is measurable, tangible data such as vital signs, intake and output, and height and weight.
Option C: A nursing diagnosis encompasses Maslow’s Hierarchy of Needs and helps to prioritize and plan care based on patient-centered outcomes. In 1943, Abraham Maslow developed a hierarchy based on basic fundamental needs innate for all individuals.
Option D: Data may come from the patient directly or from primary caregivers who may or may not be direct relation family members. Friends can play a role in data collection. Electronic health records may populate data and assist in assessment.

FNDNRS-05-002

Planning is a category of nursing behaviors in which:

A. The nurse determines the health care needed for the client.
B. The physician determines the plan of care for the client.
C. Client-centered goals and expected outcomes are established.
D. The client determines the care needed.

Correct Answer: C. Client-centered goals and expected outcomes are established.

Option A: Nursing care plans are essential in this phase of goal setting. Care plans provide a course of direction for personalized care tailored to an individual’s unique needs. Overall condition and comorbid conditions play a role in the construction of a care plan.
Option B: As explored by Salmond and Echevarria, healthcare is changing, and the traditional roles of nurses are transforming to meet the demands of this new healthcare environment. Nurses are in a position to promote change and impact patient delivery care models in the future.
Option D: Care plans enhance communication, documentation, reimbursement, and continuity of care across the healthcare continuum. Critical thinking skills will play a vital role as nurses develop plans of care for these patient populations with multiple comorbidities and embrace this challenging healthcare arena.

FNDNRS-05-003

Priorities are established to help the nurse anticipate and sequence nursing interventions when a client has multiple problems or alterations. Priorities are determined by the client’s:

A. Physician
B. Non-Emergent, non-life-threatening needs
C. Future well-being.
D. Urgency of problems

Correct Answer: D. Urgency of problems

Triage of patients involves looking for signs of serious illness or injury. These emergency signs are connected to the Airway – Breathing – Circulation/Consciousness – Dehydration and are easily remembered as ABCD. If the client does not have any emergency signs, the health worker proceeds to assess the client for priority conditions. This should not take more than a few seconds. Some of these signs will have been noticed during the ABCD triage and others need to be rechecked.

Option A: All clinical staff involved in the care of the sick should be prepared to carry out a rapid assessment to identify the few clients who are severely ill and require emergency treatment.
Option B: Triage is the process of rapidly examining sick children when they first arrive in order to place them in one of the following categories: those with EMERGENCY SIGNS who require immediate emergency treatment; those with PRIORITY SIGNS who should be given priority in the queue so they can be rapidly assessed and treated without delay; and those who have no emergency or priority signs and are NON-URGENT cases. These clients can wait their turn in the queue for assessment and treatment. The majority of sick clients will be non-urgent and will not require emergency treatment.
Option C: Ideally, all clients should be checked on their arrival by a person who is trained to assess how ill they are. This person decides whether the client will be seen immediately and receive life-saving treatment, or will be seen soon, or can safely wait for his or her turn to be examined.

FNDNRS-05-004

A client-centered goal is a specific and measurable behavior or response that reflects a client’s:

A. Desire for specific health care interventions.
B. Highest possible level of wellness and independence in function.
C. Physician’s goal for the specific client.
D. Response when compared to another client with a similar problem.

Correct Answer: B. Highest possible level of wellness and independence in function.

Client-centered practices facilitate the development of strong therapeutic relationships and enable care providers to understand how to maximize clients’ strengths and minimize challenges in achieving treatment and recovery goals.

Option A: Care providers negotiate between clients’ decisions and ongoing risk assessments. The care plan reflects safe practices and promotes interventions that minimize or reduce potential harms to the client.
Option C: Client-centred care empowers clients, promoting autonomy, rights, voice, and self-determination in the treatment planning and recovery process and supports care plans that are developed in collaboration with clients, and allows clients to express their self-identified needs and choices.
Option D: Client-centred care is about treating clients as they want to be treated, with knowledge about and respect for their values and personal priorities. Health care providers who take the time to get to know their clients can provide care that better addresses the needs of clients and improves their quality of care.

FNDNRS-05-005

For clients to participate in goal setting, they should be:

A. Alert and have some degree of independence.
B. Ambulatory and mobile.
C. Able to speak and write.
D. Able to read and write.

Correct Answer: A. Alert and have some degree of independence.

Goal setting in nursing provides direction for planning nursing interventions and evaluating patient progress. The purpose of goal setting in nursing is to enable the patient and nurse to determine when the problem has been resolved and help motivate the patient and the nurse by providing a sense of achievement.

Option B: In light of the potential benefits of patient participation in goal setting, a study by Baker, Rice, Zimmerman, Marshak, et. al. believes the following are needed: (1) patient and therapist education regarding the potential advantages of participation, (2) the enhancement of patient readiness to assume greater responsibility in their care, and (3) the development of models for use in achieving patient participation.
Option C: Patient and therapist education is needed regarding methods for patient participation during initial goal-setting activities. In a study by Baker, Rice, Zimmerman, Marshak, et. al., the therapists stated that they believed that it is important to include patients in goal-setting activities and that outcomes will be improved if patients participate. Patients also indicated that participation is important to them.
Option D: Patient participation in goal setting is emphasized in order to enhance patient management and the effectiveness of treatment. Participation should improve outcomes and could be used to identify benefits that may result from the treatment. These benefits include greater goal attainment, increased patient satisfaction, gains in function, better adherence to treatment regimens, decreased depression in patients, and reduced burnout rates among physical therapists.

FNDNRS-05-006

The nurse writes an expected outcome statement in measurable terms. An example is:

A. Client will have less pain.
B. Client will be pain-free.
C. Client will report pain acuity less than 4 on a scale of 0-10.
D. Client will take pain medication every 4 hours around the clock.

Correct Answer: C. Client will report pain acuity less than 4 on a scale of 0-10.

When developing goals for patients, the nurse needs to look at several factors. Think back to the SMART goal criteria. In order to be specific, nurses focus on questions like ‘What is the problem? What is the response desired?’ To make it measurable, ‘How will the client look or behave if the healthy response is achieved? What can I see, hear, measure, observe?’

Option A: One way to help nurses remember how to write goals is to make sure they are SMART. SMART goals are Specific, Measurable, Action-Oriented, Realistic, and Timely. ‘Specific’ refers to who, what, when, where, and why. ‘Measurable’ means that you can actually measure and evaluate the progress of that goal in a concrete way. ‘Action-oriented’ means there are actions that can be taken to reach the goal. ‘Realistic’ includes the ability to work on the goal, having the resources, attitudes, abilities, and skills to reach this goal, and how realistic it is to come to fruition. Finally, ‘Timely’ means that there is an end time frame or date at which the goal is going to be evaluated.
Option B: Goal setting occurs in the third phase of the process, planning. Is the goal for nursing care to heal patients? To help them get better? To help them get well? While these are certainly in the forefront of nurses’ minds, how do you evaluate these statements? What if the definition of wellness is different from one person to another? This is why nursing goal statements that are patient-centered and measurable are so important.
Option D: Considering action-oriented, ‘Are there steps and nursing interventions needed to reach that goal? Is this a realistic outcome for the patient? Have we considered all of the factors involved, including the client’s capabilities and limitations? Does the patient have what he or she needs to reach that goal?’ And finally, ‘Is it timely? When do we expect the goal to be reached?’

FNDNRS-05-007

As goals, outcomes, and interventions are developed, the nurse must:

A. Be in charge of all care and planning for the client.
B. Be aware of and committed to accepted standards of practice from nursing and other disciples.
C. Not change the plan of care for the client.
D. Be in control of all interventions for the client.

Correct Answer: B. Be aware of and committed to accepted standards of practice from nursing and other disciples.

Whenever a healthcare provider intervenes or implements care, they must reassess or evaluate to ensure the desired outcome has been met. Reassessment may frequently be needed depending upon overall patient condition. The plan of care may be adapted based on new assessment data.

Option A: Patients’ participation in decision-making in health care and treatment is not a new area, but currently it has become a political necessity in many countries and health care systems around the world. Emphasizing the importance of participation in the decision-making process motivates the service provider and the health care team to promote participation of patients in treatment decision-making.
Option C: A review of some literature reveals that participation of patients in health care has been associated with improved treatment outcomes. Moreover, this participation causes improved control of diabetes, better physical functioning in rheumatic diseases, enhanced patients’ compliance with secondary preventive actions, and improvement in health of patients with myocardial infarction.
Option D: With enhanced patient participation, and considering patients as equal partners in healthcare decision making patients are encouraged to actively participate in their own treatment process and follow their treatment plan and thus a better health maintenance service would be provided.

FNDNRS-05-008

When establishing realistic goals, the nurse:

A. Bases the goals on the nurse’s personal knowledge.
B. Knows the resources of the health care facility, family, and the client.
C. Must have a client who is physically and emotionally stable.
D. Must have the client’s cooperation.

Correct Answer: B. Knows the resources of the health care facility, family, and the client.

The planning stage is where goals and outcomes are formulated that directly impact patient care based on EDP guidelines. These patient-specific goals and the attainment of such assist in ensuring a positive outcome. Data may come from the patient directly or from primary caregivers who may or may not be direct relation family members. Friends can play a role in data collection. Electronic health records may populate data in and assist in assessment.

Option A: Nursing care plans are essential in this phase of goal setting. Care plans provide a course of direction for personalized care tailored to an individual’s unique needs. Overall condition and comorbid conditions play a role in the construction of a care plan.
Option C: The utilization of the nursing process to guide care is clinically significant going forward in this dynamic, complex world of patient care. Aging populations carry with them a multitude of health problems and inherent risks of missed opportunities to spot a life-altering condition.
Option D: As explored by Salmond and Echevarria, healthcare is changing, and the traditional roles of nurses are transforming to meet the demands of this new healthcare environment. Nurses are in a position to promote change and impact patient delivery care models in the future.

FNDNRS-05-009

To initiate an intervention the nurse must be competent in three areas, which include:

A. Knowledge, function, and specific skills.
B. Experience, advanced education, and skills.
C. Skills, finances, and leadership.
D. Leadership, autonomy, and skills.

Correct Answer: A. Knowledge, function, and specific skills

Critical thinking and reflection are essential skills because they can enhance nurses’ ability to solve problems and make sound decisions. Critical thinking skills enable nurses to identify multiple possibilities in clinical situations and alternatives to interventions; weigh the consequences of alternate actions; and determine the right judgment and decisions. To provide safe and effective care to the clients, nurses must integrate knowledge, skills, and attitudes to make sound judgment and decisions.

Option B: Due to the increasing internal and external expectations of higher quality nursing, it is no longer acceptable for nurses to deliver nursing care only on experience and textbook knowledge. Clinical nurses are expected to systematically gather the best research evidence, draw from nursing experience, and consider patient’s preferences when they are making professional decisions
Option C: Some research findings showed that changing the attitude and enhancing the knowledge of nurses are the first step in EBP. McCleary and Brown conducted a study on 528 graduate nurses working in educational pediatric hospitals of Canada and reported that the nurses’ knowledge of EBP and their positive attitude towards it will contribute to its implementation in the healthcare system.
Option D: Melnyk et al. stated that acquiring knowledge about research methods and having the skill to evaluate research reports critically may enable overcoming the obstacles hindering the application of research findings and thus will lead to improvement of healthcare quality. Hence, the EBP attitude, knowledge, and skills of nurses are so important.

FNDNRS-05-010

Collaborative interventions are therapies that require:

A. Physician and nurse interventions.
B. Nurse and client interventions.
C. Client and Physician intervention.
D. Multiple health care professionals.

Correct Answer: D. Multiple health care professionals.

Collaborative interventions are actions that the nurse carries out in collaboration with other health team members, such as physicians, social workers, dietitians, and therapists. These actions are developed in consultation with other health care professionals to gain their professional viewpoint.

Option A: Dependent nursing interventions are activities carried out under the physician’s orders or supervision. Includes orders to direct the nurse to provide medications, intravenous therapy, diagnostic tests, treatments, diet, and activity or rest.
Option B: Independent nursing interventions are activities that nurses are licensed to initiate based on their sound judgment and skills. Includes ongoing assessment, emotional support, providing comfort, teaching, physical care, and making referrals to other health care professionals.
Option C: Nursing interventions are activities or actions that a nurse performs to achieve client goals. Interventions chosen should focus on eliminating or reducing the etiology of the nursing diagnosis. In this step, nursing interventions are identified and written during the planning step of the nursing process; however, they are actually performed during the implementation step.

FNDNRS-05-011

Well formulated, client-centered goals should:

A. Meet immediate client needs.
B. Include preventative health care.
C. Include rehabilitation needs.
D. All of the above.

Correct Answer: D. All of the above.

The process of client-centered goal planning encourages members of the multi professional team to work in partnership with the client, his or her family, and each other, united by the aim of helping the client to achieve his or her desired outcome. Goals enable clients, their carers or partners, and the multidisciplinary team to focus on strengths rather than problems. They also enable the team to gauge where the client and family are in their ‘thinking’ (Davis and O’Connor, 1999).

Option A: Once set, goals provide a central focus for all therapeutic activity, enabling clients to move away from a period of dependency to a level of achievement and/or adjustment to their situation.
Option B: Goal planning is part of the overall care plan in which the client’s own values, beliefs, and aspirations are recognized and valued, and form the central focus of the rehabilitation process.
Option C: Goals for rehabilitation can be divided into two groups: short-term and long-term. Short-term goals can act as stepping stones to achieving longer-term targets. A short-term goal for this client might be to be able to clean her teeth.

FNDNRS-05-012

The following statement appears on the nursing care plan for an immunosuppressed client: The client will remain free from infection throughout hospitalization. This statement is an example of a (an):

A. Nursing diagnosis
B. Short-term goal
C. Long-term goal
D. Expected outcome

Correct Answer: B. Short-term goal

Short-term goals can act as stepping stones to achieving longer-term targets. For example, a client may have the long-term goal of being able to groom herself, including cleaning her teeth, washing her face, combing her hair, and applying her make-up on her own. A short-term goal for this client might be to be able to clean her teeth.

Option A: Actual or potential health problems that can be prevented or resolved by independent nursing intervention are termed nursing diagnoses. NANDA nursing diagnoses are a uniform way of identifying, focusing on, and dealing with specific client needs and responses to actual and high-risk problems.
Option C: Long-term goals are often used for clients who have chronic health problems or who live at home, in nursing homes, or extended-care facilities. Long-term goal indicates an objective to be completed over a longer period, usually over weeks or months.
Option D: Goals or desired outcomes describe what the nurse hopes to achieve by implementing the nursing interventions and are derived from the client’s nursing diagnoses. One overall goal is determined for each nursing diagnosis. The terms goal, outcome, and expected outcome are oftentimes used interchangeably.

FNDNRS-05-013

The following statements appear on a nursing care plan for a client after a mastectomy: Incision site approximated; absence of drainage or prolonged erythema at the incision site; and the client remains afebrile. These statements are examples of:

A. Nursing interventions
B. Short-term goals
C. Long-term goals
D. Expected outcomes

Correct Answer: D. Expected outcomes

Goals or desired outcomes describe what the nurse hopes to achieve by implementing the nursing interventions and are derived from the client’s nursing diagnoses. One overall goal is determined for each nursing diagnosis. The terms goal, outcome, and expected outcome are oftentimes used interchangeably.

Option A: Nursing interventions are activities or actions that a nurse performs to achieve client goals. Interventions chosen should focus on eliminating or reducing the etiology of the nursing diagnosis.
Option B: Short-term goals can act as stepping stones to achieving longer-term targets. For example, a client may have the long-term goal of being able to groom herself, including cleaning her teeth, washing her face, combing her hair, and applying her make-up on her own. A short-term goal for this client might be to be able to clean her teeth.
Option C: Long-term goals are often used for clients who have chronic health problems or who live at home, in nursing homes, or extended-care facilities. Long-term goal indicates an objective to be completed over a longer period, usually over weeks or months.

FNDNRS-05-014

The planning step of the nursing process includes which of the following activities?

A. Assessing and diagnosing.
B. Evaluating goal achievement.
C. Performing nursing actions and documenting them.
D. Setting goals and selecting interventions.

Correct Answer: D. Setting goals and selecting interventions.

The planning stage is where goals and outcomes are formulated that directly impact patient care based on EDP guidelines. These patient-specific goals and the attainment of such assist in ensuring a positive outcome. Nursing care plans are essential in this phase of goal setting. Care plans provide a course of direction for personalized care tailored to an individual’s unique needs.

Option A: Assessment is the first step and involves critical thinking skills and data collection; subjective and objective. Data may come from the patient directly or from primary caregivers who may or may not be direct relation family members. Friends can play a role in data collection. Electronic health records may populate data in and assist in assessment. The formulation of a nursing diagnosis by employing clinical judgment assists in the planning and implementation of patient care.
Option B: This final step of the nursing process is vital to a positive patient outcome. Whenever a healthcare provider intervenes or implements care, they must reassess or evaluate to ensure the desired outcome has been met. Reassessment may frequently be needed depending upon overall patient condition. The plan of care may be adapted based on new assessment data.
Option C: Implementation is the step that involves action or doing and the actual carrying out of nursing interventions outlined in the plan of care. This phase requires nursing interventions such as applying a cardiac monitor or oxygen, direct or indirect care, medication administration, standard treatment protocols, and EDP standards.

FNDNRS-05-015

The nursing care plan is:

A. A written guideline for implementation and evaluation.
B. A documentation of client care.
C. A projection of potential alterations in client behaviors.
D. A tool to set goals and project outcomes.

Correct Answer: A. A written guideline for implementation and evaluation.

Nursing care plans are essential in this phase of goal setting. Care plans provide a course of direction for personalized care tailored to an individual’s unique needs. Overall condition and comorbid conditions play a role in the construction of a care plan. Care plans enhance communication, documentation, reimbursement, and continuity of care across the healthcare continuum.

Option B: Documentation is any written or electronically generated information about a client that describes the status, care or services provided to that client. Through documentation, you communicate observations, decisions, actions, and outcomes of these actions for clients, demonstrating the nursing process.
Option C: Behavioral tools are psychological instruments that are used for understanding and interpreting human behavior. Such tools have found many applications in corporate and educational sectors, considering their exploratory and insightful nature.
Option D: A SMART goal is one that is specific, measurable, attainable, relevant and time-bound. The SMART criteria help to incorporate guidance and realistic direction in goal setting, which increases motivation and leads to better results in achieving lasting change.

FNDNRS-05-016

After determining a nursing diagnosis of acute pain, the nurse develops the following appropriate client-centered goal:

A. Encourage the client to implement guided imagery when pain begins.
B. Determine the effect of pain intensity on client function.
C. Administer analgesic 30 minutes before physical therapy treatment.
D. Pain intensity reported as a 3 or less during hospital stay.

Correct Answer: D. Pain intensity reported as a 3 or less during hospital stay.

This is measurable and objective. Goals or desired outcomes describe what the nurse hopes to achieve by implementing the nursing interventions and are derived from the client’s nursing diagnoses. Goals provide direction for planning interventions, serve as criteria for evaluating client progress, enable the client and nurse to determine which problems have been resolved, and help motivate the client and nurse by providing a sense of achievement.

Option A: This is an example of nursing intervention. Nursing interventions are activities or actions that a nurse performs to achieve client goals. Interventions chosen should focus on eliminating or reducing the etiology of the nursing diagnosis.
Option B: Evaluating is a planned, ongoing, purposeful activity in which the client’s progress towards the achievement of goals or desired outcomes, and the effectiveness of the nursing care plan (NCP).
Option C: This is an example of nursing intervention. Dependent nursing interventions are activities carried out under the physician’s orders or supervision. Includes orders to direct the nurse to provide medications, intravenous therapy, diagnostic tests, treatments, diet, and activity or rest.

FNDNRS-05-017

When developing a nursing care plan for a client with a fractured right tibia, the nurse includes in the plan of care independent nursing interventions, including:

A. Apply a cold pack to the tibia.
B. Elevate the leg 5 inches above the heart.
C. Perform a range of motion to right leg every 4 hours.
D. Administer aspirin 325 mg every 4 hours as needed.

Correct Answer: B. Elevate the leg 5 inches above the heart.

This does not require a physician’s order. Independent nursing interventions are activities that nurses are licensed to initiate based on their sound judgment and skills. Includes ongoing assessment, emotional support, providing comfort, teaching, physical care, and making referrals to other health care professionals.

Option A: This intervention requires a doctor’s order. Assessment and providing explanation while administering medical orders are also part of the dependent nursing interventions.
Option C: C is not appropriate for a fractured tibia. Isometrics contract muscles without bending joints or moving limbs and help maintain muscle strength and mass. Note: These exercises are contraindicated while acute bleeding and edema are present.
Option D: Dependent nursing interventions are activities carried out under the physician’s orders or supervision. Includes orders to direct the nurse to provide medications, intravenous therapy, diagnostic tests, treatments, diet, and activity or rest.

FNDNRS-05-018

Which of the following nursing interventions are written correctly?

A. Apply continuous passive motion machines during the day.
B. Perform neurovascular checks.
C. Elevate head of bed 30 degrees before meals.
D. Change dressing once a shift.

Correct Answer: C. Elevate head of bed 30 degrees before meals.

It is specific in what to do and when. Nursing interventions should be specific and clearly stated, beginning with an action verb indicating what the nurse is expected to do. Action verb starts the intervention and must be precise.

Option A: This intervention does not specify the location of the application. Nursing interventions are the actual treatments and actions that are performed to help the patient to reach the goals that are set for them. The nurse uses his or her knowledge, experience, and critical-thinking skills to decide which interventions will help the patient the most.
Option B: It was not stated in this intervention when the neurovascular check should be performed. Nurses must use their knowledge, experience, resources, research of evidence-based practice, the counsel of others, and critical-thinking skills to decide which nursing interventions would best benefit a specific patient.
Option D: Qualifiers of how, when, where, time, frequency, and amount provide the content of the planned activity. For example: “Educate parents on how to take temperature and notify of any changes,” or “Assess urine for color, amount, odor, and turbidity.”

FNDNRS-05-019

A client’s wound is not healing and appears to be worsening with the current treatment. The nurse first considers:

A. Notifying the physician.
B. Calling the wound care nurse.
C. Changing the wound care treatment.
D. Consulting with another nurse.

Correct Answer: B. Calling the wound care nurse.

Calling the wound care nurse as a consultant is appropriate because he or she is a specialist in the area of wound management. Professional and competent nurses recognize limitations and seek appropriate consultation. As the largest health care workforce, nurses apply their knowledge, skills, and experience to care for the various and changing needs of patients. A large part of the demands of patient care is centered on the work of nurses.

Option A: Option A may be appropriate after deciding on a plan of action with the wound care nurse specialist. The nurse may need to obtain orders for special wound care products. Interprofessional and interprofessional collaboration, through multidisciplinary teams, is important in the right work environments. Skills for teamwork are considered nontechnical and include leadership, mutual performance monitoring, adaptability, and flexibility.
Option C: Option Cis possible unless the nurse is knowledgeable in wound management, this could delay wound healing. Also, the current wound management plan could have been ordered by the physician. Clinicians working in teams will make fewer errors when they work well together, use well-planned and standardized processes, know team members and their own responsibilities, and constantly monitor team members’ performance to prevent errors before they could cause harm.
Option D: Another nurse most likely will not be knowledgeable about wounds, and the primary nurse would know the history of the wound management plan. Understanding the complexity of the work environment and engaging in strategies to improve its effects is paramount to higher-quality, safer care.

FNDNRS-05-020

When calling the nurse consultant about a difficult client-centered problem, the primary nurse is sure to report the following:

A. Length of time the current treatment has been in place.
B. The spouse’s reaction to the client’s dressing change.
C. Client’s concern about the current treatment.
D. Physician’s reluctance to change the current treatment plan.

Correct Answer: A. Length of time the current treatment has been in place.

This gives the consulting nurse facts that will influence a new plan. Other choices are subjective and emotional issues and conclusions about the current treatment plan may cause bias in the decision of a new treatment plan by the nurse consultant. In general, it is important to create a supportive environment with open and honest communication, focusing on the achievements and not on negative aspects.

Option B: Navigating the new system is very challenging and it is important for the clients to have a person to whom they could always turn with questions and concerns. It could not necessarily be a formal caseworker, but rather any clinician who had a trusting relationship and was helpful and willing to guide the client.
Option C: Education and information for both the patient and the family were mentioned by all the participants in a study as the main strategies to help them develop a clear understanding of their condition and prognosis.
Option D: Several successful strategies to improve client-centered care have been introduced in different hospitals: writing a family note (a summary that is given to the family) at the family meeting, appointing a contact person/therapy leader for each client, improving continuity and coordination of care through interdisciplinary collaborations, having the same staff working with the client, and providing written materials.

FNDNRS-05-021

The primary nurse asked a clinical nurse specialist (CNS) to consult on a difficult nursing problem. The primary nurse is obligated to:

A. Implement the specialist’s recommendations.
B. Report the recommendations to the primary physician.
C. Clarify the suggestions with the client and family members.
D. Discuss and review advised strategies with CNS.

Correct Answer: D. Discuss and review advised strategies with CNS.

The primary nurse requested the consultation, it is important that they communicate and discuss recommendations. The primary nurse can then accept or reject the CNS recommendations. Effective clinical practice thus involves many instances where critical information must be accurately communicated. Team collaboration is essential.

Option A: Some of the recommendations may not be appropriate for this client. The primary nurse would know this information. A consultation requires review of the recommendations, but not immediate implementation. Collaboration in health care is defined as health care professionals assuming complementary roles and cooperatively working together, sharing responsibility for problem-solving, and making decisions to formulate and carry out plans for patient care
Option B: This would be appropriate after first talking with the CNS about recommended changes in the plan of care and the rationale. Then the primary nurse should call the physician. Collaboration between physicians, nurses, and other health care professionals increases team members’ awareness of each others’ type of knowledge and skills, leading to continued improvement in decision making.
Option C: The client and family do not have the knowledge to determine whether new strategies are appropriate or not. Better to wait until the new plan of care is agreed upon by the primary nurse and physician before talking with the client and/or family. A study determined that improved teamwork and communication are described by health care workers as among the most important factors in improving clinical effectiveness and job satisfaction.

FNDNRS-05-022

After assessing the client, the nurse formulates the following diagnoses. Place them in order of priority, with the most important (classified as high) listed first.

1. Ineffective airway clearance
2. Ineffective tissue perfusion.
3. Constipation
4. Anticipated grieving

The correct order is shown above.

Nurses should apply the concept of ABCs to each patient situation. Prioritization begins with determining immediate threats to life as part of the initial assessment and is based on the ABC pneumonic focusing on the airway as priority, moving to breathing, and circulation (Ignatavicius et al., 2018).

1. Ineffective airway clearance can be an acute (e.g., postoperative recovery) or chronic (e.g., CVA or spinal cord injury) problem. High-risk for ineffective airway clearance are the aged individuals who have an increased incidence of emphysema and a higher prevalence of chronic cough or sputum production.
2. Decreased tissue perfusion can be temporary, with few or minimal consequences to the health of the patient, or it can be more acute or protracted, with potentially destructive effects on the patient. When diminished tissue perfusion becomes chronic, it can result in tissue or organ damage or death.
3. Constipation occurs when bowel movements become less frequent than normal. It is accompanied by a difficult or incomplete passage of stool. Though common, constipation may also be a complex problem. Chronic constipation can result in the development of hemorrhoids; diverticulosis; straining at stool, and perforation of the colon.
4. Grieving is an individual’s normal response to a loss that may be perceived or actual. Assessment is necessary in order to identify potential problems that may have led to grief and also name any event that may happen during nursing care.

FNDNRS-05-023

The nurse is reviewing the critical paths of the clients in the nursing unit. In performing a variance analysis, which of the following would indicate the need for further action and analysis?

A. A client’s family attending a diabetic teaching session.
B. Canceling physical therapy sessions on the weekend.
C. Normal VS and absence of wound infection in a post-op client.
D. A client demonstrating accurate medication administration following teaching.

Correct Answer: B. Canceling physical therapy sessions on the weekend.

Variance analysis is the identification of patient or family needs that are not anticipated and the actions related to these needs in a system of managed care. There are four kinds of origin for the variance: patient-family origin, system-institutional origin; community origin, and clinician origin.

Option A: Critical pathways are care plans that detail the essential steps inpatient care with a view to describing the expected progress of the patient. They also have a positive impact on outcomes, such as increased quality of care and patient satisfaction, improved continuity of information, and patient education.
Option C: Clinical pathways are being increasingly used for daily patient care. The pathways consist of a sequence of critical treatment events matched to the patient’s recovery. Variance analysis identifies deviations from the pathway and can be used for quality improvement and clinical audit.
Option D: Clinical pathways can be used as a means of incorporating evidence-based medicine into clinical practice. Variance analysis of the pathways can be utilized as a process of quality control and to improve patient outcomes.

FNDNRS-05-024

The RN has received her client assignment for the day shift. After making the initial rounds and assessing the clients, which client would the RN need to develop a care plan first?

A. A client who is ambulatory.
B. A client, who has a fever, is diaphoretic and restless.
C. A client scheduled for OT at 1300.
D. A client who just had an appendectomy and has just received pain medication.

Correct Answer: B. A client, who has a fever, is diaphoretic and restless.

This client’s needs are a priority. Clinical judgment and prioritization of patient care is built on the nursing process. Nurses learn the steps of the nursing process in their foundational nursing course and utilize it throughout their academic and clinical careers to direct patient care and determine priorities.

Option A: An ambulatory client would not be a priority. However, a thorough assessment should still be done to make sure that the client does not have any underlying diseases. In unfamiliar situations, patient prioritization should be approached as a structured process, highlighting risk factors that may contribute to a decline in the patient’s condition and potential interventions that can reduce the risk of adverse outcomes (Jessee, 2019).
Option C: The client does not have any emergent concerns based on the stem. Seasoned nurses are able to pull from their depth of knowledge and experience that allows them to act deductively and intuitively when prioritizing patient care.
Option D: The client has already received pain medication, therefore she is not a priority. For expert nurses, the ability to prioritize based on these processes is predominately intuitive, and tasks are completed in a prioritized manner without much conscious thought.

FNDNRS-05-025

Which of the following statements about the nursing process is most accurate?

A. The nursing process is a four-step procedure for identifying and resolving patient problems.
B. Beginning in Florence Nightingale’s days, nursing students learned and practiced the nursing process.
C. Use of the nursing process is optional for nurses since there are many ways to accomplish the work of nursing.
D. The state board examinations for professional nursing practice now use the nursing process rather than medical specialties as an organizing concept.

Correct Answer: D. The state board examinations for professional nursing practice now use the nursing process rather than medical specialties as an organizing concept.

The nursing process is a systematic decision-making method focusing on identifying and treating responses of individuals or groups to actual or potential alterations in health it- is the essential core of nursing practice to deliver holistic, patient-focused care. Nursing process provides an organizing framework for the practice of nursing and the knowledge, judgments, and actions that nurses bring to patient care.”

Option A: The nursing process is a five-step process. The nursing process functions as a systematic guide to client-centered care with 5 sequential steps. These are assessment, diagnosis, planning, implementation, and evaluation. The utilization of the nursing process to guide care is clinically significant going forward in this dynamic, complex world of patient care.
Option B: The term nursing process was first used by Hall in 1955. In 1958, Ida Jean Orlando started the nursing process that still guides nursing care today. Defined as a systematic approach to care using the fundamental principles of critical thinking, client-centered approaches to treatment, goal-oriented tasks, evidence-based practice (EDP) recommendations, and nursing intuition.
Option C: Nursing process is not optional since standards demand the use of it. Holistic and scientific postulates are integrated to provide the basis for compassionate, quality-based care. As explored by Salmond and Echevarria, healthcare is changing, and the traditional roles of nurses are transforming to meet the demands of this new healthcare environment. Nurses are in a position to promote change and impact patient delivery care models in the future.

Question related to Health Promotion and Maintenance

FNDNRS-05-026

What equipment would be necessary to complete an evaluation of cranial nerves 9 and 10 during a physical assessment?

A. A cotton ball
B. A penlight
C. An ophthalmoscope
D. A tongue depressor and flashlight

Correct Answer: D. A tongue depressor and flashlight

Cranial nerves 9 and 10 are the glossopharyngeal and vagus nerves. The gag reflex would be evaluated. The 9th (glossopharyngeal) and 10th (vagus) cranial nerves are usually evaluated together. Whether the palate elevates symmetrically when the patient says “ah” is noted. If one side is paretic, the uvula is lifted away from the paretic side. A tongue blade can be used to touch one side of the posterior pharynx, then the other, and symmetry of the gag reflex is observed; bilateral absence of the gag reflex is common among healthy people and may not be significant.

Option A: For the 5th (trigeminal) nerve, the 3 sensory divisions (ophthalmic, maxillary, mandibular) are evaluated by using a pinprick to test facial sensation and by brushing a wisp of cotton against the lower or lateral cornea to evaluate the corneal reflex. If facial sensation is lost, the angle of the jaw should be examined; sparing of this area (innervated by spinal root C2) suggests a trigeminal deficit. A weak blink due to facial weakness (eg, 7th cranial nerve paralysis) should be distinguished from depressed or absent corneal sensation, which is common in contact lens wearers. A patient with facial weakness feels the cotton wisp normally on both sides, even though blink is decreased.
Option B: A penlight provides a source of light and has become the most common used tool to assess the pupil diameter. Asymmetry of pupil constriction in response to light means one pupil constricts and the other remains dilated or constricts more slowly. It may indicate dynamic anisocoria or a Marcus Gunn pupil, a relative afferent pupillary defect (RAPD), or temporal lobe herniation in the brain.
Option C: The eye can be examined with routine equipment, including a standard ophthalmoscope; thorough examination requires special equipment and evaluation by an ophthalmologist. Ophthalmoscopy (examination of the posterior segment of the eye) can be done directly by using a handheld ophthalmoscope or with a handheld lens in conjunction with the slit lamp biomicroscope.

FNDNRS-05-027

Which technique would be best in caring for a client following receiving a diagnosis of a stage IV tumor in the brain?

A. Offering the client pamphlets on support groups for brain cancer.
B. Asking the client if there is anything he or his family needs.
C. Reminding the client that advances in technology are occurring every day.
D. Providing accurate information about the disease and treatment options.

Correct Answer: D. Providing accurate information about the disease and treatment options.

Providing information for the client is the best technique for a new diagnosis. Every clinician at one time or another faces these important questions. In the treatment of terminally ill patients, the health professional needs many skills: the ability to deliver bad news, the knowledge to provide appropriate optimal end-of-life care, and the compassion to allow a person to retain his or her dignity.

Option A: Cassem, in the Massachusetts General Hospital Handbook of General Hospital Psychiatry, recommends relaying negative information to patients through a brief, rehearsed initial statement that succinctly communicates the news and clearly indicates that the treatment team is committed to the ongoing care and support of the patient.
Option B: In considering the emotional state of a person with terminal illness, it is often helpful to consider the effects of the family members on the patient and vice versa. By observing the interactions of a patient with family, the consultant can become aware of long-standing grudges or new difficulties in communication that can make the process of coming to closure at the end of a life more difficult.
Option C: In most cases, patients who are told their diagnosis in an up-front, clear manner have better emotional adjustments to their situation than those who are not told about their condition. By providing direct, clear information in a compassionate manner, and by making clear to the patient that everything possible will be done to provide medical and emotional support, physicians can elicit trust and reduce anxiety.

FNDNRS-05-028

An 8.5 lb, 6 oz infant is delivered to a diabetic mother. Which nursing intervention would be implemented when the neonate becomes jittery and lethargic?

A. Administer insulin.
B. Administer oxygen.
C. Feed the infant glucose water (10%).
D. Place the infant in a warmer.

Correct Answer: C. Feed the infant glucose water (10%)

After birth, the infant of a diabetic mother is often hypoglycemic. Treatment will depend on the baby’s gestational age and overall health. Treatment includes giving the baby a fast-acting source of glucose. This may be as simple as a glucose and water mixture or formula as an early feeding. Or the baby may need glucose given through an IV. The baby’s blood glucose levels are checked after treatment to see if the hypoglycemia occurs again.

Option A: Second-line therapies for the treatment of persistent hypoglycemia include the use of corticosteroids or glucagon, not insulin. Glucagon is a hormone that stimulates endogenous glucose production via glycogenolysis and gluconeogenesis; thus its effectiveness depends on the infant having adequate glycogen stores. It is most useful in term infants and infants of diabetic mothers. Glucagon dosing is as a 30 mcg/kg bolus or 300 mcg/kg per minute continuous infusion.
Option B: Oxygen is not administered to hypoglycemic neonates. Early initiation of breastfeeding is crucial for all infants. For asymptomatic infants at risk of neonatal hypoglycemia, the AAP recommends initiating feeds within the first hour of life and performing initial glucose screening 30 minutes after the first feed. The AAP recommends goal blood glucose levels equal to or greater than 45 mg/dL prior to routine feedings, and intervention for blood glucose <40 mg/dL in the first 4 hours of life and <45 mg/dL at 4 to 24 hours of life.
Option D: Placing the infant in a warmer does not manage the hypoglycemia. In infants of diabetic mothers, lower glucose infusions rates of 3 to 5 mg/kg/minute may be used to minimize pancreatic stimulation and endogenous insulin secretion. Infants requiring higher rates of intravenous dextrose (>12 to 16 mg/kg/minute) or for more than 5 days are more likely to have a persistent cause of hypoglycemia.

FNDNRS-05-029

What question would be most important to ask a male client who is in for a digital rectal examination?

A. “Have you noticed a change in the force of the urinary system?”
B. “Have you noticed a change in tolerance of certain foods in your diet?”
C. “Do you notice polyuria in the AM?”
D. “Do you notice any burning with urination or any odor to the urine?”

Correct Answer: A. “Have you noticed a change in the force of the urinary system?”

This change would be most indicative of a potential complication with (BPH) benign prostate hypertrophy. The goals of the evaluation of such men are to identify the patient’s voiding or, more appropriately, urinary tract problems, both symptomatic and physiologic; to establish the etiologic role of BPH in these problems.

Option B: Food intolerances are more common in those with digestive system disorders, such as irritable bowel syndrome (IBS). According to the IBS network, most people with IBS have food intolerances. The symptoms of food intolerances can also mimic the symptoms of chronic digestive conditions, such as IBS. However, certain patterns in the symptoms can help a doctor distinguish between the two.
Option C: History can often distinguish polyuria from frequency, but rarely a 24-hour urine collection may be needed. Polyuria caused by solute diuresis is suggested by a history of diabetes mellitus. Abrupt onset of polyuria at a precise time suggests central diabetes insipidus, as does preference for extremely cold or iced water.
Option D: Dysuria is a symptom of pain and/or burning, stinging, or itching of the urethra or urethral meatus with urination. It is one of the most common symptoms experienced by most people at least once over their lifetimes. Primarily, causes of dysuria can be divided broadly into two categories, infectious and non-infectious.

FNDNRS-05-030

The nurse assesses a prolonged late deceleration of the fetal heart rate while the client is receiving oxytocin (Pitocin) IV to stimulate labor. The priority nursing intervention would be to:

A. Turn off the infusion.
B. Turn the client to the left.
C. Change the fluid to Ringer’s Lactate.
D. Increase mainline IV rate.

Correct Answer: A. Turn off the infusion

Stopping the infusion will decrease contractions and possibly remove uterine pressure on the fetus, which is a possible cause of the deceleration. When late decelerations are observed, the nurse should attempt to increase the oxygen delivery to the fetus by turning the mother on her left side and/or administering oxygen. If Oxytocin (Pitocin) is being administered, it should be stopped.

Option B: Variable decelerations are marked by a sharp decrease (“V” shape) in FHR that does not correlate to contractions. Umbilical cord compression is usually the cause of variable decelerations. Repositioning of the mother can relieve this compression if it is minor.
Option C: Late decelerations are shown by the FHR gradually decreasing around the peak of the contraction and gradually increasing when the contraction is over. These decelerations will also have a “U” shape but will not mirror the contractions. The most common cause of late decelerations is uteroplacental insufficiency (insufficient oxygen exchange between the placenta and the fetus).
Option D: Increasing the main IV line would not manage the decelerations. While caring for a patient in labor, one of the important nursing duties is monitoring the variability of the fetal heart rate (FHR) and monitoring the FHR response during contractions. Variability in the FHR during labor is a sign of fetal well-being or fetal activity or both. The expected variability usually includes slight accelerations and decelerations.

FNDNRS-05-031

Which nursing approach would be most appropriate to use while administering an oral medication to a 4-month-old?

A. Place medication in 45cc of formula.
B. Place medication in an empty nipple.
C. Place medication in a full bottle of formula.
D. Place in supine position. Administer medication using a plastic syringe.

Correct Answer: B. Place medication in an empty nipple.

This is a convenient method for administering medications to an infant. Draw up the correct amount of medicine into an oral syringe (a syringe without a needle) or an empty nipple. Let the infant suck the medicine out of the syringe or empty nipple. When giving medicine to an infant, use his natural reflexes (such as sucking) whenever possible.

Option A: Avoid mixing medicine with foods the child must have. The child may begin to dislike the foods he needs. Mix the medicine with a small amount (1 to 2 teaspoons) of applesauce or pears and give it with a spoon. This is a good way to give pills that have been crushed well. (To crush a pill, place it between two spoons and press the spoons together).
Option C: Some medicines can be put in a small amount of juice or sugar water. Follow the instructions from the doctor, nurse, or pharmacist. Do not put medicine in a full bottle or cup in case the infant does not drink very much.
Option D: Option D is partially correct however, the infant is never placed in a reclining position during a procedure due to a potential aspiration. Hold the infant in a nearly upright position. If the infant struggles, gently hold one arm and place his other arm around the waist. Hold the baby close to the body.

FNDNRS-05-032

Which nursing intervention would be a priority during the care of a 2-month-old after surgery?

A. Minimize stimuli for the infant.
B. Restrain all extremities.
C. Encourage stroking of the infant.
D. Demonstrate to the mother how she can assist with her infant’s care.

Correct Answer: C. Encourage stroking of the infant.

Tactile stimulation is imperative for an infant’s normal emotional development. After the trauma of surgery, sensory deprivation can cause failure to thrive. Most babies with FTT do not have a specific underlying disease or medical condition to account for their growth failure. This is referred to as Non-organic FTT. Up to 80% of all children with FTT have Non-organic type FTT. Non-organic FTT most commonly occurs when there is inadequate food intake or there is a lack of environmental stimuli.

Option A: Provide sensory stimulation. Attempt to cuddle the child and talk to him or her in a warm, soothing tone and allow for play activities appropriate for the child’s age. Feed the child slowly and carefully in a quiet environment; during feeding, the child might be closely snuggled and gently rocked; it may be necessary to feed the child every 2 to 3 hours initially.
Option B: Do not restrain the child. Burp the child frequently during and at the end of each feeding, and then place him or her on the side with the head slightly elevated or held in a chest-to-chest position.
Option D: If a family caregiver is present, encourage him or her to become involved in the child’s feedings. While caring for the child, point out to the caregiver the child’s development and responsiveness, noting and praising any positive parenting behaviors the caregiver displays.

FNDNRS-05-033

While performing a physical examination on a newborn, which assessment should be reported to the physician?

A. Head circumference of 40 cm.
B. Chest circumference of 32 cm.
C. Acrocyanosis and edema of the scalp.
D. Heart rate of 160 and respirations of 40.

Correct Answer: A. Head circumference of 40 cm

Average circumference of the head for a neonate ranges between 32 to 36 cm. An increase in size may indicate hydrocephalus or increased intracranial pressure. A newborn’s head is usually about 2 cm larger than the chest size. Between 6 months and 2 years, both measurements are about equal. After 2 years, the chest size becomes larger than the head.

Option B: The body of a normal newborn is essentially cylindrical; head circumference slightly exceeds that of the chest. For a term baby, the average circumference of the head is 33–35 cm (13–14 inches), and the average circumference of the chest is 30–33 cm (12–13 inches).
Option C: Peripheral cyanosis (acrocyanosis) involves the hands, feet, and circumoral area. It is evident in most infants at birth and for a short time thereafter. If limited to the extremities in an otherwise normal infant, it is due to venous stasis and is innocuous. Localized cyanosis may occur in presenting parts, particularly in association with abnormal presentations.
Option D: Heart rates normally fluctuate between 120 and 160 beats per minute. In agitated states, a rate of 200 beats per minute may occur transiently. The heart rate of premature infants is usually between 130 and 170 beats per minute, and during occasional episodes of bradycardia it may slow to 70 beats per minute or less. Normal neonates breathe at rates which vary between 40 and 60 respirations per minute. Rapid rates are likely to be present for the first few hours after birth.

FNDNRS-05-034

Which action by the mother of a preschooler would indicate a disturbed family interaction?

A. Tells her child that if he does not sit down and shut up she will leave him there.
B. Explains that the injection will burn like a bee sting.
C. Tells her child that the injection can be given while he’s in her lap.
D. Reassures the child that it is acceptable to cry.

Correct Answer: A. Tells her child that if he does not sit down and shut up she will leave him there.

Threatening a child with abandonment will destroy the child’s trust in his family. Children growing up in such families are likely to develop low self-esteem and feel that their needs are not important or perhaps should not be taken seriously by others. As a result, they may form unsatisfying relationships as adults.

Option B: It can help to describe the need for injections and blood testing in kid terms. For example, the nurse might explain that the shots and blood tests help keep the child feeling good throughout the day — and that not getting them could mean having to stay home from school or miss fun activities because of health problems.
Option C: Having both parents (or one parent plus another caregiver) involved in the management process will help keep treatment consistent and also provide support as the nurse deals with struggles over shots and blood tests.
Option D: If the child argues or cries, the parents might be tempted to skip an injection or test just this once. Nurses shouldn’t negotiate blood tests or shots. They’re necessary and not optional. The first time you’re talked out of one, you’ll set a precedent that that child won’t forget.

FNDNRS-05-035

During the history, which information from a 21-year-old client would indicate a risk for development of testicular cancer?

A. Genital Herpes
B. Hydrocele
C. Measles
D. Undescended testicle

Correct Answer: D. Undescended testicle

Undescended testicles make the client at high risk for testicular cancer. Mumps, inguinal hernia in childhood, orchitis, and testicular cancer in the contralateral testis are other predisposing factors. The risk of testicular cancer might be a little higher for men whose testicles stayed in the abdomen as opposed to one that has descended at least partway. If cancer does develop, it’s usually in the undescended testicle, but about 1 out of 4 cases occur in the normally descended testicle.

Option A: While HPV infections are very common, cancer caused by HPV is not. Most people infected with HPV will not develop cancer-related to the infection. However, some people with long-lasting infections of high-risk types of HPV, are at risk of developing cancer.
Option B: Hydroceles generally don’t pose any threat to the testicles. They’re usually painless and disappear without treatment. However, if the patient has scrotal swelling, he should see his doctor to rule out other causes that are more harmful such as testicular cancer.
Option C: Measles has a low death rate in healthy children and adults, and most people who contract the measles virus recover fully. The risk of complications is higher in the following groups: children under 5 years old. adults over 20 years old.

FNDNRS-05-036

While caring for a client, the nurse notes a pulsating mass in the client’s periumbilical area. Which of the following assessments is appropriate for the nurse to perform?

A. Measure the length of the mass.
B. Auscultate the mass.
C. Percuss the mass.
D. Palpate the mass.

Correct Answer: B. Auscultate the mass.

Auscultate the mass. Auscultation of the abdomen and finding a bruit will confirm the presence of an abdominal aneurysm and will form the basis of information given to the provider. Occasionally, an overlying mass (pancreas or stomach) may be mistaken for an AAA. An abdominal bruit is nonspecific for an unruptured aneurysm, but the presence of an abdominal bruit or the lateral propagation of the aortic pulse wave can offer subtle clues and maybe more frequently found than a pulsatile mass.

Option A: In one study, 38% of AAA cases were detected on the basis of physical examination findings, whereas 62% were detected incidentally on radiologic studies obtained for other reasons. Femoral/popliteal pulses and pedal (dorsalis pedis or posterior tibial) pulses should be palpated to determine if an associated aneurysm (femoral/popliteal) or occlusive disease exists. Flank ecchymosis (Grey Turner sign) represents retroperitoneal hemorrhage.
Option C: Do not percuss the abdominal mass. The presence of a pulsatile abdominal mass is virtually diagnostic of an AAA but is found in fewer than 50% of cases. It is more likely to be noted with a ruptured aneurysm.
Option D: The mass should not be palpated because of the risk of rupture. Most clinically significant AAAs are palpable upon routine physical examination; however, the sensitivity of palpation depends on the experience of the examiner, the size of the aneurysm, and the size of the patient.

FNDNRS-05-037

When observing 4-year-old children playing in the hospital playroom, what activity would the nurse expect to see the children participating in?

A. Competitive board games with older children.
B. Playing with their own toys alongside other children.
C. Playing alone with handheld computer games.
D. Playing cooperatively with other preschoolers.

Correct Answer: D. Playing cooperatively with other preschoolers.

Playing cooperatively with other preschoolers. Cooperative play is typical of the late preschool period. Cooperative play is the final stage of play and represents the child’s ability to collaborate and cooperate with other children towards a common goal. Children often reach the cooperative stage of play between 4 and 5 years of age after they have moved through the earlier five stages of play.

Option A: Competitive play is when children learn to play organized games with clear rules and clear guidelines on winning and losing. Ludo, snake and ladders, and football are all forms of competitive play.
Option B: After mastering onlooker play, a child will be ready to move into parallel play. During parallel play, children will play beside and in proximity to other children without actually playing with them. Children often enjoy the buzz that comes with being around other kids, but they don’t yet know how to step into others’ games or ask other kids to step into their games.
Option C: Encourage the child to play with others and be active several times a week instead of spending time in front of a screen. This can help to build healthy, active bodies. (To be clear, learning can happen during screen time, too — just not this specific type of learning.)

Questions and rationale from Scholarpill.com Feel free to print or share and link back to us! Scholarpill.com

FNDNRS-05-038

The nurse is teaching the parents of a 3 month-old infant about nutrition. What is the main source of fluids for an infant until about 12 months of age?

A. Formula or breastmilk
B. Dilute nonfat dry milk
C. Warmed fruit juice
D. Fluoridated tap water

Correct Answer: A. Formula or breastmilk

Formula or breast milk are the perfect food and source of nutrients and liquids up to 1 year of age. Breastfeeding with appropriate supplementation is the preferred method for feeding infants 0-12 months old. Iron-fortified formulas are recommended if the child is not breastfed or requires supplemental formula in addition to breast milk.

Option B: The American Academy of Pediatrics Committee on Nutrition updated their recommendations concerning infant feeding practices during the second six months of life. The committee stated that breastfeeding is the preferred method of feeding during the first year of life and that whole cow’s milk may be introduced after six months of age if adequate supplementary feedings are given. Reduced fat content milk is not recommended during infancy.
Option C: When the infants are consuming one-third of their calories from a balanced mixture of iron-fortified cereals, vegetables, fruits, and other foods providing adequate sources of both iron and Vitamin C it is considered adequate supplementary feeding.
Option D: The World Health Organization (WHO) notes that babies that are breastfed don’t need additional water, as breast milk is over 80 percent water and provides the fluids your baby needs. Children who are bottle-fed will stay hydrated with the help of their formula. Water feedings tend to fill up your baby, making them less interested in nursing. This could actually contribute to weight loss and elevated bilirubin levels.

FNDNRS-05-039

While the nurse is administering medications to a client, the client states “I do not want to take that medicine today.” Which of the following responses by the nurse would be best?

A. “That’s OK, it’s alright to skip your medication now and then.”
B. “I will have to call your doctor and report this.”
C. “Is there a reason why you don’t want to take your medicine?”
D. “Do you understand the consequences of refusing your prescribed treatment?”

Correct Answer: C. “Is there a reason why you don’t want to take your medicine?”

When a new problem is identified, it is important for the nurse to collect accurate assessment data. This is crucial to ensure that client needs are adequately identified in order to select the best nursing care approaches. The nurse should try to discover the reason for the refusal which may be that the client has developed untoward side effects.

Option A: It is not alright to skip medication. Be very matter-of-fact in communication style with the individual taking the medication. Do not beg, threaten, bribe, or force the individual. Do not say “I’ll get in trouble “ or “You’ll get in trouble”.
Option B: If they continue to refuse, document the missed dose and state the reason (individual refused), along with other relevant information if known (i.e. they indicated nausea). In addition, contact the physician under circumstances as agreed when medication was prescribed and/or implement any steps in the ISP for missed doses.
Option D: Find out if they understand what the medication is for. If they do not understand, remind them of the purpose and ask them again to take it. Find out if they understand the implications of not taking their medication. If they do not understand, remind them of the implications and ask them again to take it (In addition to physical symptoms, implications may include the need to call the physician and report the missed dose.)

FNDNRS-05-040

The nurse is assessing a 4 month-old infant. Which motor skill would the nurse anticipate finding?

A. Hold a rattle
B. Bang two blocks
C. Drink from a cup
D. Wave “bye-bye”

Correct Answer: A. Hold a rattle

The age at which a baby will develop the skill of grasping a toy with help is 4 to 6 months. The baby is becoming more dexterous and doing more with their hands. Their hands now work together to move a toy or shake a rattle. In fact, those hands will grab for just about anything within reach, including a stuffed animal, the mother’s hair, and any colorful or shiny object hanging nearby

Option B: At 9 months, babies repeat different actions with objects. They mouth objects to explore the features. They bang objects with their hand and bang two objects together to create sounds and actions. They drop objects sometimes by chance and other times on purpose.
Option C: Babies are learning functional actions with a purpose in mind. They can put things in, such as put clothes in the dryer or a shape in a puzzle. From “put in” they learn a variety of functional actions. They can put a sippy cup to their mouth to drink, a spoon in a bowl to scoop, and a spoon in their mouth to eat.
Option D: Learning how to wave bye-bye is an important milestone for an infant that usually occurs between the age of 10 months and a year. A study in Pediatrics International found premature infants mastered the bye-bye gesture significantly later than full-term babies and used different hand and wrist motions.

FNDNRS-05-041

The nurse should recognize that all of the following physical changes of the head and face are associated with the aging client except:

A. Pronounced wrinkles on the face.
B. Decreased size of the nose and ears.
C. Increased growth of facial hair.
D. Neck wrinkles.

Correct Answer: B. Decreased size of the nose and ears.

The nose and ears of the aging client actually become longer and broader. The chin line is also altered. Height doesn’t change after puberty (well, if anything we get shorter as we age) but ears and noses are always lengthening. That’s due to gravity, not actual growth. As people age, gravity causes the cartilage in the ears and nose to break down and sag. This results in droopier, longer features.

Option A: Wrinkles on the face become more pronounced and tend to take on the general mood of the client over the years. For example laugh or frown wrinkles above the eyebrows, lips, cheeks, and outer edges of the eye orbit.
Option C: The change in the androgen-estrogen ratio causes an increase in growth of facial hair in most older adults. Women develop excessive body or facial hair due to higher-than-normal levels of androgens, including testosterone. All females produce androgens, but the levels typically remain low.
Option D: The aging process shortens the platysma muscle, which contributes to neck wrinkles. Some amount of neck wrinkling is inevitable. The extent of the necklines and other signs of aging skin are determined in part by genetics. Necklines and wrinkles are a normal part of aging. They’re caused in part by skin losing elasticity and being exposed to UV light over time.

FNDNRS-05-042

All of the following characteristics would indicate to the nurse that an elder client might experience undesirable effects of medicines except:

A. Increased oxidative enzyme levels.
B. Alcohol taken with medication.
C. Medications containing magnesium.
D. Decreased serum albumin.

Correct Answer: A. Increased oxidative enzyme levels.

Oxidative enzyme levels decrease in the elderly, which affects the disposition of medication and can alter the therapeutic effects of medication. Oxidative stress causes cells and entire organisms to age. If reactive oxygen species accumulate, this causes damage to the DNA as well as changes in the protein molecules and lipids in the cell. The cell ultimately loses its functionality and dies. Over time, the tissue suffers, and the body ages.

Option B: Alcohol has a smaller water distribution level in the elderly, resulting in higher blood alcohol levels. Alcohol also interacts with various drugs to either potentiate or interfere with their effects. The older one gets, the longer alcohol stays in the system. So it’s more likely to be there when the client takes medicine. And alcohol can affect the way the meds work. It can also lead to serious side effects.
Option C: Magnesium is contained in a lot of medications older clients routinely obtain over the counter. Magnesium toxicity is a real concern. Older adults have lower dietary intakes of magnesium than younger adults. In addition, magnesium absorption from the gut decreases, and renal magnesium excretion increases with age. Older adults are also more likely to have chronic diseases or take medications that alter magnesium status, which can increase their risk of magnesium depletion
Option D: Albumin is the major drug-binding protein. Decreased levels of serum albumin mean that higher levels of the drug remain free and that there are fewer therapeutic effects and increased drug interactions.

FNDNRS-05-043

When assessing a newborn whose mother consumed alcohol during the pregnancy, the nurse would assess for which of these clinical manifestations?

A. Wide-spaced eyes, smooth philtrum, flattened nose
B. Strong tongue thrust, short palpebral fissures, simian crease
C. Negative Babinski sign, hyperreflexia, deafness
D. Shortened limbs, increased jitteriness, constant sucking

Correct Answer: A. Wide-spaced eyes, smooth philtrum, flattened nose

The nurse should anticipate that the infant may have fetal alcohol syndrome and should assess for signs and symptoms of it. These include the characteristics listed in choice A. Fetal alcohol syndrome is a condition in a child that results from alcohol exposure during the mother’s pregnancy. Fetal alcohol syndrome causes brain damage and growth problems. The problems caused by fetal alcohol syndrome vary from child to child, but defects caused by fetal alcohol syndrome are not reversible.

Option B: A single palmar crease is a single line that runs across the palm of the hand. People most often have 3 creases in their palms. A single palmar crease appears in about 1 out of 30 people. Males are twice as likely as females to have this condition. Some single palmar creases may indicate problems with development and be linked with certain disorders.
Option C: Hyperreflexia is a sign of upper motor neuron damage and is associated with spasticity and a positive Babinski sign. In infants with at CST which is not fully myelinated the presence of a Babinski sign in the absence of other neurological deficits is considered normal up to 24 months of age.
Option D: Achondroplasia is the most common form of short-limb dwarfism. It is an autosomal dominant disorder caused by a mutation in the gene that creates the cells (fibroblasts) which convert cartilage to bone. This means, if the gene is passed on by one parent, the child will have achondroplasia.

FNDNRS-05-044

Which of these statements, when made by the nurse, is most effective when communicating with a 4-year-old?

A. “Tell me where you hurt.”
B. “Other children like having their blood pressure taken.”
C. “This will be like having a little stick in your arm.”
D. “Anything you tell me is confidential.”

Correct Answer: A. “Tell me where you hurt.”

Four-year-olds are egocentric and interested in having the focus on themselves. As kids gain language skills, they also develop their conversational abilities. Kids 4 to 5 years old can follow more complex directions and enthusiastically talk about things they do. They can make up stories, listen attentively to stories, and retell stories.

Option B: They will not be interested in what it feels like to other children. By the time your child is in their later years of primary school, their language and ability to convey ideas has improved a lot. They even alter their speech to suit the circumstances. They may speak more formally in front of a teacher than they do with family and friends.
Option C: Preschoolers are concrete thinkers and would literally interpret any analogies so they are not helpful in explaining procedures. Concrete thinking is a kind of reasoning that relies heavily on what we observe in the physical world around us. It’s sometimes called literal thinking. Young children think concretely, but as they mature, they usually develop the ability to think more abstractly.
Option D: Assurance of confidential communication is most appropriate for the adolescent. In addition, confidentiality is not maintained if the child plans to harm themselves, harm someone else, or discloses abuse.

FNDNRS-05-045

A 64-year-old client scheduled for surgery with a general anesthetic refuses to remove a set of dentures prior to leaving the unit for the operating room. What would be the most appropriate intervention by the nurse?

A. Explain to the client that the dentures must come out as they may get lost or broken in the operating room.
B. Ask the client if there are second thoughts about having the procedure.
C. Notify the anesthesia department and the surgeon of the client’s refusal.
D. Ask the client if the preference would be to remove the dentures in the operating room receiving area.

Correct Answer: D. Ask the client if the preference would be to remove the dentures in the operating room receiving area.

Clients anticipating surgery may experience a variety of fears. This choice allows the client control over the situation and fosters the client’s sense of self-esteem and self-concept. Nurses need to allow patients the choice of what to do in relation to their dentures when going to the theatre, although the anesthetist must make the final decision of whether or not to remove them immediately before the anesthetic if they feel patient safety could be compromised.

Option A: According to a study, “There are no set national guidelines on how dentures should be managed during anesthesia, but it is known that leaving dentures in during bag-mask ventilation allows for a better seal during induction [when the anesthetic is being infused], and therefore many hospitals allow dentures to be removed immediately before intubation [when a tube is inserted into the airway to assist breathing]”.
Option B: The swallowing of dentures during general anesthesia is a significant problem for anesthesiologists. It is seen more often in patients with psychiatric disorders, mental retardation, alcoholism, or poor-quality dentures. It has become an important issue for anesthesiologists preoperatively due to the increase in the proportion of dentures associated with the prolongation of life.
Option C: The presence of any false teeth or dental plates should be clearly documented before and after any surgical procedure, with all members of the surgical team made aware of what is to be done with them, they add.

FNDNRS-05-046

The nurse is assessing a client who states her last menstrual period was March 17, and she has missed one period. She reports episodes of nausea and vomiting. Pregnancy is confirmed by a urine test. What will the nurse calculate as the estimated date of delivery (EDD)?

A. November 8
B. May 15
C. February 21
D. December 24

Correct Answer: D. December 24

Naegele’s rule: add 7 days and subtract 3 months from the first day of the last regular menstrual period to calculate the estimated date of delivery. Naegele’s rule, derived from a German obstetrician, subtracts 3 months and adds 7 days to calculate the estimated due date (EDD). It is prudent for the obstetrician to get a detailed menstrual history, including duration, flow, previous menstrual periods, and hormonal contraceptives.

Option A: Determining gestational age is one of the most critical aspects of providing quality prenatal care. Knowing the gestational age allows the obstetrician to provide care to the mother without compromising maternal or fetal status. It allows for the correct timing of management, such as administering steroids for fetal lung maturity, starting ASA therapy with a history of pre-eclampsia in previous pregnancies, starting hydroxyprogesterone caproate (Makena) for previous preterm deliveries.
Option B: An average pregnancy lasts 280 days from the first day of the last menstrual period (LMP) or 266 days after conception. Historically, an accurate LMP is the best estimator to determine the due date.
Option C: An official EDD is established after calculating the first-trimester sonogram EDD date and then using the LMP. If the LMP and first trimester EDD are within 7 days of each other, the LMP estimates the due date. The margin of error is reduced depending on when (i.e., how early) the sonogram occurred.

FNDNRS-05-047

The family of a 6-year-old with a fractured femur asks the nurse if the child’s height will be affected by the injury. Which statement is true concerning long bone fractures in children?

A. Growth problems will occur if the fracture involves the periosteum.
B. Epiphyseal fractures often interrupt a child’s normal growth pattern.
C. Children usually heal very quickly, so growth problems are rare.
D. Adequate blood supply to the bone prevents growth delay after fractures.

Correct Answer: B. Epiphyseal fractures often interrupt a child’s normal growth pattern.

Epiphyseal fractures often interrupt a child’s normal growth pattern. Growth plate fractures are classified based on which parts of the bone are damaged, in addition to the growth plate. Areas of the bone immediately above and below the growth plate may fracture. They are called the epiphysis (the tip of the bone) and metaphysis (the “neck” of the bone).

Option A: The most serious complication is early closure (complete or partial) of the growth plate. Complete closure means the entire growth plate of the affected bone has stopped expanding. This results in the affected bone not growing as long as the opposite side.
Option C: The severity of and need for treatment of growth plate closures depend on the location of the fracture and the age of the patient. Other complications of growth plate fractures include delayed healing of the bone, nonhealing, infection, and loss of blood flow to the area, causing death of part of the bone.
Option D: Growth plate fractures are generally treated with splints or casts. Sometimes, the bone may need to be put back in place to allow it to heal in the correct position. This may be done before or after the cast is placed and is called a closed reduction. The length of time the child needs to be in a cast or splint depends on the location and severity of the fracture. The child’s age also matters: younger patients heal faster than older patients.

FNDNRS-05-048

A client is admitted to the hospital with a history of confusion. The client has difficulty remembering recent events and becomes disoriented when away from home. Which statement would provide the best reality orientation for this client?

A. “Good morning. Do you remember where you are?”
B. “Hello. My name is Elaine Jones and I am your nurse for today.”
C. “How are you today? Remember, you’re in the hospital.”
D. “Good morning. You’re in the hospital. I am your nurse Elaine Jones.”

Correct Answer: D. “Good morning. You’re in the hospital. I am your nurse Elaine Jones.”

As cognitive ability declines, the nurse provides a calm, predictable environment for the client. This response establishes time, location, and the caregiver’s name. Orient the patient to surroundings, staff, necessary activities as needed. Present reality concisely and briefly. Avoid challenging illogical thinking—defensive reactions may result.

Option A: Modulate sensory exposure. Provide a calm environment; eliminate extraneous noise and stimuli. Increased levels of visual and auditory stimulation can be misinterpreted by the confused patient.
Option B: Give simple directions. Allow sufficient time for the patient to respond, to communicate, to make decisions. This communication method can reduce anxiety experienced in a strange environment.
Option C: Offer reassurance to the patient and use therapeutic communication at frequent intervals. Patient reassurance and communication are nursing skills that promote trust and orientation and reduce anxiety.

FNDNRS-05-049

When a client wishes to improve the appearance of their eyes by removing excess skin from the face and neck, the nurse should provide teaching regarding which of the following procedures?

A. Dermabrasion
B. Rhinoplasty
C. Blepharoplasty
D. Rhytidectomy

Correct Answer: D. Rhytidectomy

Rhytidectomy is the procedure for removing excess skin from the face and neck. It is commonly called a facelift. Rhytidectomy is a surgical procedure meant to counteract the effects of time on the aging face. In the rhytidectomy procedure (also known as a “face-lift”), the tissues under the skin are tightened and excess facial and neck skin are excised. Rhytidectomy literally means wrinkle (rhytid-) removal (-ectomy).

Option A: Dermabrasion involves the spraying of a chemical to cause light freezing of the skin, which is then abraded with sandpaper or a revolving wire brush. It is used to remove facial scars, severe acne, and pigment from tattoos. Dermabrasion is an exfoliating technique that uses a rotating instrument to remove the outer layers of skin, usually on the face. This treatment is popular with people who wish to improve the appearance of their skin. Some of the conditions it can treat include fine lines, sun damage, acne scars, and uneven texture.
Option B: Rhinoplasty is done to improve the appearance of the nose and involves reshaping the nasal skeleton and overlying skin. Rhinoplasty is surgery that changes the shape of the nose. The motivation for rhinoplasty may be to change the appearance of the nose, improve breathing, or both. The upper portion of the structure of the nose is bone, and the lower portion is cartilage.
Option C: Blepharoplasty is the procedure that removes loose and protruding fat from the upper and lower eyelids. Eyelid surgery, or blepharoplasty, is a surgical procedure to improve the appearance of the eyelids.

FNDNRS-05-050

A woman who is six months pregnant is seen in antepartal clinic. She states she is having trouble with constipation. To minimize this condition, the nurse should instruct her to

A. Increase her fluid intake to three liters/day.
B. Request a prescription for a laxative from her physician.
C. Stop taking iron supplements.
D. Take two tablespoons of mineral oil daily.

Correct Answer: A. increase her fluid intake to three liters/day.

In pregnancy, constipation results from decreased gastric motility and increased water reabsorption in the colon caused by increased levels of progesterone. Increasing fluid intake to three liters a day will help prevent constipation. The client should increase fluid intake, increase roughage in the diet, and increase exercise as tolerated.

Option B: Laxatives are not recommended because of the possible development of laxative dependence or abdominal cramping. The primary medical treatment for constipation in pregnancy is a medication called a laxative, which makes it easier and more comfortable to go to the bathroom. It is generally safe to use gentle laxatives, but it is best to avoid stimulant laxatives because they can induce uterine contractions.
Option C: Iron supplements are necessary during pregnancy, as ordered, and should not be discontinued. Daily oral iron and folic acid supplementation with 30 mg to 60 mg of elemental iron and 400 µg (0.4 mg) folic acid is recommended for pregnant women to prevent maternal anemia, puerperal sepsis, low birth weight, and preterm birth.
Option D: Mineral oil is especially bad to use as a laxative because it decreases the absorption of fat-soluble vitamins (A, D, E, K) if taken near mealtimes. Mineral oil should always be prohibited during pregnancy, as its use can cause hemorrhagic disease of the newborn due to impaired absorption of vitamin K. Similarly, castor oil is absolutely prohibited during pregnancy.

Questions related to pain management

FNDNRS-05-051

A client with chronic pain reports to you, the charge nurse, that the nurse has not been responding to requests for pain medication. What is your initial action?

A. Check the MARs and nurses’ notes for the past several days.
B. Ask the nurse educator to give an in-service about pain management.
C. Perform a complete pain assessment and history on the client.
D. Have a conference with the nurses responsible for the care of this client.

Correct Answer: D. Have a conference with the nurses responsible for the care of this client.

As a charge nurse, you must assess the performance and attitude of the staff in relation to this client. Handling conflicts in an efficient and effective manner results in improved quality, patient safety, and staff morale, and limits work stress for the caregiver. The nurse manager must approach this challenge thoughtfully because it involves working relationships that are critical for the unit to function effectively.

Option A: After gathering data from the nurses, additional information from the records and the client can be obtained as necessary. Effective resolution and management of a conflict require clear communication and a level of understanding of the perceived areas of disagreement. Conflict resolution is an essential element of a healthy work environment because a breakdown in communication and collaboration can lead to increased patient errors.
Option B: The educator may be of assistance if knowledge deficit or need for performance improvement is the problem. The American Association of Critical-Care Nurses standards for healthy work environments recognizes the importance of proficiency in communication skills and The Joint Commission’s revised leadership standards place a mandate on healthcare leadership to manage disruptive behavior that can impact patient safety.
Option C: Nursing leaders need to assess how nurses deal with conflict in the healthcare environment in an effort to develop and implement conflict management training and processes that can assist them in dealing with difficult situations.

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FNDNRS-05-052

Family members are encouraging your client to “tough it out” rather than run the risk of becoming addicted to narcotics. The client is stoically abiding by the family’s wishes. Priority nursing interventions for this client should target which dimension of pain?

A. Sensory
B. Sociocultural
C. Behavioral
D. Cognitive

Correct Answer: B. Sociocultural

The family is part of the socio-cultural dimension of pain. They are influencing the client and should be included in the teaching sessions about the appropriate use of narcotics and about the adverse effects of pain on the healing process. The other dimensions should be included to help the client/family understand the overall treatment plan and pain mechanism.

Option A: The sensory dimension encompasses both the quality and severity of pain. It includes the patient’s report of the location, quality, and intensity of pain. Assessing this dimension helps quantify the pain and clarify the extent of poorly localized or radiating pain.
Option C: The behavioral dimension of pain refers to the patient’s verbal or nonverbal behaviors exhibited in response to pain. To assess it, rely on direct observation and continued patient interaction. Watch for common behaviors associated with pain, such as guarding, splinting, tensing up, crying, moaning, and massaging a specific body part.
Option D: The cognitive dimension refers to thoughts, beliefs, attitudes, intentions, and motivations related to pain and its management. Before assessing this dimension, evaluate the patient’s cognitive capacity and functioning. Review the medical history for diseases or conditions that may impair cognition; if any exists, assess its current level of progression. In some patients, pain can temporarily worsen pre-existing cognitive limitations.

FNDNRS-05-053

A client with diabetic neuropathy reports a burning, electrical type in the lower extremities that is not responding to NSAIDs. You anticipate that the physician will order which adjuvant medication for this type of pain?

A. Amitriptyline (Elavil)
B. Corticosteroids
C. Methylphenidate (Ritalin)
D. Lorazepam (Ativan)

Correct Answer: A. Amitriptyline (Elavil)

Antidepressants such as amitriptyline can be given for diabetic neuropathy. The American Diabetes Association recommends amitriptyline, a tricyclic antidepressant, as the first choice; however, titration to higher doses is limited by its anticholinergic adverse effects.

Option B: Corticosteroids are for pain associated with inflammation. Corticosteroids produce their effect through multiple pathways. In general, they produce anti-inflammatory and immunosuppressive effects, protein and carbohydrate metabolic effects, water and electrolyte effects, central nervous system effects, and blood cell effects.
Option C: Methylphenidate is given to counteract sedation if the client is on opioids. Methylphenidate is FDA-approved for the treatment of attention deficit hyperactivity disorder (ADHD) in children and adults and as a second-line treatment for narcolepsy in adults. Children with a diagnosis of ADHD should be at least six years of age or older before being started on this medication.
Option D: Lorazepam is an anxiolytic. Lorazepam has common use as the sedative and anxiolytic of choice in the inpatient setting owing to its fast (1 to 3 minute) onset of action when administered intravenously. Lorazepam is also one of the few sedative-hypnotics with a relatively clean side effect profile.

FNDNRS-05-054

Which client is most likely to receive opioids for extended periods of time?

A. A client with fibromyalgia
B. A client with phantom limb pain
C. A client with progressive pancreatic cancer
D. A client with trigeminal neuralgia

Correct Answer: C. A client with progressive pancreatic cancer

Cancer pain generally worsens with disease progression and the use of opioids is more generous. Opioids (narcotics) are used with or without non-opioids to treat moderate to severe pain. They are often a necessary part of a pain relief plan for cancer patients. These medicines are much like natural substances (called endorphins) made by the body to control pain. They were once made from the opium poppy, but today many are man-made in a lab.

Option A: Fibromyalgia is more likely to be treated with non-opioid and adjuvant medications. It is recommended to continue nonpharmacologic measures along with the use of medications for most patients with fibromyalgia. Some patients may, however, respond adequately to nonpharmacologic measures alone. The medications that have been well studied and consistently effective are certain antidepressants and anticonvulsants.
Option B: Phantom limb pain usually subsides after ambulation begins. Treatment, unfortunately, for PLP has not proven to be very effective. While treatment for RLP tends to focus on an organic cause for the pain, PLP focuses on symptomatic control.
Option D: Trigeminal neuralgia is treated with anti-seizure medications such as carbamazepine (Tegretol). The first-line treatment for patients with classic TN and idiopathic TN is pharmacologic therapy. The most commonly used medication is the anticonvulsant drug, carbamazepine. It is usually started at a low dose, and the dose is gradually increased until it controls the pain. It controls pain for most people in the early stages of the disease.

FNDNRS-05-055

As the charge nurse, you are reviewing the charts of clients who were assigned to a newly graduated RN. The RN has correctly chartered the dose and time of medication, but there is no documentation regarding non-pharmaceutical measures. What action should you take first?

A. Make a note in the nurse’s file and continue to observe clinical performance.
B. Refer the new nurse to the in-service education department.
C. Quiz the nurse about knowledge of pain management.
D. Give praise for the correct dose and time and discuss the deficits in charting.

Correct Answer: D. Give praise for the correct dose and time and discuss the deficits in charting.

In supervising the new RN, good performance should be reinforced first and then areas of improvement can be addressed. Nursing activities are very important within the hospital and must solve the problems that the patient needs. Every nursing activity should produce documentation with critical thinking. If nursing documents are not clear and accurate, inter-professional communication and an evaluation of nursing care cannot be optimal.

Option A: Making a note and watching do not help the nurse to correct the immediate problem. Nursing activity that has been completed or that will take place should be properly documented. Accurate documentation and reports play a pivotal role in health services. This documentation is necessary to identify nursing interventions that have been provided to patients and to show patient progress during hospitalization.
Option B: In-service might be considered if the problem persists. Nursing documentation also serves as an effective tool of inter-professional communication between nurses and other health professionals for delivering ongoing nursing care, evaluating patient progress and outcomes, and providing constant patient protection. High-quality nursing documentation may improve the effectiveness of communication between health professionals in first- and higher-level healthcare facilities.
Option C: Asking the nurse about knowledge of pain management is also an option; however, it would be a more indirect and time-consuming approach. It is also an indicator of nurse performance and the nursing service quality in a hospital. Documentation provides details of patient condition, nursing interventions that have been provided, and patient response to the intervention(s).

FNDNRS-05-056

In caring for a young child with pain, which assessment tool is the most useful?

A. Simple descriptive pain intensity scale
B. 0-10 numeric pain scale
C. Faces pain-rating scale
D. McGill-Melzack pain questionnaire

Correct Answer: C. Faces pain-rating scale

The Faces pain rating scale (depicting smiling, neutral, frowning, crying, etc.) is appropriate for young children who may have difficulty describing pain or understanding the correlation of pain to numerical or verbal descriptors. The Faces Pain Scale-Revised (FPS-R) is a self-report measure of pain intensity developed for children. It was adapted from the Faces Pain Scale to make it possible to score the sensation of pain on the widely accepted 0-to-10 metric. The scale shows a close linear relationship with visual analog pain scales across the age range of 4-16 years. It is easy to administer and requires no equipment except for the photocopied faces. The other tools require abstract reasoning abilities to make analogies and use of advanced vocabulary.

Option A: The Simple Descriptive Scale exhibits degrees of pain intensity (no pain, mild pain, moderate pain, and severe pain). Risk factors for the development of chronic pain have been a major topic in pain research in the past two decades. Now, it has been realized that psychological and psychosocial factors may substantially influence pain perception in patients with chronic pain and thus may influence the surgical outcome.
Option B: This pain scale is most commonly used. A person rates their pain on a scale of 0 to 10 or 0 to 5. Zero means “no pain,” and 5 or 10 means “the worst possible pain.” These pain intensity levels may be assessed upon initial treatment, or periodically after treatment.
Option D: The McGill pain questionnaire, or MPQ, is one of the most widely used multidimensional pain scales in the world. In the MPQ, the evaluation of pain is divided into three categories: sensory, affective, and evaluative. The questionnaire is self-reported and allows individuals to describe the quality and intensity of their pain by using 78 adjectives in 20 different sections.

FNDNRS-05-057

In applying the principles of pain treatment, what is the first consideration?

A. Treatment is based on client goals.
B. A multidisciplinary approach is needed.
C. The client must believe in perceptions of own pain.
D. Drug side effects must be prevented and managed.

Correct Answer: C. The client must be believed about perceptions of own pain.

The client must be believed and his or her experience of pain must be acknowledged as valid. The data gathered via client reports can then be applied to other options in developing the treatment plan. Assist patients to develop a daily routine to support achievement and, where necessary, readjustment of habits and roles according to individual capacity and life situation.

Option A: Use a person-centered perspective to formulate collaborative intervention strategies consistent with a physical therapy perspective. Understand the need to involve family members and significant others including employers where appropriate.
Option B: Demonstrate an ability to integrate the patient assessment into an appropriate management plan using the concepts and strategies of clinical reasoning.
Option D: Understand the principles of an effective therapeutic patient/professional relationship to reduce pain, promote optimal function and reduce disability through the use of active and where appropriate, passive pain management approaches.

FNDNRS-05-058

Which route of administration is preferred if immediate analgesia and rapid titration are necessary?

A. Intraspinal
B. Patient-controlled analgesia (PCA)
C. Intravenous (IV)
D. Sublingual

Correct Answer: C. Intravenous (IV)

The IV route is preferred as the fastest and most amenable to titration. Medications may be given as repeated intermittent bolus doses or by continuous infusion. Intravenous provides almost immediate analgesia; subcutaneous may require up to 15 minutes for effect. Bolus IV dosing provides a shorter duration of action than other routes.

Option A: Intraspinal administration requires special catheter placement and there are more potential complications with this route. Intraspinal and intraventricular administration are options if maximal doses of opioids and adjuvants administered through other routes are ineffective or produce intolerable side effects {e.g., nausea/vomiting, excessive sedation, confusion}. Opioids can be administered via indwelling percutaneous or tunneled catheters into the epidural or intrathecal space.
Option B: A PCA bolus can be delivered; however, the pump will limit the dosage that can be delivered unless the parameters are changed. Patient-controlled analgesia (PCA) devices can be used to combine continuous infusion with intermittent bolus doses, allowing more flexible pain control. It is recommended that the hourly SQ volume limit not exceed 5 cc. Medications can be concentrated to maintain SQ volume limits; maximal concentrations: fentanyl 50 ug/ml, morphine 50 mgs/ml, hydromorphone 50 mgs/ml.
Option D: Sublingual is reasonably fast, but not a good route for titration, medication variety in this form is limited. An alkaline pH microenvironment that favors the unionized fraction of opioids increased sublingual drug absorption. Although absorption was found to be independent of drug concentration, it was contact time dependent for methadone and fentanyl but not for buprenorphine. These results indicate that although the sublingual absorption and apparent sublingual bioavailability of morphine are poor, the sublingual absorption of methadone, fentanyl, and buprenorphine under controlled conditions is relatively high.

FNDNRS-05-059

When titrating an analgesic to manage pain, what is the priority goal?

A. Administer smallest dose that provides relief with the fewest side effects.
B. Titrate upward until the client is pain-free.
C. Titrate downwards to prevent toxicity.
D. Ensure that the drug is adequate to meet the client’s subjective needs.

Correct Answer: A. Administer smallest dose that provides relief with the fewest side effects.

The goal is to control pain while minimizing side effects. The World Health Organization cancer pain ladder provides a helpful starting point for achieving effective pain management. Clinicians should begin with nonopioid analgesics (e.g., acetaminophen, nonsteroidal anti-inflammatory drugs [NSAIDs]), and gradually progress to more potent analgesics until pain is relieved.

Option B: For severe pain, the medication can be titrated upward until pain is controlled. Many patients with terminal illnesses require immediate opioid therapy or have contraindications to common non-opioid analgesics, such as NSAIDs.
Option C: Downward titration occurs when the pain begins to subside. Acetaminophen is useful as a primary analgesic, or in combination with other drugs, for treating mild to moderate pain. Dosages in healthy persons should be limited to no more than 4,000 mg every 24 hours to reduce the risk of hepatotoxicity.
Option D: Adequate dosing is important; however, the concept of controlled dosing applies more to potent vasoactive drugs. The World Health Organization pain ladder offers a stepwise guideline for approaching pain management. However, for many patients with terminal illnesses, strong opioids are necessary for efficient and effective analgesia.

FNDNRS-05-060

In educating clients about non-pharmaceutical alternatives, which topic could you delegate to an experienced LPN/LVN, who will function under your continued support and supervision?

A. Therapeutic touch
B. Use of heat and cold applications
C. Meditation
D. Transcutaneous electrical nerve stimulation (TENS)

Correct Answer: B. Use of heat and cold applications

Use of heat and cold applications is a standard therapy with guidelines for safe use and predictable outcomes, and an LPN/LVN will be implementing this therapy in the hospital, under the supervision of an RN. Treating pain with hot and cold can be extremely effective for a number of different conditions and injuries, and easily affordable. The tricky part is knowing what situations call for hot, and which calls for cold. Sometimes a single treatment will even include both.

Option A: Therapeutic touch requires additional training and practice. The National Center for Complementary and Alternative Medicine places therapeutic touch (TT) into the category of bio-field energy. In the TT method, the therapist’s hand is used to increase comfort and reduce pain using the body’s energy field correction mechanism
Option C: Meditation is not acceptable to all clients and an assessment of spiritual beliefs should be conducted. Mindfulness meditation is a fairly loose term that applies to many meditation practices, which have been found to improve a wide spectrum of clinically relevant cognitive and health outcomes.
Option D: Transcutaneous electrical stimulation is usually applied by a physical therapist. Transcutaneous electrical nerve stimulation (TENS) is a therapy that uses low voltage electrical current to provide pain relief. A TENS unit consists of a battery-powered device that delivers electrical impulses through electrodes placed on the surface of your skin. The electrodes are placed at or near nerves where the pain is located or at trigger points.

FNDNRS-05-061

Place the examples of drugs in the order of usage according to the World Health Organization (WHO) analgesic ladder.

1. NSAIDs and corticosteroids
2. Codeine, oxycodone, and diphenhydramine
3. Morphine, hydromorphone, acetaminophen, and lorazepam

The correct order is shown above.

The WHO analgesic ladder was a strategy proposed by the World Health Organization (WHO), in 1986, to provide adequate pain relief for cancer patients. The analgesic ladder was part of a vast health program termed the WHO Cancer Pain and Palliative Care Program aimed at improving strategies for cancer pain management through educational campaigns, the creation of shared strategies, and the development of a global network of support.

Step 1 includes non-opioids and adjuvant drugs. Mild pain: non-opioid analgesics such as nonsteroidal anti-inflammatory drugs (NSAIDs) or acetaminophen with or without adjuvants.
Step 2 includes opioids for mild pain plus Step 1 drugs and adjuvant drugs as needed. Moderate pain: weak opioids (hydrocodone, codeine, tramadol) with or without non-opioid analgesics, and with or without adjuvants.
Step 3 includes opioids for severe pain (replacing Step 2 opioids) and continuing Step 1 drugs and adjuvant drugs as needed. Severe and persistent pain: potent opioids (morphine, methadone, fentanyl, oxycodone, buprenorphine, tapentadol, hydromorphone, oxymorphone) with or without non-opioid analgesics, and with or without adjuvants.

FNDNRS-05-062

Which client is at greater risk for respiratory depression while receiving opioids for analgesia?

A. An elderly chronic pain client with a hip fracture.
B. A client with heroin addiction and back pain.
C. A young female client with advanced multiple myeloma.
D. A child with an arm fracture and cystic fibrosis.

Correct Answer: D. A child with an arm fracture and cystic fibrosis.

At greatest risk are elderly clients, opiate naïve clients, and those with underlying pulmonary disease. The child has two of the three risk factors. Many complications can occur with multiple different opioids, such as non-cardiogenic pulmonary edema, while many of the complications are unique to the opioid used as well as the route of administration.

Option A: Pain in the elderly population is especially difficult given the myriad of physiological, pharmacological, and psychological aspects of caring for geriatric patient. Opiates are the mainstay of pain treatment throughout all age groups but special attention must be paid to the efficacy and side effects of these powerful drugs when prescribing to a population with impaired metabolism, excretion, and physical reserve.
Option B: Prescription opioids and heroin are chemically similar and can produce a similar high. In some places, heroin is cheaper and easier to get than prescription opioids, so some people switch to using heroin instead. More recent data suggest that heroin is frequently the first opioid people use. In a study of those entering treatment for opioid use disorder, approximately one-third reported heroin as the first opioid they used regularly to get high.
Option C: Bone pain is one of the most common presentations of multiple myeloma and nearly all patients have skeletal involvement in the course of the disease. Consequently, many patients require narcotics for symptom management at the time of diagnosis but the long-term impact of MM treatment on pain control remains uncertain.

FNDNRS-05-063

A client appears upset and tearful, but denies pain and refuses pain medication, because “my sibling is a drug addict and has ruined our lives.” What is the priority intervention for this client?

A. Encourage expression of fears on past experiences.
B. Provide accurate information about the use of pain medication.
C. Explain that addiction is unlikely among acute care clients.
D. Seek family assistance in resolving this problem.

Correct Answer: A. Encourage expression of fears on past experiences.

This client has strong beliefs and emotions related to the issue of sibling addiction. First, encourage expression. This indicated to the client that the feelings are real and valid. It is also an opportunity to assess beliefs and fears. Verbalization of feelings in a nonthreatening environment may help the client come to terms with unresolved issues.

Option B: Giving facts and information is appropriate at the right time. Clients are often reluctant to share feelings for fear of ridicule and may have repeatedly been told to ignore feelings. Once the client begins to acknowledge and talk about these fears, it becomes apparent that the feelings are manageable.
Option C: Encourage the client to explore underlying feelings that may be contributing to irrational fears. Help the client to understand how facing these feelings, rather than suppressing them, can result in more adaptive coping abilities.
Option D: Family involvement is important, bearing in mind that their beliefs about drug addiction may be similar to those of the client. Present and discuss the reality of the situation with the client in order to recognize aspects that can be changed and those that cannot. The client must accept the reality of the situation before the work of reducing the fear can progress.

FNDNRS-05-064

A client is being tapered off opioids and the nurse is watchful for signs of withdrawal. What is one of the first signs of withdrawal?

A. Fever
B. Nausea
C. Diaphoresis
D. Abdominal cramps

Correct Answer: C. Diaphoresis

Diaphoresis is one of the early signs that occur between 6 and 12 hours. Fever, nausea, and abdominal cramps are late signs that occur between 48 and 72 hours. According to Diagnostic and Statistical Manual of Mental Disorders (DSM–5) criteria, signs, and symptoms of opioid withdrawal include lacrimation or rhinorrhea, piloerection “goose flesh,” myalgia, diarrhea, nausea/vomiting, pupillary dilation and photophobia, insomnia, autonomic hyperactivity (tachypnea, hyperreflexia, tachycardia, sweating, hypertension, hyperthermia), and yawning.

Option A: A fever can be a withdrawal symptom among people who have been addicted to various substances, or even after a period of intense substance use. Fever symptoms may range from mild to severe. Although mild fevers can accompany a variety of substance withdrawal syndromes and are usually self-limiting, fever can also be a component of a particularly dangerous type of alcohol withdrawal.
Option B: Prolonged use of these drugs changes the way nerve receptors work in the brain, and these receptors become dependent upon the drug to function. If the client becomes physically sick after he stops taking an opioid medication, it may be an indication that he’s physically dependent on the substance.
Option D: The symptoms the client is experiencing will depend on the level of withdrawal he is experiencing. Also, multiple factors dictate how long a person will experience the symptoms of withdrawal. Because of this, everyone experiences opioid withdrawal differently. However, there’s typically a timeline for the progression of symptoms.

FNDNRS-05-065

In caring for clients with pain and discomfort, which task is most appropriate to delegate to the nursing assistant?

A. Assist the client with preparation of a sitz bath.
B. Monitor the client for signs of discomfort while ambulating.
C. Coach the client to deep breathe during painful procedures.
D. Evaluate relief after applying a cold application.

Correct Answer: A. Assist the client with preparation of a sitz bath.

The nursing assistant is able to assist the client with hygiene issues and knows the principles of safety and comfort for this procedure. Proper and appropriate assignments facilitate quality care. Improper and inappropriate assignments can lead to poor quality of care, disappointing outcomes of care, the jeopardization of client safety, and even legal consequences. Monitoring the client, teaching techniques, and evaluating outcomes are nursing responsibilities.

Option B: Monitoring the client for signs of discomfort while ambulating is a nursing responsibility. When a registered nurse delegates aspects of patient care to a licensed practical nurse that are outside of the scope of practice of the licensed practical nurse, the client is in potential physical and/or psychological jeopardy because this delegated task, which is outside of the scope of practice for this licensed practical nurse, is something that this nurse was not prepared and educated to perform.
Option C: Coaching the client to deep breathe during painful procedures is a nursing responsibility. The nurse who delegates aspects of care to other members of the nursing team must balance the needs of the client with the abilities of those to which the nurse is delegating tasks and aspects of care, among other things such as the scopes of practice and the policies and procedures within the particular healthcare facility.
Option D: Evaluation of relief after applying a cold application is a nursing responsibility. The staff members’ levels of education, knowledge, past experiences, skills, abilities, and competencies are also evaluated and matched with the needs of all of the patients in the group of patients that will be cared for.

FNDNRS-05-066

The physician has ordered a placebo for a chronic pain client. You are a newly hired nurse and you feel very uncomfortable administering the medication. What is the first action that you should take?

A. Prepare the medication and hand it to the physician.
B. Check the hospital policy regarding the use of the placebo.
C. Follow a personal code of ethics and refuse to give it.
D. Contact the charge nurse for advice.

Correct Answer: D. Contact the charge nurse for advice.

A charge nurse is a resource person who can help locate and review the policy. If the physician is insistent, he or she could give the placebo personally, but delaying the administration does not endanger the health or safety of the client.

Option A: In a treatment setting it is unethical to deliberately misinform the patient. However, placebo effects can be an important factor in a biopsychosocial context. Clinicians need to consider some ethical issues relating to placebo effects. According to Pittrof and Rubenstein, the ethical use of placebo effects should always benefit the patient and involve disclosure.
Option B: Placebo effects may thus be defined as psychological and/or physiological responses that follow the administration of active and non-active substances when coupled with an affirmation of the treatment effects. The ethical use of placebo effects in a clinical setting should rely on realistic expectations and be based on best practice. The use of a placebo in clinical settings might still be seen as controversial by some.
Option C: While following one’s own ethical code is correct, you must ensure that the client is not abandoned and that care continues. Placebo effects, when considered as supplements to pharmacologically active substances, should aim to increase patients’ well-being. It is unethical to deliberately misinform patients.

FNDNRS-05-067

For a cognitively impaired client who cannot accurately report pain, what is the first action that you should take?

A. Closely assess for nonverbal signs such as grimacing or rocking.
B. Obtain baseline behavioral indicators from family members.
C. Look at the MAR and chart, to note the time of the last dose and response.
D. Give the maximum PRS dose within the minimum time frame for relief.

Correct Answer: B. Obtain baseline behavioral indicators from family members.

Complete information from the family should be obtained during the initial comprehensive history and assessment. If this information is not obtained, the nursing staff will have to rely on observation of nonverbal behavior and careful documentation to determine pain and relief patterns.

Option A: Pain can be difficult to assess in cognitively impaired individuals because their self-reports of pain can be inaccurate or difficult to obtain.Thus, behavioral observation-based assessment is optimal in these patients.
Option C: Assess potential causes of pain. The clinician should consider pathological causes of pain and any procedure known to cause pain. Address any pain history from family, significant others, and caregivers.
Option D: Use scheduled dosing when pain is chronic and/or when the patient is unable to ask for medication. When administering the medication, it is best to start with a lower dose and gradually increase the dose to alleviate the pain.

FNDNRS-05-068

Which route of administration is preferable for administration of daily analgesics (if all body systems are functional)?

A. IV
B. IM or subcutaneous
C. Oral
D. Transdermal
E. PCA

Correct Answer: C. Oral

If the gastrointestinal system is functioning, the oral route is preferred for routine analgesics because of lower cost and ease of administration. Oral route is also less painful and less invasive than the IV, IM, subcutaneous, or PCA routes. Although a few drugs taken orally are intended to be dissolved in the mouth, nearly all drugs taken orally are swallowed. Of these, most are taken for the systemic drug effects that result after absorption from the various surfaces along the gastrointestinal tract.

Option A: IV therapy allows a higher concentration of nutrients or medication into the body — and that means the body gets what it needs faster and more effectively without further damage to the GI system.
Option B: Rapid and uniform absorption of the drug especially those of the aqueous solutions. Rapid onset of the action compared to that of the oral and the subcutaneous routes. IM injection bypasses the first-pass metabolism. It also avoids the gastric factors governing drug absorption.
Option D: Transdermal route is slower and medication availability is limited compared to oral forms. Transdermal delivery systems provide continuous administration of drugs through the skin, which maintains constant plasma drug levels and avoids the peaks and troughs that are seen with oral administration.
Option E: Patient-controlled analgesia is used to treat acute, chronic, postoperative, and labor pain. A variety of medications can be used for patient-controlled analgesia and are administered intravenously (IV), through an epidural or peripheral nerve catheter, and transdermally.

FNDNRS-05-069

A first-day postoperative client on a PCA pump reports that the pain control is inadequate. What is the first action you should take?

A. Deliver the bolus dose per standing order.
B. Contact the physician to increase the dose.
C. Try non-pharmacological comfort measures.
D. Assess the pain for location, quality, and intensity.

Correct Answer: D. Assess the pain for location, quality, and intensity.

Assess the pain for changes in location, quality, and intensity, as well as changes in response to medication. This assessment will guide the next steps. Patient-controlled analgesia is used to treat acute, chronic, postoperative, and labor pain. A variety of medications can be used for patient-controlled analgesia and are administered intravenously (IV), through an epidural or peripheral nerve catheter, and transdermally.

Option A: The goal of PCA is to efficiently deliver pain relief at a patient’s preferred dose and schedule by allowing them to administer a predetermined bolus dose of medication on-demand at the press of a button. Each bolus can be administered alone or coupled with a background infusion of medication.
Option B: The initial loading dose can be titrated by a nurse to reach the minimum effective concentration (MEC) of the desired medication. The bolus or demand dose is the dose of medication delivered each time the patient presses the button. A lockout interval is the time after a demand dose in which a dose of medication will not get administered even if the patient presses the button; this is done to prevent overdosing.
Option C: The use of PCA has been proven to be more effective at pain control than non-patient-controlled opioid injections and results in higher patient satisfaction. PCA has also been found to be preferred by nurses because it allows for a reduction in their workload. PCA will enable patients to be in more control over their pain and helps them shift toward a more internal locus of control over their care.

FNDNRS-05-070

Which non-pharmacological measure is particularly useful for a client with acute pancreatitis?

A. Diversional therapy, such as playing cards or board games.
B. Massage the back and neck with warmed lotion.
C. Side-lying position with knees to chest and pillow against the abdomen.
D. Transcutaneous electrical nerve stimulation (TENS).

Correct Answer: C. Side-lying position with knees to chest and pillow against the abdomen.

The side-lying, knee-chest position opens retroperitoneal space and provides relief. The pillow provides a splinting action. Reduces abdominal pressure and tension, providing some measure of comfort and pain relief. Note: Supine position often increases pain.

Option A: Diversional therapy is not the best choice for acute pain, especially if the activity requires concentration. Keep the environment free of food odors. Sensory stimulation can activate pancreatic enzymes, increasing pain.
Option B: The additional stimulation of massage may be distressing to the client. Provide alternative comfort measures (back rub), encourage relaxation techniques (guided imagery, visualization), quiet diversional activities (TV, radio).
Option D: TENS is more appropriate for chronic muscular pain. Maintain bed rest during an acute attack. Provide a quiet, restful environment. Decreases metabolic rate and GI stimulation and secretions, thereby reducing pancreatic activity.

FNDNRS-05-071

What is the best way to schedule medication for a client with constant pain?

A. PRN at the client’s request
B. Prior to painful procedures
C. IV bolus after pain assessment
D. Around-the-clock

Correct Answer: D. Around-the-clock

If the pain is constant, the best schedule is around-the-clock, to provide steady analgesia and pain control. The other options may actually require higher doses to achieve control. Pain medication prescribed around-the-clock has the purpose of managing a patient’s baseline pain, which is the average pain intensity the patient experiences. This is generally pain that is continuously experienced.

Option A: The use of “as needed” or “pro re nata” (PRN) range opioid analgesic orders is a common clinical practice in the management of acute pain, designed to provide flexibility in dosing to meet an individual’s unique needs. Range orders enable necessary adjustments in doses based on individual response to treatment.
Option B: Of particular importance to nursing care, unrelieved pain reduces patient mobility, resulting in complications such as deep vein thrombosis, pulmonary embolism, and pneumonia. Postsurgical complications related to inadequate pain management negatively affect the patient’s welfare and the hospital performance because of extended lengths of stay and readmissions, both of which increase the cost of care.
Option C: Assessment of pain is a critical step to providing good pain management. In a sample of physicians and nurses, Anderson and colleagues found lack of pain assessment was one of the most problematic barriers to achieving good pain control. The most critical aspect of pain assessment is that it is done on a regular basis (e.g., once a shift, every 2 hours) using a standard format. The assessment parameters should be explicitly directed by hospital or unit policies and procedures.

FNDNRS-05-072

Which client(s) are appropriate to assign to the LPN/LVN, who will function under the supervision of the RN or team leader? Select all that apply.

A. A client who needs pre-op teaching for use of a PCA pump.
B. A client with a leg cast who needs neurologic checks and PRN hydrocodone.
C. A client post-op toe amputation with diabetic neuropathic pain.
D. A client with terminal cancer and severe pain who is refusing medication.

Correct Answer: B, C.

The clients with the cast and the toe amputation are stable clients and need ongoing assessment and pain management that are within the scope of practice for an LPN/LVN under the supervision of an RN. The RN should take responsibility for preoperative teaching, and terminal cancer needs a comprehensive assessment to determine the reason for refusal of medication.

Option A: Preoperative teaching is a nursing responsibility. Proper and appropriate assignments facilitate quality care. Improper and inappropriate assignments can lead to poor quality of care, disappointing outcomes of care, the jeopardization of client safety, and even legal consequences.
Option B: The clients with the cast are within the scope of practice for an LPN/LVN under the supervision of an RN. Delegation, simply defined, is the transfer of the nurse’s responsibility for the performance of a task to another nursing staff member while retaining accountability for the outcome. Responsibility can be delegated. Accountability cannot be delegated. The delegating registered nurse remains accountable for all client care despite the fact that some of these aspects of care can, and are, delegated to others.
Option C: The client with the toe amputation is a stable client and needs ongoing assessment and pain management that are within the scope of practice for an LPN/LVN under the supervision of an RN. The staff members’ levels of education, knowledge, past experiences, skills, abilities, and competencies are also evaluated and matched with the needs of all of the patients in the group of patients that will be cared for.
Option D: A client with terminal cancer and severe pain who is refusing medication is a nursing responsibility. Based on these characteristics and the total client needs for the group of clients that the registered nurse is responsible and accountable for, the registered nurse determines and analyzes all of the health care needs for a group of clients; the registered nurse delegates care that matches the skills of the person that the nurse is delegating to.

FNDNRS-05-073

For a client who is taking aspirin, which laboratory value should be reported to the physician?

A. Potassium 3.6 mEq/L
B. Hematocrit 41%
C. PT 14 seconds
D. BUN 20 mg/dL

Correct Answer: C. PT 14 seconds

When a client takes aspirin, monitor for increases in PT (normal range 11.0-12.5 seconds in 85%-100%). Also, monitor for possible decreases in potassium (normal range 3.5-5.0 mEq/L). If bleeding signs are noted, hematocrit should be monitored (normal range male 42%-52%, female 37%-47%). An elevated BUN could be seen if the client is having chronic gastrointestinal bleeding (normal range 10-20 mg/dL).

Option A: Severity is categorized as mild when the serum potassium level is 3 to 3.4 mmol/L, moderate when the serum potassium level is 2.5 to 3 mmol/L, and severe when the serum potassium level is less than 2.5 mmol/L. Values obtained from plasma and serum may differ.
Option B: HCT calculation is by dividing the lengths of the packed RBC layer by the length of total cells and plasma. As it is a ratio, it doesn’t have any unit. Multiplying the ratio by 100 gives the accurate value, which is the accepted reporting style for HCT. A normal adult male shows an HCT of 40% to 54% and female shows 36% to 48%.
Option D: BUN and creatinine levels that are within the ranges established by the laboratory performing the test suggest that the kidneys are functioning as they should. Increased BUN and creatinine levels may mean that the kidneys are not working as they should. This healthcare practitioner will consider other factors, such as the medical history and physical exam, to determine what condition, if any, may be affecting the kidneys.

FNDNRS-05-074

Which client would be appropriate to assign to a newly graduated RN, who has recently completed orientation?.

A. An anxious, chronic pain client who frequently uses the call button.
B. A client second-day post-op who needs pain medication prior to dressing changes.
C. A client with HIV who reports headache and abdominal and pleuritic chest pain.
D. A client who is being discharged with a surgically implanted catheter.

Correct Answer: B. A client second-day post-op who needs pain medication prior to dressing changes

A second-day postoperative client who needs medication prior to dressing changes has predictable and routine care that a new nurse can manage. Some staff members may possess greater expertise than others. Some, such as new graduates, may not possess the same levels of knowledge, past experiences, skills, abilities, and competencies that more experienced staff members possess.

Option A: Although clients with chronic pain can be relatively stable, the interaction with this client will be time-consuming and may cause the new nurse to fall behind. Time is finite and often the needs of the client are virtually infinite. Time management, organization, and priority setting skills, therefore, are essential to the complete and effective provision of care to an individual client and to a group of clients.
Option C: The client with HIV has complex complaints that require expert assessment skills. Staff members differ in terms of their knowledge, skills, abilities, and competencies. A staff member who has just graduated as a certified nursing assistant and a newly graduated registered nurse cannot be expected to perform patient care tasks at the same level of proficiency, skill, and competency as an experienced nursing assistant or registered nurse. It takes time for new graduates to refine the skills that they learned in school.
Option D: The client pending discharge will need special and detailed instructions. Validated and documented competencies must also be considered prior to assignment of patient care. No aspect of care can be assigned or delegated to another nursing staff member unless this staff member has documented evidence that they are deemed competent by a registered nurse to do so.

FNDNRS-05-075

A family member asks you, “Why can’t you give more medicine? He is still having a lot of pain.” What is your best response?

A. “The doctor ordered the medicine to be given every 4 hours.”
B. “If the medication is given too frequently he could suffer ill effects.”
C. “Please tell him that I will be right there to check on him.”
D. “Let’s wait about 30-40 minutes. If there is no relief I’ll call the doctor.”

Correct Answer: C. “Please tell him that I will be right there to check on him.”

Directly ask the client about the pain and do a complete pain assessment. This information will determine which action to take next. Pain assessment is critical to optimal pain management interventions. While pain is a highly subjective experience, its management necessitates objective standards of care.

Option A: Poorly managing pain may put clinicians at risk for legal action. Current standards for pain management, such as the national standards outlined by the Joint Commission (formerly known as the Joint Commission on Accreditation of Healthcare Organizations, JCAHO), require that pain is promptly addressed and managed.
Option B: Continuous, unrelieved pain also affects the psychological state of the patient and family members. Common psychological responses to pain include anxiety and depression. The inability to escape from pain may create a sense of helplessness and even hopelessness, which may predispose the patient to more chronic depression.
Option D: Inadequately managed pain can lead to adverse physical and psychological patient outcomes for individual patients and their families. Continuous, unrelieved pain activates the pituitary-adrenal axis, which can suppress the immune system and result in postsurgical infection and poor wound healing.

Fundamentals of Nursing NCLEX Practice Questions Quiz #4 | 75 Questions

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