Safety and Infection Control NCLEX Part #3 (25 Questions)

Apr 30, | Writing

NCLEX-Question-3-001

While working in a pediatric clinic, you receive a telephone call from the parent of a 10-year-old who is receiving chemotherapy for leukemia. The client’s sibling has chickenpox. Which of these actions will you anticipate taking next?

• A. Administer varicella-zoster immune globulin to the client
• B. Educate the parent about the correct use of acyclovir (Zovirax) 
• C. Prepare the client for admission to a private room in the hospital
• D. Teach the parents regarding contact and airborne precaution

Correct Answer: A. Administer varicella-zoster immune globulin to the client

Varicella-zoster immune globulin administration can prevent the development of chickenpox in high-risk clients and will typically be prescribed. The varicella-zoster immunoglobulin is used to manage patients who are immunocompromised. In addition, a live attenuated vaccine has been available since 1995. There is high seroconversion following the vaccine which is long lasting. Adverse effects of the vaccine are rare.

• Option B: In children, acyclovir decreases symptoms by one day if taken within 24 hours of the start of the rash, but it has no effect on complication rates, and it is not recommended for individuals with normal immune function.
• Option C: Hospitalization may be required if the child develops a varicella-zoster virus infection. For most children who develop chickenpox, the outcome is excellent. However, in immunocompromised individuals, there is increased morbidity and mortality.
• Option D: Contact and airborne precautions will be implemented to prevent the spread of infection to other children if the child develops varicella. It is acquired by inhalation of infected aerosolized droplets. This virus is highly contagious and can spread rapidly. The initial infection is in the mucosa of the upper airways.

NCLEX-Question-3-002

Which action will you take to most effectively reduce the incidence of hospital-associated urinary tract infections?

• A. Ensure that clients have enough adequate fluid intake
• B. Teach assistive personnel how to provide good perineal hygiene
• C. Perform dipstick urinalysis for clients with risk factors for UTI
• D. Limit the use of indwelling foley catheter (IFC)

Correct Answer: D. Limit the use of indwelling foley catheter (IFC)

The most effective way to reduce the incidence of UTIs in the hospital setting is to avoid using retention catheters. Among UTIs acquired in the hospital, approximately 75% are associated with a urinary catheter, which is a tube inserted into the bladder through the urethra to drain urine.  Between 15-25% of hospitalized patients receive urinary catheters during their hospital stay.  The most important risk factor for developing a catheter-associated UTI (CAUTI) is prolonged use of the urinary catheter.

• Option A: Adequate fluid intake may improve the symptoms of UTI, however, it can help mildly with the prevention of  hospital-acquired UTI. The DRInK-Up study provides preliminary evidence suggesting that increasing daily fluid intake by small amounts may have a potentially positive effect on the number of UTIs experienced. However, further research is still needed.
• Option B: Routine hygiene of the urethral meatus surface should be performed during daily bathing or showering. Urethral cleaning with povidone-iodine solution or soap and water has not been shown to prevent CA-UTIs. However, there is evidence that frequent urethral cleaning can lead to mucosal irritation and breakdown that may increase the risk of infection.
• Option C: Avoid breaking the collecting system to obtain urine specimens for analysis and bacterial culture. To obtain urine specimens, the sampling port for the urine collection must be used. If this is not available, urine can be aspirated with a sterile needle and syringe from the distal end of the catheter using aseptic technique. 

NCLEX-Question-3-003

You are caring for a client who has been admitted to the hospital with a leg ulcer that is infected with vancomycin-resistant S. aureus (VRSA). Which of these nursing actions can you delegate to an LPN/LVN?

• A. Assess risk for further skin breakdown
• B. Plan ways to improve the client’s oral protein intake
• C. Obtain wound cultures during dressing changes
• D. Educate the client about home care of the leg ulcer

Correct Answer: C. Obtain wound cultures during dressing changes.

LPN/LVN education and scope of practice include performing dressing changes and obtaining specimens for wound culture. It is within the scope of practice of a licensed practical nurse (LPN) to contribute to the initial assessment of wounds through the gathering and recording of assessment data and to perform basic and advanced wound care in collaboration with the RN or licensed independent practitioner (LIP) on an ongoing basis.

• Option A: The scope of practice for the registered nurse will most likely include the legal ability of the registered professional nurse to perform all phases of the nursing process including assessment, nursing diagnosis, planning, implementation and evaluation.
• Option B: Only RNs can develop the care plan and make changes, although LPNs can contribute suggestions. All of these skills are taught in nursing school but are not included in the LPN curriculum, which is focused on bedside tasks.
• Option D: Teaching is a complex action that should be carried out by a licensed nurse. An LPN can reinforce an RN’s patient teaching, but not perform independent patient education or assessments.

NCLEX-Question-3-004

You are the pediatric unit charge nurse today and are working with a new RN. Which action by the new RN requires the most immediate action on your part?

• A. The new RN wears goggles to change linens of a client who has diarrhea caused by C. difficile.
• B. The new RN places a child who has chemotherapy-induced neutropenia into a negative-pressure room.
• C. The new RN admits a new client with respiratory syncytial virus (RSV) infection to a room with another child who has RSV.
• D. The new RN tells the nursing assistant to use an N95 respirator mask when caring for a child who has pertussis.

Correct Answer: B. The new RN places a child who has chemotherapy-induced neutropenia into a negative-pressure room.

Clients who are neutropenic should be placed in positive-airflow rooms; placement of the child in a negative airflow room will increase the likelihood of infection for this client. Clean, filtered air is constantly pumped into the room. This is done to keep contagious diseases out of the room. With this type of isolation room, the client may be able to feel air blowing out of the room under a closed door.

• Option A: Goggles are not needed for changing the linens of clients infected with C. difficile; however, these protections do not increase the risk to the clients. Healthcare providers will put on gloves and wear a gown over their clothing while taking care of clients with C. diff. Visitors may also be asked to wear a gown and gloves. When leaving the room, hospital providers and visitors remove their gown and gloves and clean their hands.
• Option C: Although private rooms are preferred for clients who need droplet precautions, such as clients with RSV infection, they can be placed in rooms with other clients who are infected with the same microorganism.
• Option D: The use of an N95 respirator is not necessary for pertussis. Wearing a surgical mask within 3 feet of the client provides protection from the spread of pertussis. Oftentimes, close household contacts are the source of the child’s infection; therefore, providers should also wear masks when within 3 feet of symptomatic parents or siblings.

NCLEX-Question-3-005

A client comes to the outpatient clinic where you work complaining of abdominal pain, diarrhea, shortness of breath and epistaxis. Which of the following actions would you take first?

• A. Screening clients for upper respiratory tract symptoms
• B. Call an ambulance to take the client immediately to the hospital
• C. Ask the client about any recent travel to Asia or the Middle East
• D. Determine whether the client has had recommended immunizations

Correct Answer: C. Ask the client about any recent travel to Asia or the Middle East.

The client’s clinical manifestation suggests possible avian influenza  (bird flu). If the client has traveled recently in Asia or the Middle East, where outbreaks of bird flu have occurred, you will need to institute airborne and contact precautions immediately. The other actions may also be appropriate but are not the initial action to take for this client, who may transmit the infection to other clients or staff members

• Option A: Most patients present with symptoms consistent with a flu-like viral illness. In these patients, especially during a known avian influenza outbreak, a thorough history is necessary to evaluate for clues that the illness is due to avian influenza.
• Option B: Whenever there is a possible outbreak of avian influenza, the essential way to reduce the severity and population impact are to reduce the spread of the virus. Since human-to-human transmission is uncommon, the focus should be on reinforcing appropriate sanitation habits in the population, especially those that work around birds or that are involved in food preparation.
• Option D: There is currently an FDA-licensed vaccine for the H5N1 strain of avian influenza in the United States. In the case of an H5N1 outbreak in the United States, the CDC and public health officials may decide to vaccinate at-risk populations to reduce spread.

NCLEX-Question-3-006

A client who has recently traveled to China comes to the emergency department (ED) with increasing shortness of breath and is strongly suspected of having a severe acute respiratory syndrome (SARS). Which of these prescribed actions will you take first?

• A. Obtain blood, urine, and sputum for cultures
• B. Infuse normal saline at 100ml/hr
• C. Administer methylprednisolone (Solu-Medrol) 1 gram/IV
• D. Place the client on contact and airborne precautions

Correct Answer: D. Place the client on contact and airborne precautions.

Since SARS is a severe disease with a high mortality rate, the initial action should be to protect other clients and health care workers by placing the client in isolation. If an airborne-agent isolation (negative pressure) room is not available in the ED, droplet precautions should be initiated until the client can be moved to a negative-pressure room.

• Option A: SARS-CoV testing for diagnosis should be done via PCR from samples obtained from at least two sites and as early in the illness as possible and then repeated five to seven days later if symptoms continue.
• Option B: There are potential agents for use against SARS. Lopinavir-ritonavir has shown some activity in vitro only thus far. Additionally, the experimental agent for Ebola, Remdesivir, has shown activity against both SARS and MERS coronaviruses.
• Option C: There is no specific treatment for severe acute respiratory syndrome (SARS), and supportive care is emphasized. To date, no antiviral agents have been found to be beneficial, nor were glucocorticoids shown to have a beneficial effect.

NCLEX-Question-3-007

Four clients with infections arrive at the emergency department with some existing infection, however, only one private room is available. Which of the following clients is the most appropriate to assign to the private room?

• A. A client with toxic shock syndrome and a temperature of 102.4°F (39.1°C).
• B. A client with diarrhea caused by C. difficile.
• C. A client with a wound infected with VRE.
• D. A client with a cough who may have Koch disease

Correct Answer: D. A client with a cough who may have Koch disease.

Clients with infections that require airborne precautions (such as TB) need to be in private rooms. Secondary environmental controls consist of controlling the airflow to prevent contamination of air in areas adjacent to the source airborne infection isolation (AII) rooms, and cleaning the air by using high-efficiency particulate air (HEPA) filtration, or ultraviolet germicidal irradiation.

• Option A: Standard precautions are required for the client with toxic shock syndrome. At a minimum, standard precautions should be used in the hospital setting to prevent transmission to patients and staff. The CDC has recommended for the first 24 hours of effective antibiotics to have the patient in both contact and droplet isolation.
• Option B: Use contact precautions for patients with known or suspected CDI. Place these patients in private rooms. If private rooms are not available, they can be placed in rooms (cohort) with other CDI patients. Wear gloves and a gown when entering CDI patient rooms and during their care.
• Option C: Clients with infections that require contact precautions (such as C.difficile and VRE infections) should ideally be placed in private rooms; however, they can be placed in rooms with other clients with the same diagnosis. Wear gloves (clean, non-sterile gloves are adequate) when entering the room of a VRE-infected or colonized patient because VRE can extensively contaminate such an environment. When caring for a patient, a change of gloves might be necessary after contact with a material that could contain high concentrations of VRE.

NCLEX-Question-3-008

You are caring for four clients who are receiving IV infusions of normal saline. Which client is at highest risk for bloodstream infections?

• A. A client who has a non-tunneled central line in the left internal jugular vein.
• B. A client with an implanted port in the right subclavian vein.
• C. A client with a peripherally inserted central catheter (PICC) line in the right upper arm.
• D. A client who has a midline IV catheter in the left antecubital fossa.

Correct Answer: A. A client who has a non-tunneled central line in the left internal jugular vein.

Several factors increase the risk for infection for this client: central lines are associated with a higher infection risk, the skin of the neck and chest having a high number of microorganisms, and the line is tunneled. The concern that physicians have with non-tunneled catheters is that they have a short duration of use. Because of this, they should be removed as soon as possible in order to prevent complications like infections or thrombosis.

• Option B: Implanted ports are placed under the skin and so are less likely to be associated with catheter infection than a nontunneled central IV line. For long-term use, implanted ports are preferred as they have better cosmetic results and less infection as compared to non-tunneled catheters and tunneled catheters.
• Option C: PICC lines can remain inserted for weeks to months. They are indicated in situations where the patient needs an intravenous delivery of antibiotics or chemotherapy drugs while preserving the integrity of the peripheral vascular system.
• Option D: Peripherally inserted IV lines such as midline catheters and PICC lines are associated with a lower incidence of infection. A peripherally inserted central catheter or a PICC line is a thin, flexible tube that is inserted into an upper arm vein and then guided into the superior vena cava on the right side of the heart.

NCLEX-Question-3-009

A client who has frequent watery stools and a possible Clostridium difficile infection is hospitalized with dehydration. Which nursing action should the charge nurse delegate to an LPN/LVN?

• A. Assess the client’s hydration status
• B. Explain the purpose of ordered stool cultures to the client and family
• C. Administer metronidazole (Flagyl) 500 mg PO as ordered to the client
• D. Review the client’s medical history for any risk factors for diarrhea

Correct Answer: C. Administer metronidazole (Flagyl) 500 mg PO as ordered to the client

LPN/LVN education and scope of practice and education include the administration of medications. The administration of medications is recognized as the responsibility of the Registered Nurse (RN) and *Licensed Practical Nurses (LPNs). All orders for medications must be legible, complete, and non-ambiguous.

• Option A: The scope of practice for the registered nurse will most likely include the legal ability of the registered professional nurse to perform all phases of the nursing process including assessment, nursing diagnosis, planning, implementation, and evaluation.
• Option B: Teaching is a complex activity that should be carried out by a licensed nurse. An LPN can reinforce an RN’s patient teaching, but not perform independent patient education or assessments.
• Option D: Assessment of risk factors for diarrhea should be done by a licensed nurse. A Licensed Practical Nurse (LPN) may not perform an initial assessment. Initial assessments are to be performed by a Registered Nurse (RN). The initial assessment is to be used to determine a patient’s baseline and develop an initial nursing plan of care.

NCLEX-Question-3-010

You are a school nurse. Which action will you take to have the most impact on the incidence of infectious disease in the school?

• A. Provide written information about infection control to all patients.
• B. Ensure that students are immunized according to national guidelines.
• C. Make soap and water readily available in the classrooms.
• D. Teach students how to cover their mouths when coughing.

Correct Answer: B. Ensure that students are immunized according to national guidelines.

The incidence of once common infectious diseases such as measles, chickenpox, and mumps has been most effectively reduced by immunization of all school-aged children. School immunization requirements exist to protect students and members of their community from serious vaccine-preventable diseases by ensuring high vaccination rates.

• Option A: Relevant studies showed that implementation of health education for school students was conducive for students to consciously adopt healthy behaviors and lifestyle, eliminating or mitigating risk factors that affect spread of infectious diseases, preventing infectious diseases, and promoting health and improving quality of life.
• Option C: Soap and water are also helpful in reducing the incidence of infectious diseases at school. Alcohol-based antiseptics for hand hygiene are an appealing innovation because of their efficacy in reducing hand contamination and their ease of use, especially when sinks and supplies for hand washing are limited.
• Option D: Recommended cough etiquette maneuvers did not block the release and dispersion of a variety of different diameter droplets to the surrounding environment. Droplets smaller than one-micron size dominate the total number of droplets leaked when practicing assessed maneuvers.

NCLEX-Question-3-011

You are caring for a newly admitted client with increasing dyspnea and dehydration who has possible avian influenza (bird flu). Which of these prescribed actions will you implement first?

• A. Provide oxygen using a non-rebreather mask
• B. Infuse 5% dextrose in water at 75ml/hr
• C. Administer the first dose of oseltamivir (Tamiflu)
• D. Obtain blood and sputum specimens for testing

Correct Answer: A. Provide oxygen using a non-rebreather mask.

Because the respiratory manifestations associated with avian influenza are potentially life-threatening, the nurse’s initial action should be to start oxygen therapy. Patients with respiratory compromise should be placed on supplemental oxygen and monitored closely for signs of deterioration as these patients are at high risk of requiring intubation and mechanical ventilation. The other interventions should be implemented after addressing the client’s respiratory problem.

• Option B: Treatment may include hospitalization and supportive care, such as intravenous fluids. Additionally, studies suggest that antiviral drugs help minimize the severity of bird flu in people. However, changes in the virus may limit its effectiveness in the future.
• Option C: The World Health Organization released Rapid Advice Guidelines in 2007, outlining consensus treatment recommendations for H5N1 influenza outbreaks. These recommendations include neuraminidase inhibitors (especially oseltamivir) for strongly suspected or confirmed cases of H5N1.
• Option D: The preferred source of a sample for testing is a nasopharyngeal swab or aspirate, but other body fluids are usable if the nasopharyngeal swab or aspirate is not available. RT-PCR identification of the virus in viral cultures is the standard of care for diagnosis of AIV, and viral detection is typically possible within a few days of disease onset.

NCLEX-Question-3-012

A hospitalized 88-year-old client who has been receiving antibiotics for 10 days tells you that he is having frequent watery stools. Which action will you take first?

• A. Obtain stool specimens for culture
• B. Place the client on contact precaution
• C. Notify the physician about the loose stools
• D. Instruct the client about correct handwashing

Correct Answer: B. Place the client on contact precaution

The client’s age, history of antibiotic therapy, and watery stools suggest that he may have Clostridium difficile infection. The initial action should be able to place him on contact precautions to prevent the spread of C. difficile to other clients. Clostridium difficile is a gram-positive bacterium that is the cause most implicated in antibiotic-associated diarrhea. The other actions are also needed and should be taken after placing the client on contact precautions.

• Option A: Patients with new-onset 3 or more loose or unformed stools in 24 hours with no obvious other etiology should be checked for testing for C. difficile infection. Stool examination for C. difficile toxins or toxigenic C. difficile bacillus is the commonly used diagnostic test used to diagnose C. difficile infection.
• Option C: The management of C. difficile infection includes a multi-step approach of discontinuing the usage of inciting antibiotics, isolating the patient, and administering the antibiotic based on the severity of the infection.
• Option D: General strategies such as early detection of the disease, placing the patient under isolation with a dedicated toilet and contact precautions, promoting hygiene measures such as improved hand hygiene, and environmental cleaning are effective measures in preventing infections from C. difficile infections.

NCLEX-Question-3-013

Which of the following information about a client who has meningococcal meningitis has the best indicator that you can discontinue droplet precautions?

• A. Pupils are equal and reactive to light
• B. Temperature is lower than 100°F (37.8°C)
• C. Appropriate antibiotics have been given for 24 hours
• D. Cough is productive of clear, nonpurulent mucus

Correct Answer: C. Appropriate antibiotics have been given for 24 hours.

Current CDC evidence-based guidelines indicate that droplet precautions for clients with meningococcal meningitis can be discontinued when the client has received antibiotic therapy for 24 hours. Antibiotic dose should be given as soon as meningitis is suspected and should not be delayed awaiting confirmatory studies. The other information may indicate that the client’s condition is improving but does not indicate that droplet precaution should be discontinued.

• Option A: Meningeal irritability can be confirmed by provocative tests like Kernig and Brudzinski sign. A thorough neurologic exam should be performed looking for alteration in mental status, as well as any focal deficits.
• Option B: Older children and adults will present with headaches, fever, photophobia, vomiting, neck stiffness, and altered mental status. Patients can present with abnormal vital signs, including fever, tachypnea, tachycardia, and hypotension. Hypotension with elevated pulse rate is suggestive of early vascular instability.
• Option D: The classic triad of neck stiffness, fever, and altered mental status is a more specific sign for meningitis. Infants can present with a variety of non-specific symptoms, which include lethargy, irritability, and in some cases bulging fontanelles. 

NCLEX-Question-3-014

You are the charge nurse on the pediatric unit when a pediatrician calls wanting to admit a child with rubeola (measles). Which of these factors is of most concern in determining whether to admit the child to your unit?

• A. No negative-airflow rooms are available on the unit
• B. The infection control nurse liaison is not on the unit today
• C. There are several children receiving chemotherapy on the unit
• D. The unit is not staffed with the usual number of RNs

Correct Answer: A. No negative-airflow rooms are available on the unit

Because clients with rubeola require the implementation of airborne precautions, which include placement in a negative airflow room, this child cannot be admitted to the pediatric unit. An airborne isolation room is also known as a negative pressure room. This negative pressure room is usually a single-occupancy patient-care room frequently used to isolated individuals with confirmed or suspected airborne infections. The other circumstances may require actions such as staff reassignments but would not prevent the admission of a client with rubeola.

• Option B: The absence of the infection control nurse liaison should not prevent the admission of the child with rubeola. Before transferring a patient with an airborne infection, one must always communicate with the relevant department first. The earlier the airborne prevention methods are adopted, the lower the risk of transmission to other patients and healthcare staff.
• Option C: The clients receiving therapy can be transferred to a different location far from the isolation room. The door to the room of the isolation area must be kept closed to maintain negative pressure even if the client is not in the room. The windows in the room should remain closed at all times; opening the window may cause the reversal of airflow, which counters the benefits of a negative pressure room.
• Option D: Only healthcare providers immunized to the organism in question should enter a room where airborne precautions are in place for varicella or measles. A respirator is not necessary for immunized individuals but is required for non-immunized workers who provide care.

NCLEX-Question-3-015

A client who states that he may have been contaminated by anthrax arrives at the ED. The following actions are part of the ED protocol for possible anthrax exposure or infection. Which action will you take first?

• A. Assess the client for signs of infection
• B. Notify hospital security personnel about the client
• C. Escort the client to a decontamination room
• D. Administer ciprofloxacin (Cipro) 250 mg PO

Correct Answer: C. Escort the client to a decontamination room

To prevent contamination of staff or other clients by anthrax, decontamination of the client by removal and disposal of clothing and showering is the initial action in possible anthrax exposure. Clients should remove contaminated clothing and store it in labeled, plastic bags. Clothing should be handled as little as possible to avoid agitation. Clients should shower thoroughly with soap and water.

• Option A: Assessment of the client for signs of infection should be done before decontamination. Initial symptoms of inhalation anthrax are mild and nonspecific and may include fever, malaise, fatigue, and a mild cough or chest discomfort; acute symptoms of respiratory distress, fever, and shock follow, with death occurring shortly thereafter.
• Option B: Notification of security personnel is necessary in the case of possible bioterrorism, but this should occur before decontaminating and caring for the client. During the 2001 anthrax outbreak, the New York City Department of Health and Mental Hygiene established the Cutaneous Anthrax Rapid Referral System for rapid referral and early diagnosis of anthrax cases (Redd 2005). This system functioned to efficiently assess patients but also provided a mechanism for rapid centralized reporting, which could be a good surveillance model in the setting of known mass exposure to anthrax.
• Option D: According to the CDC guidelines, antibiotics should be administered only if there are signs of infection or the contaminating substance tests positive for anthrax. Early initiation of appropriate antibiotics is paramount for patient survival of IA. Initial therapy for adults with IA due to a strain with unknown antibiotic susceptibilities should include ciprofloxacin OR doxycycline PLUS one or two additional antibiotics effective against anthrax.

NCLEX-Question-3-016

A client has been diagnosed with disseminated herpes zoster. Which personal protective equipment (PPE) will you need to put on when preparing to assess the client? Select all that apply.

• A. Goggles
• B. Gown
• C. Gloves
• D. Shoe covers
• E. N95 respirator
• F. Surgical face mask

Correct Answer: B, C, & E

Because herpes zoster is spread through airborne means and by direct contact with the lesions, you should wear an N95 respirator or high-efficiency particulate air filter respirator, a gown, and gloves.

• Option A: Goggles are not needed for airborne or contact precautions. Wear a surgical mask and goggles or face shield if there is a reasonable chance that a splash or spray of blood or body fluids may occur to the eyes, mouth, or nose.
• Option B: Wear a gown if skin or clothing is likely to be exposed to blood or body fluids. If PPE or other disposable items are saturated with blood or body fluids such that fluid may be poured, squeezed, or dripped from the item, discard into a biohazard bag. PPE that is not saturated may be placed directly in the trash. 
• Option C: Wear gloves when touching blood, body fluids, non-intact skin, mucous membranes, and contaminated items. Remove PPE immediately after use and wash hands. It is important to remove PPE in the proper order to prevent contamination of skin or clothing. 
• Option D: Wear shoe covers to provide a barrier against possible exposure to airborne organisms or contact with a contaminated environment. Shoe covers should also be worn as part of Full Barrier Precautions. Full Barrier Precautions are the combination of airborne and contact precautions, plus eye protection, in addition to standard precautions.
• Option E: Put on a NIOSH-certified fit-tested N-95 respirator just before entry to an area of shared air space and wear at all times while in the area of shared air space. Remove and discard the respirator just after exiting the area. The respirator may be discarded into the regular trash unless contact precautions must also be followed. In this case, place the respirator in a plastic zip-lock bag, seal and then discard into the trash. 
• Option F: Surgical face mask filters only large particles and will not provide protection from herpes zoster. Airborne and contact precautions until disseminated infection is ruled out. Airborne and contact precautions until lesions are dry and crusted.

NCLEX-Question-3-017

As the infection control nurse in an acute care hospital, which action will you take to most effectively reduce the incidence of health-care-associated infections?

• A. Develop policies that automatically start antibiotic therapy for clients colonized by multidrug resistant organisms.
• B. Screen all newly admitted clients for colonization or infection with MRSA.
• C. Require nursing staff to don gowns to change wound dressings for all clients.
• D. Ensure that dispensers for alcohol-based hand rubs are readily available in all client care areas of the hospital.

Correct Answer: D. Ensure that dispensers for alcohol-based hand rubs are readily available in all client care areas of the hospital.

Because the hands of healthcare workers are the most common means of transmission of infection from one client to another, the most effective method of preventing the spread of infection is to make supplies for hand hygiene readily available for staff to use.

• Option A: Because administration of antibiotics to individuals who are colonized by bacteria may promote the development of antibiotic resistance, antibiotic use should be restricted to clients who have clinical manifestations of infection.
• Option B: Although some hospitals have started screening newly admitted clients for MRSA, there is no evidence that this decreases the spread of infection. Although results of MRSA screening are not intended to guide empirical treatment, they may offer an additional benefit among patients in whom clinical infection with S. aureus develops.
• Option C: Wearing a gown to care for clients who are not on contact precautions is not necessary. They must be worn when undertaking all direct care procedures with patients, when there is a likelihood of contact with blood, secretions, excretions or body fluids (Loveday et al, 2014).

NCLEX-Question-3-018

You are preparing to leave the room after performing oral suctioning on a client who is on contact and airborne precautions. In which order will you perform the following actions?

• 3. Remove gloves
• 4. Take off goggles
• 5. Take off the gown
• 1. Remove N95 respirator
• 2. Perform hand hygiene

Correct Answer: 3, 4, 5, 1, 2

The sequence will prevent contact of the contaminated gloves and gowns with areas (such as your hair) that cannot be easily cleaned after client contact and stop transmission of microorganisms to you and your other clients.

• The outside of the gloves is contaminated, therefore, if the hands are contaminated during glove removal, the nurse should immediately wash their hands or use alcohol-based hand sanitizer. Using the gloved hand, the nurse should grasp the palm area of the other gloved hand, peel off the first glove, and hold the removed glove in the gloved hand. Slide the fingers of the ungloved hand under the remaining glove at wrist and peel off the second glove over the first glove, then discard it in a waste container.
• Goggles or face shields should be removed from the back by lifting headband or ear pieces. If the item is reusable, the nurse may place it in a designated receptacle for reprocessing. Otherwise, it can be discarded in a waste container.
• The nurse should keep in mind that the front of the gown and the sleeves are contaminated. To remove the gown, the nurse should unfasten the gown ties, taking care that the sleeves don’t contact the body when reaching for the ties. The gown should be pulled away from the neck and shoulders, touching the inside of the gown only, then turning it inside out. Finally, the gown should be rolled or folded into a bundle and discarded in a waste container.
• The front of the respirator should never be touched because it is contaminated. To remove the respirator, the nurse should grasp the bottom ties or elastics of the respirator, then the ones at the top, and remove them without touching the front.
• After doffing, it is imperative for the nurse to wash their hands immediately or use an alcohol-based hand sanitizer immediately after removing all of the PPE. Hand hygiene should also be performed in between steps if hands become contaminated.

NCLEX-Question-3-019

You are preparing to change the linens on the bed of a client who has a draining sacral wound infected by MRSA. Which PPE items will you plan to use? Select all that apply

• A. N95 respirator
• B. Surgical Mask
• C. Gloves
• D. Goggles
• E. Gown

Correct Answer: C & E

A gown and gloves should be used when coming in contact with linens that may be decontaminated by the client’s wound secretions. Contact precautions (gloves and gowns) are used during clinical encounters with clients who are colonized or infected with MRSA. The other items are not necessary because transmission by splashes, droplets, or airborne means will not occur when the bed is changed.

• Option A: A surgical N95 (also referred as a medical respirator) is recommended only for use by healthcare personnel (HCP) who need protection from both airborne and fluid hazards (e.g., splashes, sprays). These respirators are not used or needed outside of healthcare settings.
• Option B: Surgical masks are Class II medical devices. These masks meet certain fluid barrier protection standards and flammability requirements (that is, Class I or Class II, per 16 CFR 1610.4). Surgical masks are also tested for particulate and bacterial filtration efficiencies and biocompatibility and are considered personal protective equipment (PPE).
• Option C: Gloves must be worn when contact with blood or body fluids, mucous membranes, non intact skin, or potentially contaminated objects or the environment is anticipated. Since hand contamination may occur due to holes, leaks, tears, or improper removal, gloves are not a substitute for proper hand hygiene. Hand hygiene must be performed following removal of gloves. 
• Option D: Safety goggles are tight-fitting eye protection that completely cover the eyes, eye sockets and the facial area around the eyes and provide protection from impact, dust, mists, and splashes. Safety goggles can be worn over prescription lenses.
• Option E: Gowns must be worn to protect the arms and prevent soiling or contamination of clothing during procedures and direct care activities when caring for patients on Contact Precautions. 

NCLEX-Question-3-020

You are preparing to care for a 6-year-old who has just undergone allogeneic stem cell transplantation and will need protective environment isolation. Which nursing tasks will you delegate to a nursing assistant? Select all that apply.

• A. Teaching the client to perform thorough hand washing after using the bathroom.
• B. Talking to the family members about the reasons for the isolation.
• C. Stocking the client’s room with the needed PPE items.
• D. Reminding visitors to wear a respirator mask, gloves, and gown.
• E. Posting the precautions for protective isolation on the door of the client’s room.

Correct Answer: C, D, & E

Because all staff who care for clients should be familiar with the various types of isolation, the nursing assistant will be able to stock the room and post the precautions on the client’s door. CNAs work directly with clients and nurses, helping with the many physical and complex tasks for client care. 

• Option A: Teaching is a complex action that should be carried out by a licensed nurse. A nursing assistant can reinforce an RN’s patient teaching, but not perform independent patient education or assessments.
• Option B: Client discussion of the reason for protective isolation falls within the RN-level scope of practice. A certified nursing assistant helps clients with direct health care needs, often under the supervision of a nurse.
• Option C: Gathering and stocking medical supplies is a nursing assistant’s responsibility. Different hospitals and facilities will have unique requirements and responsibilities for their CNAs. But in essence, certified nursing assistants help perform critical tasks that ensure the clients are well-cared for and safe during their hospital stay
• Option D: Reminding visitors about previously taught information is a task that can be done by the nursing assistant, although the RN is responsible for the initial teaching. It is within an LPN’s scope of practice to assist the RN with collecting data and monitoring client findings
• Option E: The nursing assistant may post helpful information within the hospital rooms for the benefit of educating the client and others. Furthermore, they can also tidy up the client’s room and change the linens.  It also means getting the chance to have regular, one-on-one contact with clients—the compassionate relationships that can help people make it through times of illness with dignity.

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

NCLEX-Question-3-021

A 26-year-old client is diagnosed with scarlet fever. Which of the following is the most appropriate type of isolation for this client?

• A. Airborne
• B. Contact
• C. Droplet
• D. Standard

Correct Answer: Answer: C. Droplet.

Scarlet fever is an infection caused by Group A Streptococcus bacteria. This bacteria lives in the throat and nose and is highly contagious. It is spread by droplet transmission when an infected individual coughs or sneezes. Droplet Precautions are used to prevent the spread of pathogens that are passed through respiratory secretions and do not survive for long in transit. These droplets are relatively large particles that cannot travel through the air very far. 

• Option A: Airborne precautions prevent transmission of infectious agents that remain infectious over long distances when suspended in the air (e.g., rubeola virus [measles], varicella virus [chickenpox], M. tuberculosis, and possibly SARS-CoV).
• Option B: Contact precautions are intended to prevent transmission of infectious agents, including epidemiologically important microorganisms, which are spread by direct or indirect contact with the patient or the patient’s environment.
• Option D: Standard precautions combine the major features of Universal Precautions (UP) and Body Substance Isolation (BSI) and are based on the principle that all blood, body fluids, secretions, excretions except sweat, non intact skin, and mucous membranes may contain transmissible infectious agents.

NCLEX-Question-3-022

A newly admitted client with streptococcal pharyngitis (tonsillitis) has been placed on droplet precaution. Which of the following statements indicates the best understanding for this type of isolation?

• A. Must maintain a spatial distance of 3 feet
• B. The client can be placed in a room with another client with measles (rubeola)
• C. A special mask (N95) should be worn when working with the client
• D. Gloves should be only worn when giving direct care

Correct Answer: A. Must maintain a spatial distance of 3 feet.

The most common forms of transmission of an organism in a client with tonsillitis are through coughing, sneezing, and talking. Droplets can travel no more than 3ft so precautions should be maintained when there is a possibility of entering this distance.

• Option B: Client requires a private room. Ensure appropriate client placement in a single room if possible. In acute care hospitals, if single rooms are not available, utilize the recommendations for alternative client placement considerations in the Guideline for Isolation Precautions.
• Option C: An N95 mask is not required for this client. A face mask instead can be used when dealing with the client. Don mask upon entry into the patient room or patient space. Instruct clients to follow Respiratory Hygiene/Cough Etiquette recommendations.
• Option D: Gloves, gowns, face masks and eye protection should be worn in giving direct care. A face mask is worn upon entry into the client room. PPE must be removed at the point of exit; do not reuse face masks. 

NCLEX-Question-3-023

Malcolm is newly assigned as a triage nurse, on his first day of work, the following clients arrive at the ED. Which among the clients require the most rapid action to protect other clients in the ED from infection?

• A. An infant with a runny nose and whose older brother has pertussis.
• B. A travel blogger who needs tuberculosis testing after an exposure to a person with TB during his trip.
• C. An elderly woman who has a history of a methicillin-resistant Staphylococcus aureus (MRSA) leg wound infection.
• D. A pregnant woman with a blister-like rash on the face and is possibly having varicella.

Correct Answer: D. A pregnant woman with a blister-like rash on the face and is possibly having varicella.

Chickenpox (Varicella) is transmitted by airborne and that can be easily transferred to the other clients in the emergency unit. The pregnant woman with the rash should be isolated right away from other clients through placement in a negative-pressure room. In pregnant women, antibodies produced as a result of immunization or previous infection are transferred via the placenta to the fetus. Varicella infection in pregnant women could spread via the placenta and infect the fetus.

• Option A: Droplet precautions should be instituted for the client with pertussis, but this can be done after isolating the client with possible varicella. Strict isolation is important while the client remains infectious. Pertussis is contagious throughout the catarrhal phase and for 3 weeks after the onset of the paroxysmal phase. In patients treated with antibiotics, isolation should be continued for at least 5 days after treatment is initiated.
• Option B: The client who has been exposed to TB does not place the other clients at risk for infection because there are no symptoms of active TB. The body’s ability to effectively limit or eliminate the infective inoculum is determined by the immune status of the individual, genetic factors and whether it is a primary or secondary exposure to the organism.
• Option C: Contact precautions should be instituted for the client with MRSA infection. Contact precautions include the use of gowns, gloves, and possibly masks during clinical encounters with clients with MRSA infection. Infection control also may include keeping clients in isolated rooms or the same rooms of other clients who have a MRSA infection.

NCLEX-Question-3-024

A client with a vancomycin-resistant enterococcus (VRE) infection is admitted to the medical unit. Which action can be delegated to a nursing assistant who is assisting with the client’s care?

• A. Monitor the results of the laboratory culture and sensitivity test.
• B. Educate the client and family members on ways to prevent transmission of VRE.
• C. Implement contact precautions when handling the client.
• D. Collaborate with other departments when the client is transported for an ordered test.

Correct Answer: C. Implement contact precautions when handling the client.

All hospital personnel who care for the client are responsible for correct implementation of contact precautions. They are responsible for ensuring that the convenience, hygiene and safety of patients are well-established during their entire stay in the medical facility.

• Option A: Nursing assistants may not monitor the laboratory results of the client. Certified nursing assistants may only check and record a patient’s vital signs daily. The CNA also measures the client’s height and weight, monitors intake and output and collects specimens to test.
• Option B: Teaching is a complex action that should be carried out by a licensed nurse. A nursing assistant can reinforce an RN’s patient teaching, but not perform independent patient education or assessments.
• Option D: Collaboration is not within the scope of the nursing assistant’s practice. When the client must be moved, the assistants also transfer the client between the bed and a wheelchair. If the client is able to stand, the CNA may walk the individual to an appointment or for exercise.

NCLEX-Question-3-025

Which of the following infection control activities should be delegated to an experienced nursing assistant?

• A. Screening clients for upper respiratory tract symptoms
• B. Disinfecting blood pressure cuffs after clients are discharged
• C. Demonstrating correct handwashing techniques to client and family
• D. Asking clients about the duration of antibiotic therapy

Correct Answer: B. Disinfecting blood pressure cuffs after clients are discharged

Nursing assistants can follow agency protocol to disinfect items that come in contact with intact skin by cleaning with chemicals such as alcohol. Depending on daily needs, this can involve changing soiled sheets, cleaning up spills, changing bedpans, setting up equipment, and reducing the spread of germs and infection in the client’s living area.

• Option A: The daily direct contact that the nursing assistant has with a client also gives them the opportunity to identify bruises, blood in urine, and other injuries and report them to medical staff who can initiate care.
• Option C: Teaching is a complex action that should be carried out by a licensed nurse. A nursing assistant can reinforce an RN’s patient teaching, but not perform independent patient education or assessments.
• Option D: Inquiring about medication therapy is the nurse’s responsibility. However, nursing assistants serve as a channel between clients and nurses and physicians so that all client issues are communicated.

Fundamentals of Nursing NCLEX Practice Questions Quiz #2 | 75 Questions

Apr 30, | Writing

FNDNRS-02-001

Which intervention is an example of primary prevention?

• A. Administering digoxin (Lanoxicaps) to a patient with heart failure.
• B. Administering measles, mumps, and rubella immunization to an infant.
• C. Obtaining a Papanicolaou smear to screen for cervical cancer.
• D. Using occupational therapy to help a patient cope with arthritis.

Correct Answer: B. Administering measles, mumps, and rubella immunization to an infant.

Immunizing an infant is an example of primary prevention, which aims to prevent health problems. Primary prevention includes those preventive measures that come before the onset of illness or injury and before the disease process begins. Examples include immunization and taking regular exercise to prevent health problems developing in the future.

• Option A: Administering d

• igoxin to treat heart failure and obtaining a smear for a screening test are examples for secondary prevention, which promotes early detection and treatment of disease. Those preventive measures that lead to early diagnosis and prompt treatment of a disease, illness, or injury to prevent more severe problems developing. Here health educators such as Health Extension Practitioners can help individuals acquire the skills of detecting diseases in their early stages.
• Option C: Obtaining a Papanicolau smear is a secondary prevention. Secondary prevention includes those preventive measures that lead to early diagnosis and prompt treatment of a disease, illness or injury. This should limit disability, impairment, or dependency and prevent more severe health problems developing in the future.
• Option D: Using occupational therapy to help a patient cope with arthritis is an example of tertiary prevention, which aims to help a patient deal with the residual consequences of a problem or to prevent the problem from recurring. Tertiary prevention includes those preventive measures aimed at rehabilitation following significant illness. At this level, health educators work to retrain, re-educate and rehabilitate the individual who has already had an impairment or disability.

FNDNRS-02-002

The nurse in charge is assessing a patient’s abdomen. Which examination technique should the nurse use first?

• A. Auscultation
• B. Inspection
• C. Percussion
• D. Palpation

Correct Answer: B. Inspection

Inspection always comes first when performing a physical examination. It is important to begin with the general examination of the abdomen with the patient in a completely supine position. The presence of any of the following signs may indicate specific disorders. Percussion and palpation of the abdomen may affect bowel motility and therefore should follow auscultation.

• Option A: The last step of the abdominal examination is auscultation with a stethoscope. The diaphragm of the stethoscope should be placed on the right side of the umbilicus to listen to the bowel sounds, and their rate should be calculated after listening for at least two minutes. Normal bowel sounds are low-pitched and gurgling, and the rate is normally 2-5/min. Absent bowel sounds may indicate paralytic ileus and hyperactive rushes (borborygmi) are usually present in small bowel obstruction and sometimes may be auscultated in lactose intolerance.
• Option C: A proper technique of percussion is necessary to gain maximum information regarding the abdominal pathology. While percussing, it is important to appreciate tympany over air-filled structures such as the stomach and dullness to percussion which may be present due to an underlying mass or organomegaly (for example, hepatomegaly or splenomegaly).
• Option D: The ideal position for abdominal examination is to sit or kneel on the right side of the patient with the hand and forearm in the same horizontal plane as the patient’s abdomen. There are three stages of palpation that include the superficial or light palpation, deep palpation, and organ palpation and should be performed in the same order. Maneuvers specific to certain diseases are also a part of abdominal palpation.

FNDNRS-02-003

Which statement regarding heart sounds is correct?

• A. S1 and S2 sound equally loud over the entire cardiac area.
• B. S1 and S2 sound fainter at the apex.
• C. S1 and S2 sound fainter at the base.
• D. S1 is loudest at the apex, and S2 is loudest at the base.

Correct Answer: D. S1 is loudest at the apex, and S2 is loudest at the base.

The S1 sound—the “lub” sound—is loudest at the apex of the heart. It sounds longer, lower, and louder there than the S2 sounds. The S2—the “dub” sound—is loudest at the base. It sounds shorter, sharper, higher, and louder there than S1. Heart sounds are created from blood flowing through the heart chambers as the cardiac valves open and close during the cardiac cycle. Vibrations of these structures from the blood flow create audible sounds — the more turbulent the blood flow, the more vibrations that get created.

• Option A: The S1 heart sound is produced as the mitral and tricuspid valves close in systole. This structural and hemodynamic change creates vibrations that are audible at the chest wall. The mitral valve closing is the louder component of S1. It also occurs sooner because of the left ventricle contracts earlier in systole. 
• Option B: Changes in the intensity of S1 are more attributable to forces acting on the mitral valve. Such causes include a change in left ventricular contractility, mitral structure, or the PR interval. However, under normal resting conditions, the mitral and tricuspid sounds occur close enough together not to be discernible. The most common reasons for a split S1 are things that delay right ventricular contraction, like a right bundle branch block.
• Option C: The S2 heart sound is produced with the closing of the aortic and pulmonic valves in diastole. The aortic valve closes sooner than the pulmonic valve, and it is the louder component of S2; this occurs because the pressures in the aorta are higher than the pulmonary artery.

FNDNRS-02-004

The nurse in charge identifies a patient’s responses to actual or potential health problems during which step of the nursing process?

• A. Assessment
• B. Nursing diagnosis
• C. Planning
• D. Evaluation

Correct Answer: B. Nursing diagnosis

The nurse identifies human responses to actual or potential health problems during the nursing diagnosis step of the nursing process. The formulation of a nursing diagnosis by employing clinical judgment assists in the planning and implementation of patient care. The North American Nursing Diagnosis Association (NANDA) provides nurses with an up to date list of nursing diagnoses. A nursing diagnosis, according to NANDA, is defined as a clinical judgment about responses to actual or potential health problems on the part of the patient, family or community. 

• Option A: During the assessment step, the nurse systematically collects data about the patient or family. 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: During the planning step, the nurse develops strategies to resolve or decrease the patient’s problem. 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. 
• Option D: During the evaluation step, the nurse determines the effectiveness of the plan of care. 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.

FNDNRS-02-005

A female patient is receiving furosemide (Lasix), 40 mg P.O. B.I.D. in the plan of care, the nurse should emphasize teaching the patient about the importance of consuming:

• A. Fresh, green vegetables
• B. Bananas and oranges
• C. Lean red meat
• D. Creamed corn

Correct Answer: B. Bananas and oranges

Because furosemide is a potassium-wasting diuretic, the nurse should plan to teach the patient to increase intake of potassium-rich foods, such as bananas and oranges. Potassium is a mineral in the cells. It helps the nerves and muscles work as they should. The right balance of potassium also keeps the heart beating at a steady rate. Fresh, green vegetables; lean red meat; and creamed corn are not good sources of potassium.

• Option A: GLVs are considered as natural caches of nutrients for human beings as they are a rich source of vitamins, such as ascorbic acid, folic acid, tocopherols, β-carotene, and riboflavin, as well as minerals such as iron, calcium, and phosphorous.
• Option C: Lean red meat is an excellent source of high biological value protein, vitamin B12, niacin, vitamin B6, iron, zinc, and phosphorus. It is a source of long‐chain omega‐3 polyunsaturated fats, riboflavin, pantothenic acid, selenium, and, possibly, also vitamin D. It is also relatively low in fat and sodium.
• Option D: Corn has several health benefits. Because of the high fiber content, it can aid with digestion. It also contains valuable B vitamins, which are important to your overall health. Corn also provides our bodies with essential minerals such as zinc, magnesium, copper, iron, and manganese.

FNDNRS-02-006

The nurse in charge must monitor a patient receiving chloramphenicol for adverse drug reaction. What is the most toxic reaction to chloramphenicol?

A. Lethal arrhythmias

B. Malignant hypertension

C. Status epilepticus

D. Bone marrow suppression

Correct Answer: D. Bone marrow suppression

The most toxic reaction to chloramphenicol is bone marrow suppression. Chloramphenicol is a synthetically manufactured broad-spectrum antibiotic. It was initially isolated from the bacteria Streptomyces venezuelae in 1948 and was the first bulk produced synthetic antibiotic. However, chloramphenicol is a rarely used drug in the United States because of its known severe adverse effects, such as bone marrow toxicity and grey baby syndrome. Chloramphenicol is not known to cause lethal arrhythmias, malignant hypertension, or status epilepticus.

• Option A: Chloramphenicol is associated with severe hematological side effects when administered systemically. Since 1982, chloramphenicol has reportedly caused fatal aplastic anemia, with possible increased risk when taken together with cimetidine. This adverse side effect can occur even with the topical administration of the drug, which is most likely due to the systemic absorption of the drug after topical application.
• Option B: Besides causing fatal aplastic anemia and bone marrow suppression, other side effects of chloramphenicol include ototoxicity with the use of topical ear drops, gastrointestinal reactions such as oesophagitis with oral use, neurotoxicity, and severe metabolic acidosis.
• Option C: Optic neuritis is the most commonly associated neurotoxic complication that can arise from chloramphenicol use. This adverse effect usually takes more than six weeks to manifest, presenting with either acute or subacute vision loss, with possible fundal changes. It may also present with peripheral neuropathy, which may present as numbness or tingling. If optic neuropathy occurs, the drug should be withdrawn immediately, which will usually lead to partial or complete recovery of vision.

FNDNRS-02-007

A female patient is diagnosed with deep-vein thrombosis. Which nursing diagnosis should receive highest priority at this time?

• A. Impaired gas exchanges related to increased blood flow.
• B. Fluid volume excess related to peripheral vascular disease.
• C. Risk for injury related to edema.
• D. Altered peripheral tissue perfusion related to venous congestion.

Correct Answer: D. Altered peripheral tissue perfusion related to venous congestion.

Altered peripheral tissue perfusion related to venous congestion” takes highest priority because venous inflammation and clot formation impede blood flow in a patient with deep-vein thrombosis. A deep-vein thrombosis (DVT) is a blood clot that forms within the deep veins, usually of the leg, but can occur in the veins of the arms and the mesenteric and cerebral veins. Deep-vein thrombosis is a common and important disease. It is part of the venous thromboembolism disorders which represent the third most common cause of death from cardiovascular disease after heart attacks and stroke. 

• Option A: Option A is incorrect because impaired gas exchange is related to decreased, not increased, blood flow. Depending on the relative balance between the coagulation and thrombolytic pathways, thrombus propagation occurs. DVT is commonest in the lower limb below the knee and starts at low-flow sites, such as the soleal sinuses, behind venous valve pockets.
• Option B: Option B is inappropriate because no evidence suggests that this patient has a fluid volume excess. Nurses need to educate the patients on the importance of ambulation, being compliant with compression stockings, and taking the prescribed anticoagulation medications.
• Option C: Option C may be warranted but is secondary to altered tissue perfusion. Thrombosis is a protective mechanism that prevents the loss of blood and seals off damaged blood vessels. Fibrinolysis counteracts or stabilizes the thrombosis. The triggers of venous thrombosis are frequently multifactorial, with the different parts of the triad of Virchow contributing in varying degrees in each patient, but all result in early thrombus interaction with the endothelium. This then stimulates local cytokine production and causes leukocyte adhesion to the endothelium, both of which promote venous thrombosis.

FNDNRS-02-008

When positioned properly, the tip of a central venous catheter should lie in the:

• A. Superior vena cava
• B. Basilica vein
• C. Jugular vein
• D. Subclavian vein

Correct Answer: A. Superior vena cava

When the central venous catheter is positioned correctly, its tip lies in the superior vena cava, inferior vena cava, or the right atrium—that is, in central venous circulation. Blood flows unimpeded around the tip, allowing the rapid infusion of large amounts of fluid directly into circulation. The basilica, jugular, and subclavian veins are common insertion sites for central venous catheters.

• Option B: There are three main access sites for the placement of central venous catheters. The internal jugular vein, common femoral vein, and subclavian veins are the preferred sites for temporary central venous catheter placement. Additionally, for mid-term and long-term central venous access, the basilic and brachial veins are utilized for peripherally inserted central catheters (PICCs).
• Option C: The internal jugular vein (IJ) is often chosen for its reliable anatomy, accessibility, low complication rates, and the ability to employ ultrasound guidance during the procedure. The individual clinical scenario may dictate laterality in some cases (such as with trauma, head and neck cancer, or the presence of other invasive devices or catheters), but all things being equal, many physicians prefer the right IJ. As compared to the left, the right IJ forms a more direct path to the superior vena cava (SVC) and right atrium. It is also wider in diameter and more superficial, thus presumably easier to cannulate.
• Option D: The subclavian vein site has the advantage of low rates of both infectious and thrombotic complications. Additionally, the SC site is accessible in trauma, when a cervical collar negates the choice of the IJ. However, disadvantages include a higher relative risk of pneumothorax, less accessibility to use ultrasound for CVC placement, and the non-compressible location posterior to the clavicle.

FNDNRS-02-009

Nurse Nikki is revising a client’s care plan. During which step of the nursing process does such revision take place?

• A. Assessment
• B. Planning
• C. Implementation
• D. Evaluation

Correct Answer: D. Evaluation

During the evaluation step of the nursing process, the nurse determines whether the goals established in the care plan have been achieved, and evaluates the success of the plan. If a goal is unmet or partially met the nurse reexamines the data and revises the plan. 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. Assessment involves data collection. Planning involves setting priorities, establishing goals, and selecting appropriate interventions.

• Option A: 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 B: 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. 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 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-02-010

A 65-year-old female who has diabetes mellitus and has sustained a large laceration on her left wrist asks the nurse, “How long will it take for my scars to disappear?” Which statement would be the nurse’s best response?

• A. “The contraction phase of wound healing can take 2 to 3 years.”
• B. “Wound healing is very individual but within 4 months the scar should fade.”
• C. “With your history and the type of location of the injury, it’s hard to say.”
• D. “If you don’t develop an infection, the wound should heal any time between 1 and 3 years from now.”

Correct Answer: C. “With your history and the type of location of the injury, it’s hard to say.”

Wound healing in a client with diabetes will be delayed. Providing the client with a time frame could give the client false information. There is no doubt that diabetes plays a detrimental role in wound healing. It does so by affecting the wound healing process at multiple steps. Wound hypoxia, through a combination of impaired angiogenesis, inadequate tissue perfusion, and pressure-related ischemia, is a major driver of chronic diabetic wounds. 

• Option A: Ischemia can lead to prolonged inflammation, which increases the levels of oxygen radicals, leading to further tissue injury. Elevated levels of matrix metalloproteases in chronic diabetic wounds, sometimes up to 50-100 times higher than acute wounds, cause tissue destruction and prevent normal repair processes from taking place. Furthermore, diabetes is associated with impaired immunity, with critical defects occurring at multiple points within the immune system cascade of the wound healing process.
• Option B: To further complicate matters, these wounds have defects in angiogenesis and neovascularization. Normally, wound hypoxia stimulates mobilization of endothelial progenitor cells via vascular endothelial growth factor (VEGF). In diabetic wounds, there are aberrant levels of VEGF and other angiogenic factors such as angiopoietin-1 and angiopoietin-2 that lead to dysangiogenesis.
• Option D: Diabetic neuropathy may also play a role in poor wound healing. Lower levels of neuropeptides, as well as reduced leukocyte infiltration as a result of sensory denervation, have been shown to impair wound healing. When combined, all these diverse factors play a role in the formation and propagation of chronic, debilitating wounds in patients with diabetes.

FNDNRS-02-011

One aspect of implementation related to drug therapy is:

• A. Developing a content outline.
• B. Documenting drugs given.
• C. Establishing outcome criteria.
• D. Setting realistic client goals.

Correct Answer: B. Documenting drugs given.

Although documentation isn’t a step in the nursing process, the nurse is legally required to document activities related to drug therapy, including the time of administration, the quantity, and the client’s reaction. Developing a content outline, establishing outcome criteria, and setting realistic client goals are part of planning rather than implementation.

• Option A: UE has a common goal with the pharmaceutical care it supports: to improve an individual patient’s quality of life through the achievement of predefined, medication-related therapeutic outcomes. Through its focus on the system of medication use, the MUE process helps to identify actual and potential medication-related problems, resolve actual medication-related problems, and prevent potential medication-related problems that could interfere with achieving optimum outcomes from medication therapy.
• Option C: Although distinctions historically have been made among the terms drug-use evaluation, drug-use review, and medication use evaluation (MUE), they all refer to the systematic evaluation of medication use employing standard, observational quality-improvement methods. MUE is a quality-improvement activity, but it also can be considered a formulary system management technique. An MUE is a performance improvement method that focuses on evaluating and improving medication-use processes with the goal of optimal patient outcomes.  
• Option D: MUE encompasses the goals and objectives of drug use evaluation (DUE) in its broadest application, emphasizing improving patient outcomes. The use of MUE, rather than DUE, emphasizes the need for a more multifaceted approach to improving medication use.

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

FNDNRS-02-012

A female client is readmitted to the facility with a warm, tender, reddened area on her right calf. Which contributing factor would the nurse recognize as most important?

• A. A history of increased aspirin use.
• B. Recent pelvic surgery.
• C. An active daily walking program.
• D. A history of diabetes.

Correct Answer: B. Recent pelvic surgery

The client shows signs of deep vein thrombosis (DVT). The pelvic area is rich in blood supply, and thrombophlebitis of the deep vein is associated with pelvic surgery. Thrombosis is a protective mechanism that prevents the loss of blood and seals off damaged blood vessels. Fibrinolysis counteracts or stabilizes the thrombosis. The triggers of venous thrombosis are frequently multifactorial, with the different parts of the triad of Virchow contributing in varying degrees in each patient, but all result in early thrombus interaction with the endothelium. This then stimulates local cytokine production and causes leukocyte adhesion to the endothelium, both of which promote venous thrombosis. 

• Option A: Aspirin, an antiplatelet agent, and an active walking program help decrease the client’s risk of DVT. The use of thrombolytic therapy can result in an intracranial bleed, and hence, careful patient selection is vital. Recently endovascular interventions like catheter-directed extraction, stenting, or mechanical thrombectomy have been tried with moderate success.
• Option C: Treatment of DVT aims to prevent pulmonary embolism, reduce morbidity, and prevent or minimize the risk of developing post-thrombotic syndrome. The cornerstone of treatment is anticoagulation. NICE guidelines only recommend treating proximal DVT (not distal) and those with pulmonary emboli. In each patient, the risks of anticoagulation need to be weighed against the benefits.
• Option D: In general, diabetes is a contributing factor associated with peripheral vascular disease. In the hospital, the most commonly associated conditions are malignancy, congestive heart failure, obstructive airway disease, and patients undergoing surgery. In the hospital, the most commonly associated conditions are malignancy, congestive heart failure, obstructive airway disease, and patients undergoing surgery.

FNDNRS-02-013

Which intervention should the nurse in charge try first for a client that exhibits signs of sleep disturbance?

• A. Administer sleeping medication before bedtime.
• B. Ask the client each morning to describe the quantity of sleep during the previous night.
• C. Teach the client relaxation techniques, such as guided imagery, medication, and progressive muscle relaxation.
• D. Provide the client with normal sleep aids, such as pillows, back rubs, and snacks.

Correct Answer: D. Provide the client with normal sleep aids, such as pillows, back rubs, and snacks

The nurse should begin with the simplest interventions, such as pillows or snacks, before interventions that require greater skill such as relaxation techniques. Sleep is a complex biological process. It is a reversible state of unconsciousness in which there are reduced metabolism and motor activity. Sleep disorders are a group of conditions that disturb the normal sleep patterns of a person. Sleep disorders are one of the most common clinical problems encountered. Inadequate or non-restorative sleep can interfere with normal physical, mental, social, and emotional functioning. Sleep disorders can affect overall health, safety, and quality of life.

• Option A: Sleep medication should be avoided whenever possible. Histamine type 1 receptor blockers: due to their sedative effects, these drugs can be helpful in patients with sleep disorders. Benzodiazepines (BZD) are the mainstay in the treatment of insomnia. Non-benzodiazepine hypnotics are used for the treatment of acute and short term insomnia.
• Option B: At some point, the nurse should do a thorough sleep assessment, especially if common sense interventions fail. The sleep diary, or sleep log, is a subjective paper record of sleep and wakefulness over a period of weeks to a month. Patients should record the detailed description of sleep, such as bedtime, duration until sleep onset, the number of awakenings, duration of awakenings, and nap times. 
• Option C: Relaxation techniques may be implemented before sleep. Meditation and breathing exercises are some of the relaxation techniques. It begins with being in a comfortable position and closing eyes. The mind and thoughts should be redirected towards a peaceful image, and relaxation should be allowed to spread throughout the body.

FNDNRS-02-014

While examining a client’s leg, the nurse notes an open ulceration with visible granulation tissue in the wound. Until a wound specialist can be contacted, which type of dressings is most appropriate for the nurse in charge to apply?

• A. Dry sterile dressing
• B. Sterile petroleum gauze
• C. Moist, sterile saline gauze
• D. Povidone-iodine-soaked gauze

Correct Answer: C. Moist, sterile saline gauze

Moist, sterile saline dressings support would heal and are cost-effective. If the wound is infected and there are a lot of sloughs, which cannot be mechanically debrided, then a chemical debridement can be done with collagenase-based products. The goal is to help the wound heal as soon as possible by using an appropriate dressing material to maintain the right amount of moisture. When the wound bed is dry, use a dressing to increase moisture and if too wet and the surrounding skin is macerated, use material that will absorb excess fluid and protect the surrounding healthy skin.

• Option A: Dry sterile dressings adhere to the wound and debride the tissue when removed. Tulle is a non-adherent dressing impregnated with paraffin. It aids healing but doesn’t absorb exudate. It also requires a secondary dressing to hold it in place. It is ideal for burns as one can add topical antibiotics to the dressing. It is known to cause allergies, and this limits its wider use.
• Option B: Petroleum supports healing but is expensive. The semipermeable dressing allows for moisture to evaporate and also reduces pain. This dressing also acts as a barrier to prevent environmental contamination. The semipermeable dressing does not absorb moisture and requires regular inspection. It also requires a secondary dressing to hold the semipermeable dressing in place.
• Option D: Povidone-iodine can irritate epithelial cells, so it shouldn’t be left on an open wound. Plastic film dressings are known to absorb exudate and can be used for wounds with a moderate amount of exudate. They should not be used on dry wounds. They often require a secondary dressing to hold the plastic in place.

FNDNRS-02-015

A male client in a behavioral-health facility receives a 30-minute psychotherapy session, and the provider uses a current procedure terminology (CPT) code that bills for a 50-minute session. Under the False Claims Act, such illegal behavior is known as:

• A. Unbundling
• B. Overbilling
• C. Upcoding
• D. Misrepresentation

Correct Answer: C. Upcoding

Upcoding is the practice of using a CPT code that’s reimbursed at a higher rate than the code for the service actually provided. Upcoding is fraudulent medical billing in which a bill sent for a health service is more expensive than it should have been based on the service that was performed. An upcoded bill can be sent to any payer—whether a private health insurer, Medicaid, Medicare, or the patient. Unbundling, overbilling, and misrepresentation aren’t the terms used for this illegal practice.

• Option A: Unbundling refers to using multiple CPT codes for those parts of the procedure, either due to misunderstanding or in an effort to increase payment.
• Option B: Overbilling (sometimes spelled as over-billing) is the practice of charging more than is legally or ethically acceptable on an invoice or bill.
• Option D: A misrepresentation is a false statement of a material fact made by one party which affects the other party’s decision in agreeing to a contract. If the misrepresentation is discovered, the contract can be declared void, and depending on the situation, the adversely impacted party may seek damages.

FNDNRS-02-016

A nurse assigned to care for a postoperative male client who has diabetes mellitus. During the assessment interview, the client reports that he’s impotent and says that he’s concerned about its effect on his marriage. In planning this client’s care, the most appropriate intervention would be to:

• A. Encourage the client to ask questions about personal sexuality.
• B. Provide time for privacy.
• C. Provide support for the spouse or significant other.
• D. Suggest referral to a sex counselor or other appropriate professional.

Correct Answer: D. Suggest referral to a sex counselor or other appropriate professional

The nurse should refer this client to a sex counselor or other professional. Making appropriate referrals is a valid part of planning the client’s care. Therefore, providing time for privacy and providing support for the spouse or significant other are important, but not as important as referring the client to a sex counselor.

• Option A: The nurse doesn’t normally provide sex counseling. The nurse is ideally placed in the primary care field to help ease the upset caused; however, in order to offer care that is effective, insight and understanding of the condition are required as well as the various treatment options available to help men manage their health and wellbeing.
• Option B: The key goal of management is to diagnose and treat the cause of ED when this is possible, enabling the man or couple to enjoy a satisfactory sexual experience. This can occur when the nurse has identified and treated any curable causes of ED, initiating lifestyle change and risk factor modification, including drug-related factors, and offering education and counselling to patients and their partners.
• Option C: The potential benefits of lifestyle changes (e.g. weight management, smoking cessation) may be particularly important in individuals with ED and specific comorbid cardiovascular or metabolic diseases, such as diabetes or hypertension. As well as improving erectile function, lifestyle changes may also benefit overall cardiovascular and metabolic health. Further studies are needed to clarify the role of lifestyle changes in the management of ED and related cardiovascular disease.

FNDNRS-02-017

Using Abraham Maslow’s hierarchy of human needs, a nurse assigns highest priority to which client need?

• A. Security
• B. Elimination
• C. Safety
• D. Belonging

Correct Answer: B. Elimination

According to Maslow, elimination is a first-level or physiological need and therefore takes priority over all other needs. In 1943, Abraham Maslow developed a hierarchy based on basic fundamental needs innate for all individuals. Maslow’s hierarchy of needs is a motivational theory in psychology comprising a five-tier model of human needs, often depicted as hierarchical levels within a pyramid. From the bottom of the hierarchy upwards, the needs are: physiological (food and clothing), safety (job security), love and belonging needs (friendship), esteem, and self-actualization. Security and safety are second-level needs; belonging is a third-level need. Second- and third-level needs can be met only after a client’s first-level needs have been satisfied.

• Option A: Once an individual’s physiological needs are satisfied, the needs for security and safety become salient. People want to experience order, predictability, and control in their lives. These needs can be fulfilled by the family and society (e.g. police, schools, business, and medical care).
• Option C: Physiological and safety needs provide the basis for the implementation of nursing care and nursing interventions. For example, emotional security, financial security (e.g. employment, social welfare), law and order, freedom from fear, social stability, property, health, and wellbeing (e.g. safety against accidents and injury).
• Option D: After physiological and safety needs have been fulfilled, the third level of human needs is social and involves feelings of belongingness. The need for interpersonal relationships motivates behavior. Examples include friendship, intimacy, trust, and acceptance, receiving and giving affection and love. Affiliating, being part of a group (family, friends, work).

FNDNRS-02-018

A male client on prolonged bed rest has developed a pressure ulcer. The wound shows no signs of healing even though the client has received skin care and has been turned every 2 hours. Which factor is most likely responsible for the failure to heal?

A. Inadequate vitamin D intake.

B. Inadequate protein intake.

C. Inadequate massaging of the affected area.

D. Low calcium level.

Correct Answer: B. Inadequate protein intake.

A client on bed rest suffers from a lack of movement and a negative nitrogen balance. Therefore, inadequate protein intake impairs wound healing. Decubitus ulcers, also termed bedsores or pressure ulcers, are skin and soft tissue injuries that form as a result of constant or prolonged pressure exerted on the skin. These ulcers occur at bony areas of the body such as the ischium, greater trochanter, sacrum, heel, malleolus (lateral than medial), and occiput. Inadequate vitamin D intake and low calcium levels aren’t factors in poor healing for this client. A pressure ulcer should never be massaged.

• Option A: Decubitus ulcer formation is multifactorial (external and internal factors), but all these results in a common pathway leading to ischemia and necrosis. Tissues can sustain an abnormal amount of external pressure, but constant pressure exerted over a prolonged period is the main culprit.
• Option C: External pressure must exceed the arterial capillary pressure (32 mmHg) to impede blood flow and must be greater than the venous capillary closing pressure (8 to 12 mmHg) to impair the return of venous blood. If the pressure above these values is maintained, it causes tissue ischemia and further resulting in tissue necrosis. This enormous pressure can be exerted due to compression by a hard mattress, railings of hospital beds, or any hard surface with which the patient is in contact.
• Option D: Friction caused by skin rubbing against surfaces like clothing or bedding can also lead to the development of ulcers by contributing to breaks in the superficial layers of the skin. Moisture can cause ulcers and worsens existing ulcers via tissue breakdown and maceration.

FNDNRS-02-019

A female client who received general anesthesia returns from surgery. Postoperatively, which nursing diagnosis takes highest priority for this client?

• A. Acute pain related to surgery.
• B. Deficient fluid volume related to blood and fluid loss from surgery.
• C. Impaired physical mobility related to surgery.
• D. Risk for aspiration related to anesthesia.

Correct Answer: D. Risk for aspiration related to anesthesia.

Risk for aspiration related to anesthesia takes priority for this client because general anesthesia may impair the gag and swallowing reflexes, possibly leading to aspiration. The gag reflex, also known as the pharyngeal reflex, is a reflex contraction of the muscles of the posterior pharynx after stimulation of the posterior pharyngeal wall, tonsillar area, or base of the tongue. The gag reflex is believed to be an evolutionary reflex that developed as a method to prevent the aspiration of solid food particles. It is an essential component of evaluating the medullary brainstem and plays a role in the declaration of brain death.The other options, although important, are secondary.

• Option A: Postoperative pain can additionally characterize as somatic or visceral. The somatic division of pain is composed of a rich input of nociceptive myelinated, rapidly conducting A-beta-fibers found in cutaneous and deep tissue, which contribute to a more localized, sharp quality. The visceral division of pain is composed of a network of unmyelinated C-fibers and thinly myelinated A-delta-fibers that span across multiple viscera and converge together before entering the spinal cord. Also, visceral afferent fibers run close to autonomic ganglia before their entrance into the dorsal root of the spinal cord. These characteristic features of visceral nociceptive fibers are what contribute to a more diffuse, poorly localized pattern of pain that may be accompanied by autonomic reactions such as a change in heart rate or blood pressure.
• Option B: The acid-base and electrolyte changes observed in the perioperative period could be secondary to the underlying illness or surgical procedure, for example, hyponatremia occurring with transurethral resection of the prostate where glycine or other hypotonic fluid is used for irrigation. Serum sodium concentration <120 mmol/L will cause confusion and irritability, whereas <110 mmol/L may cause seizures and coma.
• Option C: Complete physiologic recovery takes place by 40 min in 40% of the patients. The functional quality of recovery in all domains occurs in only 11% of the patients by day 3. Thus, the concept of awakening is involved with far greater dimensions than judging the anesthetic effect as terminated and assessing a patient as being “recovered” or “awakened.” Patients cannot be considered fully recovered until they have returned to their preoperative physiological state.

FNDNRS-02-020

The nurse inspects a client’s back and notices small hemorrhagic spots. The nurse documents that the client has:

• A. Extravasation
• B. Osteomalacia
• C. Petechiae
• D. Uremia

Correct Answer: C. Petechiae

Petechiae are small hemorrhagic spots. Petechiae are tiny purple, red, or brown spots on the skin. They usually appear on the arms, legs, stomach, and buttocks. They can also be found inside the mouth or on the eyelids. These pinpoint spots can be a sign of many different conditions — some minor, others serious. They can also appear as a reaction to certain medications.

• Option A: Extravasation is the leakage of fluid in the interstitial space. Extravasation is the leakage of a fluid out of its container into the surrounding area, especially blood or blood cells from vessels. In the case of inflammation, it refers to the movement of white blood cells from the capillaries to the tissues surrounding them (leukocyte extravasation, also known as diapedesis).
• Option B: Osteomalacia is the softening of bone tissue. Osteomalacia refers to a marked softening of the bones, most often caused by severe vitamin D deficiency. The softened bones of children and young adults with osteomalacia can lead to bowing during growth, especially in weight-bearing bones of the legs. Osteomalacia in older adults can lead to fractures.
• Option D: Uremia is an excess of urea and other nitrogen products in the blood. Uremia is the condition of having high levels of urea in the blood. Urea is one of the primary components of urine. It can be defined as an excess of amino acid and protein metabolism end products, such as urea and creatinine, in the blood that would be normally excreted in the urine.

FNDNRS-02-021

Which document addresses the client’s right to information, informed consent, and treatment refusal?

• A. Standard of Nursing Practice
• B. Patient’s Bill of Rights
• C. Nurse Practice Act
• D. Code for Nurses

Correct Answer: B. Patient’s Bill of Rights

The Patient’s Bill of Rights addresses the client’s right to information, informed consent, timely responses to requests for services, and treatment refusal. A legal document, it serves as a guideline for the nurse’s decision making. Standards of Nursing Practice, the Nurse Practice Act, and the Code for Nurses contain nursing practice parameters and primarily describe the use of the nursing process in providing care.

• Option A: Standards of nursing practice developed by the American Nurses’ Association (ANA) provide guidelines for nursing performance. They are the rules or definition of what it means to provide competent care. The registered professional nurse is required by law to carry out care in accordance with what other reasonably prudent nurses would do in the same or similar circumstances. Thus, provision of high-quality care consistent with established standards is critical.
• Option C: Every state and territory in the US set laws to govern the practice of nursing. These laws are defined in the Nursing Practice Act (NPA). The NPA is then interpreted into regulations by each state and territorial nursing board with the authority to regulate the practice of nursing care and the power to enforce the laws.
• Option D: The ANA Code of Ethics for Nurses serves the following purposes: It is a succinct statement of the ethical obligations and duties of every individual who enters the nursing profession. It is the profession’s nonnegotiable ethical standard. It is an expression of nursing’s own understanding of its commitment to society.

FNDNRS-02-022

If a blood pressure cuff is too small for a client, blood pressure readings taken with such a cuff may do which of the following?

• A. Fail to show changes in blood pressure.
• B. Produce a false-high measurement.
• C. Cause sciatic nerve damage.
• D. Produce a false-low measurement.

Correct Answer: B. Produce a false-high measurement.

Using an undersized blood pressure cuff produces a falsely elevated blood pressure because the cuff can’t record brachial artery measurements unless it’s excessively inflated. 

• Option A: Using a blood pressure cuff that’s too large or too small can give inaccurate blood pressure readings. The doctor’s office should have several sizes of cuffs to ensure an accurate blood pressure reading. When one measures their blood pressure at home, it’s important to use the proper size cuff.
• Option C: The sciatic nerve wouldn’t be damaged by hyperinflation of the blood pressure cuff because the sciatic nerve is located in the lower extremity.
• Option D: The inflatable part of the blood pressure cuff should cover about 40% of the distance around (circumference of) the upper arm. The cuff should cover 80% of the area from the elbow to the shoulder.

FNDNRS-02-023

Nurse Elijah has been teaching a client about a high-protein diet. The teaching is successful if the client identifies which meal as high in protein?

• A. Baked beans, hamburger, and milk
• B. Spaghetti with cream sauce, broccoli, and tea
• C. Bouillon, spinach, and soda
• D. Chicken cutlet, spinach, and soda

Correct Answer: A. Baked beans, hamburger, and milk

Baked beans, hamburger, and milk are all excellent sources of protein. Good choices include soy protein, beans, nuts, fish, skinless poultry, lean beef, pork, and low-fat dairy products. Avoid processed meats. 

• Option B: The spaghetti-broccoli-tea choice is high in carbohydrates. The quality of the carbohydrates (carbs) one eats is important too. Cut processed carbs from the diet, and choose carbs that are high in fiber and nutrient-dense, such as whole grains and vegetables and fruit.
• Option C: The bouillon-spinach-soda choice provides liquid and sodium as well as some iron, vitamins, and carbohydrates.
• Option D: Chicken provides protein but the chicken-spinach-soda combination provides less protein than the baked beans-hamburger-milk selection.

FNDNRS-02-024

A male client is admitted to the hospital with blunt chest trauma after a motor vehicle accident. The first nursing priority for this client would be to:

• A. Assess the client’s airway.
• B. Provide pain relief.
• C. Encourage deep breathing and coughing.
• D. Splint the chest wall with a pillow.

Correct Answer: A. Assess the client’s airway.

The first priority is to evaluate airway patency before assessing for signs of obstruction, sternal retraction, stridor, or wheezing. Airway management is always the nurse’s first priority. Blunt trauma, on the whole, is a more common cause of traumatic injuries and can be equally life-threatening. It is important to know the mechanism as management may be different.  Most blunt trauma is managed non-operatively, whereas penetrating chest trauma often requires operative intervention. Pain management and splinting are important for the client’s comfort but would come after airway assessment. 

• Option B: Pain control greatly affects mortality and morbidity in patients with chest trauma.  Pain leads to splints which worsen or prevent healing. In many cases, it can lead to pneumonia. Early analgesia should be considered to decrease splinting. In the acute setting, push doses of short-acting narcotics should be used.
• Option C: Coughing and deep breathing may be contraindicated if the client has internal bleeding and other injuries. Minor injuries may simply require close monitoring and pain control. Care should be taken in the young and the elderly. Patients with 3 or more rib fractures, a flail segment, and any number of rib fractures with pulmonary contusions, hemopneumothorax, hypoxia, or pre-existing pulmonary disease should be monitored at an advanced level of care.
• Option D: Immediate life-threatening injuries require prompt intervention, such as emergent tube thoracostomy for large pneumothoraces, and initial management of hemothorax. For cases of hemothorax, adequate drainage is imperative to prevent retained hemothorax. Retained hemothorax can lead to empyema requiring video-assisted thoracoscopic surgery.

FNDNRS-02-025

A newly hired charge nurse assesses the staff nurses as competent individually but ineffective and unproductive as a team. In addressing her concern, the charge nurse should understand that the usual reason for such a situation is:

• A. Unhappiness about the charge in leadership.
• B. Unexpected feelings and emotions among the staff.
• C. Fatigue from overwork and understaffing.
• D. Failure to incorporate staff in decision making.

Correct Answer: B. Unexpected feelings and emotions among the staff.

The usual or most prevalent reason for lack of productivity in a group of competent nurses is inadequate communication or a situation in which the nurses have unexpected feelings and emotions. Although the other options could be contributing to the problematic situation, they’re less likely to be the cause.

• Option A: Providing employees with acknowledgment of the good work that they have done is one of the easiest management tasks. However, it is also as easily neglected. For instance, a study in the financial sector shows that only 20% of employees feel strongly valued at work.
• Option C: Another big issue that causes low productivity is workplace stress. A study by Health Advocate shows that there are about one million employees who are suffering from low productivity due to stress, which costs companies $600 dollars per worker every single year.
• Option D: An important reason for low employee productivity might be the fact that they do not feel that they belong with the company that they are part of. It is important for every manager to make sure that the environment in their business is welcoming to new hires and does not make them feel underappreciated.

FNDNRS-02-026

A male client blood test results are as follows: white blood cell (WBC) count, 100ul; hemoglobin (Hb) level, 14 g/dl; hematocrit (HCT), 40%. Which goal would be most important for this client?

• A. Promote fluid balance
• B. Prevent infection
• C. Promote rest
• D. Prevent injury

Correct Answer: B. Prevent infection

The client is at risk for infection because WBC count is dangerously low. Neutrophils play an essential role in immune defenses because they ingest, kill, and digest invading microorganisms, including fungi and bacteria. Failure to carry out this role leads to immunodeficiency, which is mainly characterized by the presence of recurrent infections. Hb level and HCT are within normal limits; therefore, fluid balance, rest, and prevention of injury are inappropriate.

• Option A: Neutrophils play a role in the immune defense against extracellular bacteria, including Staphylococci, Streptococci, and Escherichia coli, among others. They also protect against fungal infections, including those produced by Candida albicans. Once their count is below 1 x 10/L recurrent infections start. As compensation, the monocyte count may increase. 
• Option C: Application of granulocyte-colony stimulating factor (G-CSF) can improve neutrophil functions and number. Prophylactic use of antibiotics and antifungals is reserved for some forms of alteration in neutrophil function such as chronic granulomatous disease CGD).
• Option D: In primary neutropenia disorders such as chronic granulomatous disease presents with recurrent infections affecting many organs since childhood. It is caused by a failure to produce toxic reactive oxygen species so that the neutrophils can ingest the microorganisms, but they are unable to kill them, as a significant consequence granuloma can obstruct organs such as the stomach, esophagus, or bladder. Patients with this disease are very susceptible to opportunistic infections by certain bacteria and fungi, especially with Serratia and Burkholderia.

FNDNRS-02-027

Following a tonsillectomy, a female client returns to the medical-surgical unit. The client is lethargic and reports having a sore throat. Which position would be most therapeutic for this client?

• A. Semi-Fowler’s
• B. Supine
• C. High-Fowler’s
• D. Side-lying

Correct Answer: D. Side-lying

Because of lethargy, the post-tonsillectomy client is at risk for aspirating blood from the surgical wound. Therefore, placing the client in the side-lying position until he awake is best. The semi-Fowler’s, supine, and high-Fowler’s position don’t allow for adequate oral drainage in a lethargic post-tonsillectomy client and increase the risk of blood aspiration.

• Option A: Semi-Fowler’s would not be able to facilitate effective drainage. Bleeding is one of the most common and feared complications following tonsillectomy with or without adenoidectomy. A study from 2009 to 2013 involving over one hundred thousand children showed that 2.8% of children had unplanned revisits for bleeding following tonsillectomy, 1.6% percent of patients came through the emergency department, and 0.8% required a procedure.
• Option B: Supine position predisposes the patient to aspiration. Frequency is higher at night with 50% of bleeding occurring between 10pm-1am and 6am-9am; this is thought to be from changes in circadian rhythm, vibratory effects of snoring on the oropharynx, or drying of the oropharyngeal mucosa from mouth breathing. Risk of bleeding in patients with known coagulopathies may be significantly higher.
• Option C: Tonsillectomy can be either extracapsular or intracapsular. The “hot” extracapsular technique with monopolar cautery is the most popular technique in the United States. 

FNDNRS-02-028

The nurse inspects a client’s pupil size and determines that it’s 2 mm in the left eye and 3 mm in the right eye. Unequal pupils are known as:

• A. Anisocoria
• B. Ataxia
• C. Cataract
• D. Diplopia

Correct Answer: A. Anisocoria

Unequal pupils are called anisocoria. Anisocoria, or unequal pupil sizes, is a common condition. The varied causes have implications ranging from life-threatening to completely benign, and a clinically guided history and examination is the first step in establishing a diagnosis.

• Option B: Ataxia is uncoordinated actions of involuntary muscle use. Ataxia is a degenerative disease of the nervous system. Many symptoms of Ataxia mimic those of being drunk, such as slurred speech, stumbling, falling, and incoordination. These symptoms are caused by damage to the cerebellum, the part of the brain that is responsible for coordinating movement.
• Option C: A cataract is an opacity of the eye’s lens. A cataract is a clouding of the normally clear lens of the eye. For people who have cataracts, seeing through cloudy lenses is a bit like looking through a frosty or fogged-up window. Clouded vision caused by cataracts can make it more difficult to read, drive a car (especially at night) or see the expression on a friend’s face.
• Option D: Diplopia is double vision. Diplopia is the perception of 2 images of a single object. Diplopia may be monocular or binocular. Monocular diplopia is present when only one eye is open. Binocular diplopia disappears when either eye is closed.

FNDNRS-02-029

The nurse in charge is caring for an Italian client. He’s complaining of pain, but he falls asleep right after his complaint and before the nurse can assess his pain. The nurse concludes that:

• A. He may have a low threshold for pain.
• B. He was faking pain.
• C. Someone else gave him medication.
• D. The pain went away.

Correct Answer: A. He may have a low threshold for pain.

People of Italian heritage tend to verbalize discomfort and pain. The pain was real to the client, and he may need medication when he wakes up. Italian females reported the highest sensitivity to both mechanical and electrical stimulation, while Swedes reported the lowest sensitivity. Mechanical pain thresholds differed more across cultures than did electrical pain thresholds. Cultural factors may influence response to type of pain test.

• Option B: Our pain threshold is the minimum point at which something, such as pressure or heat, causes us pain. For example, someone with a lower pain threshold might start feeling pain when only minimal pressure is applied to part of their body. Pain tolerance and threshold varies from person to person.
• Option C: When we feel pain, nearby nerves send signals to the brain through the spinal cord. The brain interprets this signal as a sign of pain, which can set off protective reflexes. For example, when one touches something very hot, the brain receives signals indicating pain. This in turn can make one quickly pull the hand away without even thinking.
• Option D: Biofeedback is a type of therapy that helps increase the awareness of how the body responds to stressors and other stimuli. This includes pain. During a biofeedback session, a therapist will teach the client how to use relaxation techniques, breathing exercises, and mental exercises to override the body’s response to stress or pain.

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

FNDNRS-02-030

A female client is admitted to the emergency department with complaints of chest pain and shortness of breath. The nurse’s assessment reveals jugular vein distention. The nurse knows that when a client has jugular vein distension, it’s typically due to:

• A. A neck tumor
• B. An electrolyte imbalance
• C. Dehydration
• D. Fluid overload

Correct Answer: D. Fluid overload

Fluid overload causes the volume of blood within the vascular system to increase. This increase causes the vein to distend, which can be seen most obviously in the neck veins. JVD is a sign of increased central venous pressure (CVP). That’s a measurement of the pressure inside the vena cava. CVP indicates how much blood is flowing back into the heart and how well the heart can move that blood into the lungs and the rest of the body.

• Option A: A neck tumor doesn’t typically cause jugular vein distention. Right-sided heart failure is a common cause. Right-sided heart failure usually develops after a left-sided heart failure. The left ventricle pumps blood out through the aorta to most of the body. The right ventricle pumps blood to the lungs. When the left ventricle’s pumping power weakens, fluid can back up into the lungs. This eventually weakens the right ventricle.
• Option B: An electrolyte imbalance may result in fluid overload, but it doesn’t directly contribute to jugular vein distention. The pericardium is a thin, fluid-filled sac that surrounds the heart. An infection of the pericardium, called constrictive pericarditis, can restrict the volume of the heart. As a result, the chambers can’t fill with blood properly, so blood can back up into veins, including the jugular veins.
• Option C: Dehydration does not cause JVD. Another common cause is pulmonary hypertension. Pulmonary hypertension occurs when the pressure in your lungs increases, sometimes as a result of changes to the lining of the artery walls. This can also lead to right-sided heart failure.

FNDNRS-02-031

Critical thinking and the nursing process have which of the following in common? Both:

• A. Are important to use in nursing practice.
• B. Use an ordered series of steps.
• C. Are patient-specific processes.
• D. Were developed specifically for nursing.

Correct Answer: A. Are important to use in nursing practice.

Nurses make many decisions: some require using the nursing process, whereas others are not client related but require critical thinking. Neither is linear. Critical thinking applies to any discipline. n 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. Holistic and scientific postulates are integrated to provide the basis for compassionate, quality-based care.

• Option B: The nursing process has specific steps; critical thinking does not. The nursing process functions as a systematic guide to client-centered care with 5 sequential steps. These are assessment, diagnosis, planning, implementation, and evaluation.
• 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: Critical thinking skills will play a vital role as we develop plans of care for these patient populations with multiple comorbidities and embrace this challenging healthcare arena. Thus, the trend towards concept-based curriculum changes will assist us in the navigation of these uncharted waters. 

FNDNRS-02-032

In which step of the nursing process does the nurse analyze data and identify client problems?

• A. Assessment
• B. Diagnosis
• C. Planning outcomes
• D. Evaluation

Correct Answer: B. Diagnosis

In the diagnosis phase, the nurse identifies the client’s health status. The North American Nursing Diagnosis Association (NANDA) provides nurses with an up to date list of nursing diagnoses. A nursing diagnosis, according to NANDA, is defined as a clinical judgment about responses to actual or potential health problems on the part of the patient, family, or community.

• Option A: In the assessment phase, the nurse gathers data from many sources for analysis in the diagnosis phase. 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: In the planning outcomes phase, the nurse formulates goals and outcomes. 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. 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 D: In the evaluation phase, which occurs after implementing interventions, the nurse gathers data about the client’s responses to nursing care to determine whether client outcomes were met. 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.

FNDNRS-02-033

In which phase of the nursing process does the nurse decide whether her actions have successfully treated the client’s health problem?

• A. Assessment
• B. Diagnosis
• C. Planning outcomes
• D. Evaluation

Correct Answer: D. Evaluation

During the implementation phase, the nurse carries out the interventions or delegates them to other health care team members. During the evaluation phase, the nurse judges whether her actions have been successful in treating or preventing the identified client health problem. 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 A: In the assessment phase, the nurse gathers data from many sources for analysis in the diagnosis phase. 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 B: In the diagnosis phase, the nurse identifies the client’s health status. The North American Nursing Diagnosis Association (NANDA) provides nurses with an up to date list of nursing diagnoses. A nursing diagnosis, according to NANDA, is defined as a clinical judgment about responses to actual or potential health problems on the part of the patient, family or community. 
• Option C: In the planning outcomes phase, the nurse and client decide on goals they want to achieve. In the intervention planning phase, the nurse identifies specific interventions to help achieve the identified goal. 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. 

FNDNRS-02-034

What is the most basic reason that self-knowledge is important for nurses? Because it helps the nurse to:

• A. Identify personal biases that may affect his thinking and actions.
• B. Identify the most effective interventions for a patient.
• C. Communicate more efficiently with colleagues, patients, and families.
• D. Learn and remember new procedures and techniques.

Correct Answer: A. Identify personal biases that may affect his thinking and actions.

The most basic reason is that self-knowledge directly affects the nurse’s thinking and the actions he chooses. Indirectly, thinking is involved in identifying effective interventions, communicating, and learning procedures. However, because identifying personal biases affect all the other nursing actions, it is the most basic reason.

• Option B: In philosophy, “self-knowledge” standardly refers to knowledge of one’s own sensations, thoughts, beliefs, and other mental states. At least since Descartes, most philosophers have believed that our knowledge of our own mental states differs markedly from our knowledge of the external world (where this includes our knowledge of others’ thoughts).
• Option C: Perhaps the most widely accepted view along these lines is that self-knowledge, even if not absolutely certain, is especially secure, in the following sense: self-knowledge is immune from some types of error to which other kinds of empirical knowledge—most obviously, perceptual knowledge—are vulnerable. 
• Option D: Self-awareness is important because when we have a better understanding of ourselves, we are able to experience ourselves as unique and separate individuals. We are then empowered to make changes and to build on our areas of strength as well as identify areas where we would like to make improvements.

FNDNRS-02-035

Arrange the steps of the nursing process in the sequence in which they generally occur.

• 1. Assessment
• 2. Diagnosis
• 3. Planning outcomes
• 4. Planning interventions
• 5. Evaluation

The correct order is shown above.

Logically, the steps are assessment, diagnosis, planning outcomes, planning interventions, and evaluation. Keep in mind that steps are not always performed in this order, depending on the patient’s needs, and that steps overlap.

• 1. 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.
• 2. The formulation of a nursing diagnosis by employing clinical judgment assists in the planning and implementation of patient care. The North American Nursing Diagnosis Association (NANDA) provides nurses with an up to date list of nursing diagnoses. A nursing diagnosis, according to NANDA, is defined as a clinical judgment about responses to actual or potential health problems on the part of the patient, family, or community. 
• 3. 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. 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.
• 4. Implementation is the step which 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.
• 5. 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.

FNDNRS-02-036

How are critical thinking skills and critical thinking attitudes similar? Both are:

• A. Influences on the nurse’s problem solving and decision making.
• B. Like feelings rather than cognitive activities.
• C. Cognitive activities rather than feelings.
• D. Applicable in all aspects of a person’s life.

Correct Answer: A. Influences on the nurse’s problem solving and decision making.

Cognitive skills are used in complex thinking processes, such as problem solving and decision making. Critical thinking attitudes determine how a person uses her cognitive skills. Critical thinking attitudes are traits of the mind, such as independent thinking, intellectual curiosity, intellectual humility, and fair-mindedness, to name a few. Critical thinking skills refer to the cognitive activities used in complex thinking processes. A few examples of these skills involve recognizing the need for more information, recognizing gaps in one’s own knowledge, and separating relevant information from irrelevant data. Critical thinking, which consists of intellectual skills and attitudes, can be used in all aspects of life.

• Option B: Critical Thinking is, in short, self-directed, self-disciplined, self-monitored, and self-corrective thinking. It presupposes assent to rigorous standards of excellence and mindful command of their use. It entails effective communication and problem solving abilities and a commitment to overcome our native egocentrism and sociocentrism.
• Option C: Critical Thinking is a domain-general thinking skill. The ability to think clearly and rationally is important whenever one chooses to do. But critical thinking skills are not restricted to a particular subject area. Being able to think well and solve problems systematically is an asset for any career.
• Option D: A critical thinking attitude is related to the motivation to try to reason well, but it can also motivate an attempt to use various strategies to overcome personal limitations. Additionally, a person with the critical thinking attitude should often rely on the expertise of others rather than to try to assess all arguments on her own because expertise is often required to properly evaluate an argument.

FNDNRS-02-037

The nurse is preparing to admit a patient from the emergency department. The transferring nurse reports that the patient with chronic lung disease has a 30+ year history of tobacco use. The nurse used to smoke a pack of cigarettes a day at one time and worked very hard to quit smoking. She immediately thinks to herself, “I know I tend to feel negatively about people who use tobacco, especially when they have a serious lung condition; I figure if I can stop smoking, they should be able to. I must remember how physically and psychologically difficult that is, and be very careful not to let it be judgmental of this patient.” This best illustrates:

• A. Theoretical knowledge
• B. Self-knowledge
• C. Using reliable resources
• D. Use of the nursing process

Correct Answer: B. Self-knowledge

Personal knowledge is self-understanding—awareness of one’s beliefs, values, biases, and so on. That best describes the nurse’s awareness that her bias can affect her patient care. Self-knowledge refers to knowledge of one’s own mental states, processes, and dispositions. Most agree it involves a capacity for understanding the representational properties of mental states and their role in shaping behavior.

• Option A: Theoretical knowledge consists of information, facts, principles, and theories in nursing and related disciplines; it consists of research findings and rationally constructed explanations of phenomena. Theoretical knowledge is a knowledge of why something is true. A set of true affirmations (factual knowledge) does not necessarily explain anything. In order to explain something, it is necessary to state why these truths are true. An explanation is required.
• Option C: Using reliable resources is a critical thinking skill. Critical thinking is, in short, self-directed, self-disciplined, self-monitored, and self-corrective thinking. It presupposes assent to rigorous standards of excellence and mindful command of their use. It entails effective communication and problem solving abilities and a commitment to overcome our native egocentrism and sociocentrism.
• Option D: The nursing process is a problem-solving process consisting of the steps of assessing, diagnosing, planning outcomes, planning interventions, implementing, and evaluating. The nurse has not yet met this patient, so she could not have begun the nursing process.

FNDNRS-02-038

Which organization’s standards require that all patients be assessed specifically for pain?

• A. American Nurses Association (ANA)
• B. State nurse practice acts
• C. National Council of State Boards of Nursing (NCSBN)
• D. The Joint Commission

Correct Answer: D. The Joint Commission

The Joint Commission has developed assessment standards, including that all clients be assessed for pain. 

• Option A: The ANA has developed standards for clinical practice, including those for assessment, but not specifically for pain. The American Nurses Association (ANA) is the premier organization representing the interests of the nation’s 4 million registered nurses. ANA is at the forefront of improving the quality of health care for all. Founded in 1896, and with members in all 50 states and U.S. territories, ANA is the strongest voice for the profession.
• Option B: State nurse practice acts regulate nursing practice in individual states. An NPA is enacted by state legislation and its purpose is to govern and guide nursing practice within that state. An NPA is actually a law and must be adhered to as law. Each state has a Board of Nursing (BON) that interprets and enforces the rules of the NPA.
• Option C: The NCSBN asserts that the scope of nursing includes a comprehensive assessment but does not specifically include pain. National Council of State Boards of Nursing (NCSBN) is an independent, not-for-profit organization through which nursing regulatory bodies act and counsel together on matters of common interest and concern affecting public health, safety and welfare, including the development of nursing licensure examinations.

FNDNRS-02-039

Which of the following is an example of data that should be validated?

• A. The urinalysis report indicates there are white blood cells in the urine.
• B. The client states she feels feverish; you measure the oral temperature at 98°F.
• C. The client has clear breath sounds; you count a respiratory rate of 18.
• D. The chest x-ray report indicates the client has pneumonia in the right lower lobe.

Correct Answer: B. The client states she feels feverish; you measure the oral temperature at 98°F.

Validation should be done when subjective and objective data do not make sense. For instance, it is inconsistent data when the patient feels feverish and you obtain a normal temperature. The other distractors do not offer conflicting data. Validation is not usually necessary for laboratory test results.

• Option A: When this test is positive and/or the WBC count in urine is high, it may indicate that there is inflammation in the urinary tract or kidneys. The most common cause for WBCs in urine (leukocyturia) is a bacterial urinary tract infection (UTI), such as a bladder or kidney infection.
• Option C: Breath sounds are the noises produced by the structures of the lungs during breathing. Normal lung sounds occur in all parts of the chest area, including above the collarbones and at the bottom of the rib cage. Using a stethoscope, the doctor may hear normal breathing sounds, decreased or absent breath sounds, and abnormal breath sounds. Normal respiration rates for an adult person at rest range from 12 to 16 breaths per minute.
• Option D: The most common organisms which cause lobar pneumonia are Streptococcus pneumoniae, also called pneumococcus, Haemophilus influenzae and Moraxella catarrhalis. Mycobacterium tuberculosis, the tubercle bacillus, may also cause lobar pneumonia if pulmonary tuberculosis is not treated promptly.

FNDNRS-02-040

Which of the following is an example of appropriate behavior when conducting a client interview?

• A. Recording all the information on the agency-approved form during the interview.
• B. Asking the client, “Why did you think it was necessary to seek health care at this time?”
• C. Using precise medical terminology when asking the client questions.
• D. Sitting, facing the client in a chair at the client’s bedside, using active listening.

Correct Answer: D. Sitting, facing the client in a chair at the client’s bedside, using active listening.

Active listening should be used during an interview. The nurse should face the patient, have relaxed posture, and keep eye contact. Nonjudgmental interest in the patient’s problems (active listening), empathy (communicating to the patient an accurate assessment of emotional state), and concern for the patient as a unique person are among the most important tools in the physician’s interpersonal repertoire. The difference between interviewing a patient who is lying flat in bed and one who is sitting in a chair can be striking. This simple act can emphasize patient autonomy and active involvement in the interview.

• Option A: Note-taking interferes with eye contact. By recognizing the patient’s emotions and responding to them in a supportive manner, the clinician can conduct an effective patient-centered interview.
• Option B: Asking “why” may make the client defensive. Frequently used opening questions include, “What problems brought you to the hospital (or office) today?” or “What kind of problems have you been having recently?” or “What kind of problems would you like to share with me?” These open-ended, nondirective questions encourage the patient to report any and all problems. At this point in the interview it is important to let the patient talk spontaneously rather than restricting and directing the flow of information with multiple questions.
• Option C: The client may not understand medical terminology or health care jargon. Questions should be worded so that the patient has no difficulty understanding what is being asked. Avoid using technical terms and diagnostic labels. The interviewer’s questions should indicate what type of information is requested, but not what answer is expected. 

FNDNRS-02-041

The nurse wishes to identify nursing diagnoses for a patient. She can best do this by using a data collection form organized according to: Select all that apply.

• A. A body systems model
• B. A head-to-toe framework
• C. Maslow’s hierarchy of needs
• D. Gordon’s functional health patterns
• E.  Adaptation Model of Nursing

Correct Answer: C & D

Nursing models produce a holistic database that is useful in identifying nursing rather than medical diagnoses. Body systems and Maslow’s hierarchy is not a nursing model, but it is holistic, so it is acceptable for identifying nursing diagnoses. Gordon’s functional health patterns are a nursing model.

• Option A: A body system model is not a nursing model. It is a representation of all the systems of the body in a figurine.
• Option B: Head-to-toe framework is not a nursing model, and they are not holistic; they focus on identifying physiological needs or disease.
• Option C: Maslow’s hierarchy of needs is a motivational theory in psychology comprising a five-tier model of human needs, often depicted as hierarchical levels within a pyramid. From the bottom of the hierarchy upwards, the needs are: physiological (food and clothing), safety (job security), love and belonging needs (friendship), esteem, and self-actualization.
• Option D: Gordon’s functional health patterns is a method devised by Marjory Gordon to be used by nurses in the nursing process to provide a more comprehensive nursing assessment of the patient.
• Option E: The Adaptation Model of Nursing is a prominent nursing theory aiming to explain or define the provision of nursing science. In her theory, Sister Callista Roy‘s model sees the individual as a set of interrelated systems that strives to maintain a balance between various stimuli.

FNDNRS-02-042

The nurse is recording assessment data. She writes, “The patient seems worried about his surgery. Other than that, he had a good night.” Which errors did the nurse make? Select all that apply.

• A. Used a vague generality.
• B. Did not use the patient’s exact words.
• C. Used a “waffle” word (e.g., appears).
• D. Recorded an inference rather than a cue.
• E. Did not record the patient’s vital signs.

Correct Answer: A, C, D & E

The initial nursing assessment, the first step in the five steps of the nursing process, involves the systematic and continuous collection of data; sorting, analyzing, and organizing that data; and the documentation and communication of the data collected. Subjective and objective data collection are an integral part of this process.

• Option A: The nurse recorded a vague generality: “he has had a good night.” The assessment identifies current and future care needs of the patient by allowing the formation of a nursing diagnosis. The nurse recognizes normal and abnormal patient physiology and helps prioritize interventions and care.
• Option B: The nurse did not use the patient’s exact words, but she did not quote the patient at all, so that is not one of her errors.
• Option C: The nurse used the “waffle” word, “seems” worried instead of documenting what the patient said or did to lead her to that conclusion. Asking about how the client feels and their response to those feelings is part of a psychological assessment.
• Option D: The nurse recorded these inferences: worried and had a good night. The psychological examination may include perceptions, whether justifiable or not, on the part of the patient or client. Religion and cultural beliefs are critical areas to consider.
• Option E: Part of the assessment includes data collection by obtaining vital signs such as temperature, respiratory rate, heart rate, blood pressure, and pain level using age or condition appropriate pain scale.

FNDNRS-02-043

A patient is admitted with shortness of breath, so the nurse immediately listens to his breath sounds. Which type of assessment is the nurse performing?

• A. Ongoing assessment
• B. Comprehensive physical assessment
• C. Focused physical assessment
• D. Psychosocial assessment

Correct Answer: C. Focused physical assessment

The nurse is performing a focused physical assessment, which is done to obtain data about an identified problem, in this case shortness of breath. Detailed nursing assessment of specific body system(s) relating to the presenting problem or current concern(s) of the patient. This may involve one or more body systems.

• Option A: An ongoing assessment is performed as needed, after the initial data are collected, preferably with each patient contact. Repeat of the focused or rapid emergency department assessment of a prehospital patient to detect changes in condition and to judge the effectiveness of treatment before or during transport. Repeated every 5 minutes for an unstable patient and every 15 minutes for a stable patient.
• Option B: A comprehensive physical assessment includes an interview and a complete examination of each body system. A comprehensive health assessment gives nurses insight into a patient’s physical status through observation, the measurement of vital signs, and self-reported symptoms. It includes a medical history, a general survey, and a complete physical examination.
• Option D: A psychosocial assessment examines both psychological and social factors affecting the patient. The nurse conducting a psychosocial assessment would gather information about stressors, lifestyle, emotional health, social influences, coping patterns, communication, and personal responses to health and illness, to name a few aspects.

FNDNRS-02-044

The nurse is assessing vital signs for a patient just admitted to the hospital. Ideally, and if there are no contraindications, how should the nurse position the patient for this portion of the admission assessment?

• A. Sitting upright.
• B. Lying flat on the back with knees flexed.
• C. Lying flat on the back with arms and legs fully extended.
• D. Side-lying with the knees flexed.

Correct Answer: A. Sitting upright.

If the patient is able, the nurse should have the patient sit upright to obtain vital signs in order to allow the nurse to easily access the anterior and posterior chest for auscultation of heart and breath sounds. It allows for full lung expansion and is the preferred position for measuring blood pressure. Additionally, patients might be more comfortable and feel less vulnerable when sitting upright (rather than lying down on the back) and can have direct eye contact with the examiner. However, other positions can be suitable when the patient’s physical condition restricts the comfort or ability of the patient to sit upright.

• Option B: Lying flat on the back with knees flexed or supine horizontal recumbent is most commonly used during breast exam.
• Option C: Lying flat on the back with arms and legs fully extended can make the patient feel uncomfortable. 
• Option D: Sim’s position is usually used to obtain rectal temperature.

FNDNRS-02-045

For all body systems except the abdomen, what is the preferred order for the nurse to perform the following examination techniques?

• 1. Inspection
• 2. Palpation
• 3. Percussion
• 4. Auscultation

The correct order is shown above.

Inspection begins immediately as the nurse meets the patient, as she observes the patient’s appearance and behavior. Observational data are not intrusive to the patient. When performing assessment techniques involving physical touch, the behavior, posture, demeanor, and responses might be altered. Palpation, percussion, and auscultation should be performed in that order, except when performing an abdominal assessment. During abdominal assessment, auscultation should be performed before palpation and percussion to prevent altering bowel sounds.

• 1. It is important to begin with the general examination of the abdomen with the patient in a completely supine position. The presence of any of the following signs may indicate specific disorders. Distension of the abdomen could be present due to small bowel obstruction, masses, tumors, cancer, hepatomegaly, splenomegaly, constipation, abdominal aortic aneurysm, and pregnancy. 
• 2. The ideal position for abdominal examination is to sit or kneel on the right side of the patient with the hand and forearm in the same horizontal plane as the patient’s abdomen. There are three stages of palpation that include the superficial or light palpation, deep palpation, and organ palpation and should be performed in the same order. Maneuvers specific to certain diseases are also a part of abdominal palpation.
• 3. A proper technique of percussion is necessary to gain maximum information regarding the abdominal pathology. While percussing, it is important to appreciate tympany over air-filled structures such as the stomach and dullness to percussion which may be present due to an underlying mass or organomegaly (for example, hepatomegaly or splenomegaly).
• 4. The last step of the abdominal examination is auscultation with a stethoscope. The diaphragm of the stethoscope should be placed on the right side of the umbilicus to listen to the bowel sounds, and their rate should be calculated after listening for at least two minutes. Normal bowel sounds are low-pitched and gurgling, and the rate is normally 2-5/min. Absent bowel sounds may indicate paralytic ileus and hyperactive rushes (borborygmi) are usually present in small bowel obstruction and sometimes may be auscultated in lactose intolerance.

FNDNRS-02-046

The nurse is assessing a patient admitted to the hospital with rectal bleeding. The patient had a hip replacement 2 weeks ago. Which position should the nurse avoid when examining this patient’s rectal area?

• A. Sims’
• B. Supine
• C. Dorsal recumbent
• D. Semi-Fowler’s

Correct Answer: A. Sims’

Sims’ position is typically used to examine the rectal area. However, the position should be avoided if the patient has undergone hip replacement surgery The patient with a hip replacement can assume the supine, dorsal recumbent, or semi-Fowler’s positions without causing harm to the joint. 

• Option B: Supine position is lying on the back facing upward. The supine position means lying horizontally with the face and torso facing up, as opposed to the prone position, which is face down. When used in surgical procedures, it allows access to the peritoneal, thoracic and pericardial regions; as well as the head, neck and extremities.
• Option C: The patient in dorsal recumbent is on his back with knees flexed and soles of feet flat on the bed. A position in which the patient lies on the back with the lower extremities moderately flexed and rotated outward. It is employed in the application of obstetrical forceps, repair of lesions following parturition, vaginal examination, and bimanual palpation.
• Option D: In semi-Fowler’s position, the patient is supine with the head of the bed elevated and legs slightly elevated. The Semi-Fowler’s position is a position in which a patient, typically in a hospital or nursing home is positioned on their back with the head and trunk raised to between 15 and 45 degrees, although 30 degrees is the most frequently used bed angle.

FNDNRS-02-047

How should the nurse modify the examination for a 7-year-old child?

• A. Ask the parents to leave the room before the examination.
• B. Demonstrate equipment before using it.
• C. Allow the child to help with the examination.
• D. Perform invasive procedures (e.g., otoscopic) last.

Correct Answer: B. Demonstrate equipment before using it.

The nurse should modify his examination by demonstrating equipment before using it to examine a school-age child. The physical examination is often the first direct contact between the nurse and the child. Establishing a trusting relationship between the child and the examiner is important. Throughout the examination the nurse should be sensitive to the cultural needs of and differences among children. Providing a quiet, private environment for the history and physical examination is important. The classic systematic approach to the physical examination is to begin at the head and proceed through the entire body to the toes. When examining a child, however, the examiner tailors the physical assessment to the child’s age and developmental level.

• Option A: The nurse should make sure parents are not present during the physical examination of an adolescent, but they usually help younger children feel more secure. To establish trust with the school-age child, the examiner asks the child questions the child can answer. Children in elementary school will talk about school, favorite friends, and activities. Older school-age children may have to be encouraged to talk about their school performance and activities. The examiner encourages the parent to support and reinforce the child’s participation in the examination.
• Option C: The nurse should allow a preschooler to help with the examination when possible, but not usually a school-age child. The examination proceeds from head to toe. Children of this age prefer a simple drape over their underpants or a colorful examination gown, and the examiner should be sensitive to the child’s modesty. The examination is a wonderful opportunity to teach the child about the body and personal care. The nurse answers questions openly and in simple terms.
• Option D: It is best to perform invasive procedures last for all age groups; therefore, this does not represent a modification. Toddlers are often fearful of invasive procedures, so those should be performed last in this age group. 

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

FNDNRS-02-048

The nurse must examine a patient who is weak and unable to sit unaided or to get out of bed. How should she position the patient to begin and perform most of the physical examination?

• A. Dorsal recumbent
• B. Semi-Fowler’s
• C. Lithotomy
• D. Sims’

Correct Answer: B. Semi-Fowler’s

If a patient is unable to sit up, the nurse should place him lying flat on his back, with the head of the bed elevated. The Semi–Fowler’s position is a position in which a patient, typically in a hospital or nursing home is positioned on their back with the head and trunk raised to between 15 and 45 degrees, although 30 degrees is the most frequently used bed angle.

• Option A: Dorsal recumbent position is used for abdominal assessment if the patient has abdominal or pelvic pain. The patient in dorsal recumbent is on his back with knees flexed and soles of feet flat on the bed.
• Option C: Lithotomy position is used for female pelvic examination. It is similar to dorsal recumbent position, except that the patient’s legs are well separated and thighs are acutely flexed. Feet are usually placed in stirrups. Fold sheet or bath blanket crosswise over thighs and legs so that genital area is easily exposed. Keep the patient covered as much as possible.
• Option D: The patient in Sim’s position is on the left side with right knee flexed against abdomen and left knee slightly flexed. Left arm is behind the body; the right arm is placed comfortably. Sims’ position is used to examine the rectal area. In semi-Fowler’s position, the patient is supine with the head of the bed elevated and legs slightly elevated.

FNDNRS-02-049

The nurse should use the diaphragm of the stethoscope to auscultate which of the following?

• A. Heart murmurs
• B. Jugular venous hums
• C. Bowel sounds
• D. Carotid bruits

Correct Answer: C. Bowel sounds

The bell of the stethoscope should be used to hear low-pitched sounds, such as murmurs, bruits, and jugular hums. The diaphragm should be used to hear high-pitched sounds that normally occur in the heart, lungs, and abdomen. The diaphragm is best for higher-pitched sounds, like breath sounds and normal heart sounds. The bell is best for detecting lower pitch sounds, like some heart murmurs, and some bowel sounds.

• Option A: Earpieces should be angled forwards to match the direction of the practitioner’s external auditory meatus. The bell is used to hear low-pitched sounds. Use for mid-diastolic murmur of mitral stenosis or S3 in heart failure.
• Option B: The stethoscope bell is lightly applied in each supraclavicular fossa over the subclavian artery. As usual, the examiner’s free hand palpates the contralateral carotid pulse for timing purposes. If a bruit is appreciated, firmly compress the patient’s ipsilateral radial artery, noting the effect on the murmur.
• Option D: If the intensity of sound is greater above the clavicle it is most likely a carotid bruit. If it is louder below the clavicle it is most likely a heart murmur. Use either the bell or the diaphragm when listening for the carotid bruit, at a point just lateral to Adam’s apple.

FNDNRS-02-050

The nurse calculates a body mass index (BMI) of 18 for a young adult woman who comes to the physician’s office for a college physical. This patient is considered:

• A. Obese
• B. Overweight
• C. Average
• D. Underweight

Correct Answer: D. Underweight

For adults, BMI should range between 20 and 25. Body mass index (BMI) is a person’s weight in kilograms divided by the square of height in meters. BMI is an inexpensive and easy screening method for the weight category—underweight, healthy weight, overweight, and obesity.

• Option A: BMI greater than 30 is considered obese For adults 20 years old and older, BMI is interpreted using standard weight status categories. These categories are the same for men and women of all body types and ages. 
• Option B: BMI 25 to 29.9 is overweight. The prevalence of adult BMI greater than or equal to 30 kg/m2 (obese status) has greatly increased since the 1970s. Recently, however, this trend has leveled off, except for older women. Obesity has continued to increase in adult women who are 60 years and older.
• Option C: BMI less than 20 is considered underweight. BMI can be a screening tool, but it does not diagnose the body fatness or health of an individual. To determine if BMI is a health risk, a healthcare provider performs further assessments. Such assessments include skinfold thickness measurements, evaluations of diet, physical activity, and family history.

FNDNRS-02-051

Using the principles of standard precautions, the nurse would wear gloves in what nursing interventions?

• A. Providing a back massage.
• B. Feeding a client.
• C. Providing hair care.
• D. Providing oral hygiene.

Correct Answer: D. Providing oral hygiene

Doing oral care requires the nurse to wear gloves. Standard precautions apply to the care of all patients, irrespective of their disease state. These precautions apply when there is a risk of potential exposure to (1) blood; (2) all body fluids, secretions, and excretions, except sweat, regardless of whether or not they contain visible blood; (3) non-intact skin, and (4) mucous membranes. This includes the use of hand hygiene and personal protective equipment (PPE), with hand hygiene being the single most important means to prevent transmission of disease.

• Option A: Must be worn when touching blood, body fluids, secretions, excretions, mucous membranes, or non-intact skin. Change when there is contact with potentially infected material in the same patient to avoid cross-contamination. Remove before touching surfaces and clean items. Wearing gloves does not mitigate the need for proper hand hygiene.
• Option B: Hand washing after feeding the client is sufficient. Handwashing with soap and water for at least 40 to 60 seconds, making sure not to use clean hands to turn off the faucet, must be performed if hands are visibly soiled, after using the restroom, or if potential exposure to spore-forming organisms.
• Option C: Gloves are not needed in providing hair care. Hand rubbing with alcohol applied generously to cover hands completely should be performed and hands rubbed until dry.

FNDNRS-02-052

The nurse is preparing to take vital signs in an alert client admitted to the hospital with dehydration secondary to vomiting and diarrhea. What is the best method used to assess the client’s temperature?

• A. Oral
• B. Axillary
• C. Radial
• D. Heat sensitive tape

Correct Answer: B. Axillary

Axilla is the most accessible body part in this situation. Body temperature is a numerical expression of the body’s heat and metabolic activity balance and can be a major indicator of a person’s health status. Assessing a patient’s body temperature is a common procedure nurses perform to monitor for signs of infection, environmental exposure, shock, ovulation, or therapeutic response to medications or medical procedures. A normal body temperature can be a potentially positive sign that the patient isn’t experiencing a disease process, infection, or trauma and that the body’s cells, tissues, and organs aren’t under metabolic distress.

• Option A: The esophageal temperature probe (ETP) is an 18-in (45.7 cm) long, thin, flexible catheter that has a rounded tip that should be lubricated with water-soluble lubricant before being placed through the nares or mouth, extending into the esophagus at least 2 to 3 in (5 to 7.6 cm). The external end portion of the catheter has a small, coated wire with a plug that can be attached to a telemetry monitor for continuous temperature monitoring. 
• Option C: The ETP and RTP (rectal temperature probe) are the same device but can be used in either orifice depending on the patient’s medical condition. Again, the tip should be lubricated with water-soluble lubricant, and then placed approximately 3 in (7.6 cm) inside the rectal vault. The RTP can also be attached to a telemetry monitor cable for continuous temperature monitoring.
• Option D: This is a latex-free, disposable, adhesive strip that can be applied to the forehead. These strips contain embedded liquid crystals and chemical compounds that react to the temperature (heat) of the skin by changing colors. After it has been on the forehead for approximately 2 minutes, the color will illuminate a line and correlate numeric temperature. The strips measure temperatures ranging from 96.6[degrees] F to 104.6[degrees] F (35.8[degrees] C to 40.3[degrees] C). Consider use for infants, children, and adults with cognitive deficits because they’re painless.

FNDNRS-02-053

A nurse obtained a client’s pulse and found the rate to be above normal. The nurse document these findings as:

• A. Tachypnea
• B. Hyperpyrexia
• C. Arrhythmia
• D. Tachycardia

Correct Answer: D. Tachycardia

Tachycardia means rapid heart rate. Tachycardia refers to a heart rate that’s too fast. How that’s defined may depend on age and physical condition. Generally speaking, for adults, a heart rate of more than 100 beats per minute (BPM) is considered too fast.

• Option A: Tachypnea refers to rapid respiratory rate. Tachypnea is a respiration rate greater than normal, resulting in abnormally rapid breathing. In adult humans at rest, any respiratory rate between 12 and 20 breaths is normal and tachypnea is indicated by a rate greater than 20 breaths per minute.
• Option B: Hyperpyrexia means increase in temperature. Hyperpyrexia is another term for a very high fever. The medical criterion for hyperpyrexia is when someone is running a body temperature of more than 106.7°F or 41.5°C. Hyperpyrexia is an emergency that needs immediate attention from a medical professional.
• Option C: Arrhythmia means irregular heart rate. An arrhythmia is a problem with the rate or rhythm of the heartbeat. During an arrhythmia, the heart can beat too fast, too slowly, or with an irregular rhythm. When a heart beats too fast, the condition is called tachycardia. When a heart beats too slowly, the condition is called bradycardia.

FNDNRS-02-054

Which of the following actions should the nurse take to use wide base support when assisting a client to get up in a chair?

• A. Bend at the waist and place arms under the client’s arms and lift.
• B. Face the client, bend knees, and place hands-on client’s forearm and lift.
• C. Spread his or her feet apart.
• D. Tighten his or her pelvic muscles.

Correct Answer: B. Face the client, bend knees, and place hands-on client’s forearm and lift.

This is the proper way of supporting the client to get up in a chair that conforms to safety and proper body mechanics. It is important to use proper body mechanics as a health care professional for many reasons, foremost of which is to prevent injuries to both patient and provider. Health care professionals at the front line, especially those who deliver direct care to patients, are often in situations where they have to assist with moving patients from one position to another.

• Option A: Keep the back straight throughout the transfer to avoid bending or straining the back. Get as close to the person as possible while still allowing him/her to lean forward as needed to assist with the transfer.
• Option C: Allow the patient to help as much as possible. Estimate the patient’s weight and mentally practice.  Make sure that the floor is free of any obstacles or liquids. Keep your feet shoulder-width apart.  Keep the person (or object) as close to your body as possible. Tighten your stomach muscles.
• Option D: Position patients appropriately for transfer. While standing in front of the patient, maintain proper posture with the back straight and knees bent. Hold a strong abdominal contraction. Position the body close to the patient to decrease strain on the back. Before movement, contract the abdominal muscles to protect the back. Use the knees and the lower body during transfer to decrease strain on the back.

FNDNRS-02-055

A client had oral surgery following a motor vehicle accident. The nurse assessing the client finds the skin flushed and warm. Which of the following would be the best method to take the client’s body temperature?

• A. Oral
• B. Axillary
• C. Arterial line
• D. Rectal

Correct Answer: B. Axillary

Taking the temperature via the axilla is the most appropriate route. Body temperature is a numerical expression of the body’s heat and metabolic activity balance and can be a major indicator of a person’s health status. Assessing a patient’s body temperature is a common procedure nurses perform to monitor for signs of infection, environmental exposure, shock, ovulation, or therapeutic response to medications or medical procedures. A normal body temperature can be a potentially positive sign that the patient isn’t experiencing a disease process, infection, or trauma and that the body’s cells, tissues, and organs aren’t under metabolic distress.

• Option A: Taking the temperature via the oral route is incorrect since the client had oral surgery. The esophageal temperature probe (ETP) is an 18-in (45.7 cm) long, thin, flexible catheter that has a rounded tip that should be lubricated with water-soluble lubricant before being placed through the nares or mouth, extending into the esophagus at least 2 to 3 in (5 to 7.6 cm). The external end portion of the catheter has a small, coated wire with a plug that can be attached to a telemetry monitor for continuous temperature monitoring.
• Option C: A PiCCO thermodilution catheter (Pulsion Medical Systems) containing a temperature thermistor was inserted into the brachial artery at the antecubital fossa and doubled as the arterial pressure monitoring line and arterial blood sampling portal. This measured brachial artery temperature from the time of insertion to the time the patient left the operating room.
• Option D: This is unnecessary. The ETP and RTP (rectal temperature probe) are the same device but can be used in either orifice depending on the patient’s medical condition. Again, the tip should be lubricated with water-soluble lubricant, and then placed approximately 3 in (7.6 cm) inside the rectal vault. The RTP can also be attached to a telemetry monitor cable for continuous temperature monitoring.

FNDNRS-02-056

A client who is unconscious needs frequent mouth care. When performing mouth care, the best position of a client is:

• A. Fowler’s position
• B. Side-lying
• C. Supine
• D. Trendelenburg

Correct Answer: B. Side-lying

An unconscious client is best placed on his side when doing oral care to prevent aspiration. An unconscious patient is placed in the side-lying position when mouth care is provided because this position prevents pooling of secretions at the back of the oral cavity, thereby reducing the risk of aspiration. Oral hygiene is especially important for patients receiving oxygen therapy, patients who have nasogastric tubes, and patients who are NPO. Their oral mucosa dries out much faster than normal due to their mouth-breathing.

• Option A: A soft toothbrush or gauze-padded tongue blade may be used to clean the teeth and mouth. The patient should be positioned in the lateral position with the head turned toward the side to provide for drainage and to prevent aspiration.
• Option C: This is the most common position for surgery with a patient lying on his or her back with head, neck, and spine in neutral positioning and arms either adducted alongside the patient or abducted to less than 90 degrees.
• Option D: A variation of supine in which the head of the bed is tilted down such that the pubic symphysis is the highest point of the trunk facilitates venous return and improves exposure during abdominal and laparoscopic surgeries.

FNDNRS-02-057

A client is hospitalized for the first time, which of the following actions ensure the safety of the client?

• A. Keep unnecessary furniture out of the way.
• B. Keep the lights on at all times.
• C. Keep side rails up at all times.
• D. Keep all equipment out of view.

Correct Answer: C. Keep side rails up at all time

Keeping the side rails up at all times ensures the safety of the client. The risk of falling increases with age and the number of times someone has been in hospital. During the client’s hospital stay, he may be more unsteady on his feet because of illness or surgery, or because he is unfamiliar with the hospital environment or is taking new medication.

• Option A: Home health care providers need to know the risk factors for falls and demonstrate effective assessment and interventions for fall and injury prevention. Falls are generally the result of a complex set of intrinsic patient and extrinsic environmental factors. Use of a fall-prevention program, standardized tools, and an interdisciplinary approach may be effective for reducing fall-related injuries.
• Option B: Make sure the client’s pajamas, dressing gown, and day clothes are the right length so they don’t trip over them. Check that their slippers or other footwear fit properly and are not slippery. If they have to wear pressure stockings, wear slippers over them so they do not slip.
• Option D: Keep personal items and the call button within reach to avoid standing and walking to get them. Ask for help when in need to get out of bed to use the toilet if not feeling at all unsteady.

FNDNRS-02-058

A walk-in client enters the clinic with a chief complaint of abdominal pain and diarrhea. The nurse takes the client’s vital sign hereafter. What phrase of the nursing process is being implemented here by the nurse?

• A. Assessment
• B. Diagnosis
• C. Planning
• D. Implementation

Correct Answer: A. Assessment

Assessment is the first phase of the nursing process where a nurse collects information about the client. 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 B: Diagnosis is the formulation of the nursing diagnosis from the information collected during the assessment. The formulation of a nursing diagnosis by employing clinical judgment assists in the planning and implementation of patient care. The North American Nursing Diagnosis Association (NANDA) provides nurses with an up to date list of nursing diagnoses. A nursing diagnosis, according to NANDA, is defined as a clinical judgment about responses to actual or potential health problems on the part of the patient, family, or community.  
• Option C: In Planning, the nurse sets achievable and measurable short and long-term goals. 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. 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 D: Implementation is where nursing care is given. Implementation is the step which 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-02-059

It is best described as a systematic, rational method of planning and providing nursing care for individual, families, group, and community

• A. Assessment
• B. Nursing Process
• C. Diagnosis
• D. Implementation

Correct Answer: B. Nursing Process

The statement describes the Nursing Process. The Nursing Process is the essential core of practice for the registered nurse to deliver holistic, patient-focused care. 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. Holistic and scientific postulates are integrated to provide the basis for compassionate, quality-based care.

• Option A: 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: The formulation of a nursing diagnosis by employing clinical judgment assists in the planning and implementation of patient care. The North American Nursing Diagnosis Association (NANDA) provides nurses with an up to date list of nursing diagnoses. A nursing diagnosis, according to NANDA, is defined as a clinical judgment about responses to actual or potential health problems on the part of the patient, family, or community.  
• Option D: Implementation is the step which 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-02-060

Exchange of gases takes place in which of the following organs?

• A. Kidney
• B. Lungs
• C. Liver
• D. Heart

Correct Answer: B. Lungs

Gas exchange is the transport of oxygen from the lungs to the bloodstream and the expulsion of carbon dioxide from the bloodstream to the lungs. It transpires in the lungs between the alveoli and a network of tiny blood vessels called capillaries, which are located in the walls of the alveoli.

• Option A: The renal system consists of the kidney, ureters, and urethra. The overall function of the system filters approximately 200 liters of fluid a day from renal blood flow which allows for toxins, metabolic waste products, and excess ions to be excreted while keeping essential substances in the blood. The kidney regulates plasma osmolarity by modulating the amount of water, solutes, and electrolytes in the blood. It ensures long-term acid-base balance and also produces erythropoietin which stimulates the production of red blood cells.
• Option C: The liver is a critical organ in the human body that is responsible for an array of functions that help support metabolism, immunity, digestion, detoxification, vitamin storage among other functions. It comprises around 2% of an adult’s body weight. The liver is a unique organ due to its dual blood supply from the portal vein (approximately 75%) and the hepatic artery (approximately 25%).
• Option D: The heart is a muscular organ situated in the center of the chest behind the sternum. It consists of four chambers: the two upper chambers are called the right and left atria, and the two lower chambers are called the right and left ventricles. The right atrium and ventricle together are often called the right heart, and the left atrium and left ventricle together functionally form the left heart.

FNDNRS-02-061

The chamber of the heart that receives oxygenated blood from the lungs is the:

• A. Left atrium
• B. Right atrium
• C. Left ventricle
• D. Right ventricle

Correct Answer: A. Left atrium

The left atrium receives oxygenated blood from the lungs and pumps it to the left ventricle. In the lungs, the blood oxygenates as it passes through the capillaries where it is close enough to the oxygen in the alveoli of the lungs. This oxygenated blood is collected by the four pulmonary veins, two from each lung. All four of these veins open into the left atrium that acts as a collection chamber for oxygenated blood. Just like the right atrium, the left atrium passes the blood onto its ventricle both by passive flow and active pumping.

• Option B: The right atrium receives blood from the veins and pumps it to the right ventricle. The right atrium receives deoxygenated blood from the entire body except for the lungs (the systemic circulation) via the superior and inferior vena cavae. Also, deoxygenated blood from the heart muscle itself drains into the right atrium via the coronary sinus. The right atrium, therefore, acts as a reservoir to collect deoxygenated blood.
• Option C: The left ventricle (the strongest chamber) pumps oxygen-rich blood to the rest of the body, its vigorous contractions create the blood pressure. Oxygenated blood thus fills the left ventricle, passing through the mitral valve. The left ventricle, which is the main pumping chamber of the left heart, then pumps, sending freshly oxygenated blood to the systemic circulation through the aortic valve
• Option D: The right ventricle receives blood from the right atrium and pumps it to the lungs, where it is loaded with oxygen. The right ventricle pumps blood through the right ventricular outflow tract, across the pulmonic valve, and into the pulmonary artery that distributes it to the lungs for oxygenation.

FNDNRS-02-062

A muscular enlarged pouch or sac that lies slightly to the left which is used for temporary storage of food…

• A. Gallbladder
• B. Urinary bladder
• C. Stomach
• D. Lungs
• E. Rugae of the stomach

Correct Answer: C. Stomach

The stomach is a muscular organ located on the left side of the upper abdomen. It is a saclike expansion of the digestive tract of a vertebrate that is located between the esophagus and duodenum. The major part of the digestion of food occurs in the stomach.

• Option A: The gallbladder is a small hollow organ about the size and shape of a pear. It is a part of the biliary system, also known as the biliary tree or biliary tract. The biliary system is a series of ducts within the liver, gallbladder, and pancreas that empty into the small intestine. There are intrahepatic (within the liver) and extrahepatic (outside of the liver) components. The gallbladder is a component of the extrahepatic biliary system where bile is stored and concentrated.
• Option B: The bladder forms an integral part of the genitourinary system. Urine, created by the kidneys, is drained into the bladder by the bilateral ureters. The bladder then acts as the storage site for this waste product until higher-order centers within the central nervous system initiate the micturition (i.e., urination) process, which permits the expulsion of urine into the urethra, located on the inferior aspect of the bladder. 
• Option D: The purpose of the lung is to provide oxygen to the blood. Anatomically, the lung has an apex, three borders, and three surfaces. The apex lies above the first rib. The function of the lung is to get oxygen from the air to the blood, performed by the alveoli. The alveoli are a single cell membrane that allows for gas exchange to the pulmonary vasculature. There are a couple of muscles that help with inspiration and expiration, such as the diaphragm and intercostal muscles.
• Option E. The inner layer of the stomach is full of wrinkles known as rugae (or gastric folds). Rugae both allow the stomach to stretch in order to accommodate large meals and help to grip and move food during digestion.

FNDNRS-02-063

The ability of the body to defend itself against scientific invading agent such as bacteria, toxin, viruses, and foreign body:

• A. Hormones
• B. Secretion
• C. Immunity
• D. Glands

Correct Answer: C. Immunity

Immunity is the ability of an organism to resist a particular infection or toxin by the action of specific antibodies or sensitized white blood cells. The Immune response is the body’s ability to stay safe by affording protection against harmful agents and involves lines of defense against most microbes as well as specialized and highly specific responses to a particular offender. This immune response classifies as either innate which is non-specific and adaptive acquired which is highly specific.

• Option A: The endocrine hormones are a wide array of molecules that traverse the bloodstream to act on distant tissues, leading to alterations in metabolic functions within the body. They can broadly divide into peptides, steroids, and tyrosine derivatives that may work on either cell surface or intracellular receptors.
• Option B: Secretion, in biology, production and release of a useful substance by a gland or cell; also, the substance produced. In addition to the enzymes and hormones that facilitate and regulate complex biochemical processes, body tissues also secrete a variety of substances that provide lubrication and moisture.
• Option D: A gland is an organ which produces and releases substances that perform a specific function in the body. There are two types of gland. Endocrine glands are ductless glands and release the substances that they make (hormones) directly into the bloodstream.

FNDNRS-02-064

Hormones secreted by Islets of Langerhans

• A. Progesterone
• B. Testosterone
• C. Insulin
• D. Hemoglobin

Correct Answer: C. Insulin

The Islets of Langerhans are the regions of the pancreas that contain its endocrine cells. Insulin is a peptide hormone secreted in the body by beta cells of islets of Langerhans of the pancreas and regulates blood glucose levels. Medical treatment with insulin is indicated when there is inadequate production or increased demands of insulin in the body.

• Option A: Progesterone (Choice A) is produced by the ovaries. Progesterone is an endogenous steroid hormone that is commonly produced by the adrenal cortex as well as the gonads, which consist of the ovaries and the testes. Progesterone is also secreted by the ovarian corpus luteum during the first ten weeks of pregnancy, followed by the placenta in the later phase of pregnancy.
• Option B: Testosterone (Choice B) is secreted by the testicles of males and ovaries of females. Testosterone is the primary male hormone responsible for regulating sex differentiation, producing male sex characteristics, spermatogenesis and fertility. Testosterone is responsible for the development of primary sexual development, which includes testicular descent, spermatogenesis, enlargement of the penis and testes, and increasing libido. 
• Option D: Hemoglobin (Choice D) is a protein molecule in the red blood cells that carries oxygen from the lungs to the body’s tissues and returns carbon dioxide. Hemoglobin is an oxygen-binding protein found in erythrocytes which transports oxygen from the lungs to tissues. Each hemoglobin molecule is a tetramer made of four polypeptide globin chains. Each globin subunit contains a heme moiety formed of an organic protoporphyrin ring and a central iron ion in the ferrous state (Fe2+). The iron molecule in each heme moiety can bind and unbind oxygen, allowing for oxygen transport in the body.

FNDNRS-02-065

It is a transparent membrane that focuses the light that enters the eyes to the retina.

• A. Lens
• B. Sclera
• C. Cornea
• D. Pupils

Correct Answer: A. Lens

The lens is located in the eye. By changing its shape, the lens changes the focal distance of the eye. In other words, it focuses the light rays that pass through it (and onto the retina) in order to create clear images of objects that are positioned at various distances. It also works together with the cornea to refract, or bend, light. The lens consists of the lens capsule, the lens epithelium, and the lens fibers. The lens capsule is the smooth, transparent outermost layer of the lens, while the lens fibers are long, thin, transparent cells that form the bulk of the lens. The lens epithelium lies between these two and is responsible for the stable functioning of the lens. It also creates lens fibers for the lifelong growth of the lens.

• Option B: The sclera is the white part of the eye that surrounds the cornea. In fact, the sclera forms more than 80 percent of the surface area of the eyeball, extending from the cornea all the way to the optic nerve, which exits the back of the eye. Only a small portion of the anterior sclera is visible.
• Option C: The cornea is the eye’s clear, protective outer layer. Along with the sclera (the white of your eye), it serves as a barrier against dirt, germs, and other things that can cause damage. The cornea can also filter out some of the sun’s ultraviolet light. It also plays a key role in vision. As light enters the eye, it gets refracted, or bent, by the cornea’s curved edge. This helps determine how well the eye can focus on objects close-up and far away.
• Option D: Pupils are the black center of the eye. Their function is to let in light and focus it on the retina (the nerve cells at the back of the eye) so one can see. Muscles located in the iris (the colored part of your eye) control each pupil.

FNDNRS-02-066

Which of the following is included in Orem’s theory?

• A. Maintenance of a sufficient intake of air.
• B. Self perception.
• C. Love and belongingness.
• D. Physiologic needs.

Correct Answer: A. Maintenance of a sufficient intake of air.

Dorothea Orem’s Self-Care Theory defined Nursing as “The act of assisting others in the provision and management of self-care to maintain or improve human functioning at home level of effectiveness.” The Self-Care or Self-Care Deficit Theory of Nursing is composed of three interrelated theories: (1) the theory of self-care, (2) the self-care deficit theory, and (3) the theory of nursing systems, which is further classified into wholly compensatory, partial compensatory and supportive-educative. Choices B, C, and D are from Abraham Maslow’s Hierarchy of Needs.

• Option B: At the fourth level in Maslow’s hierarchy is the need for appreciation and respect. When the needs at the bottom three levels have been satisfied, the esteem needs begin to play a more prominent role in motivating behavior. At this point, it becomes increasingly important to gain the respect and appreciation of others. People have a need to accomplish things and then have their efforts recognized. In addition to the need for feelings of accomplishment and prestige, esteem needs include such things as self-esteem and personal worth.
• Option C: The social needs in Maslow’s hierarchy include such things as love, acceptance, and belonging. At this level, the need for emotional relationships drives human behavior.  In order to avoid problems such as loneliness, depression, and anxiety, it is important for people to feel loved and accepted by other people. Personal relationships with friends, family, and lovers play an important role, as does involvement in other groups that might include religious groups, sports teams, book clubs, and other group activities.
• Option D: The basic physiological needs are probably fairly apparent—these include the things that are vital to our survival. In addition to the basic requirements of nutrition, air and temperature regulation, the physiological needs also include such things as shelter and clothing. Maslow also included sexual reproduction in this level of the hierarchy of needs since it is essential to the survival and propagation of the species.

FNDNRS-02-067

Which of the following cluster of data belong to Maslow’s hierarchy of needs

• A. Love and belonging
• B. Physiological needs
• C. Self actualization
• D. All of the above

Correct Answer: D. All of the above

All of the choices are part of Maslow’s Hierarchy of Needs. Maslow first introduced his concept of a hierarchy of needs in his 1943 paper “A Theory of Human Motivation” and his subsequent book Motivation and Personality. This hierarchy suggests that people are motivated to fulfill basic needs before moving on to other, more advanced needs. As a humanist, Maslow believed that people have an inborn desire to be self-actualized, that is, to be all they can be. In order to achieve these ultimate goals, however, a number of more basic needs must be met such as the need for food, safety, love, and self-esteem.

• Option A: The social needs in Maslow’s hierarchy include such things as love, acceptance, and belonging. At this level, the need for emotional relationships drives human behavior. In order to avoid problems such as loneliness, depression, and anxiety, it is important for people to feel loved and accepted by other people. Personal relationships with friends, family, and lovers play an important role, as does involvement in other groups that might include religious groups, sports teams, book clubs, and other group activities.
• Option B: The basic physiological needs are probably fairly apparent—these include the things that are vital to our survival. In addition to the basic requirements of nutrition, air and temperature regulation, the physiological needs also include such things as shelter and clothing. Maslow also included sexual reproduction in this level of the hierarchy of needs since it is essential to the survival and propagation of the species.
• Option C: At the very peak of Maslow’s hierarchy are the self-actualization needs. “What a man can be, he must be,” Maslow explained, referring to the need people have to achieve their full potential as human beings. According to Maslow’s definition of self-actualization, “It may be loosely described as the full use and exploitation of talents, capabilities, potentialities, etc. Such people seem to be fulfilling themselves and to be doing the best that they are capable of doing. They are people who have developed or are developing to the full stature of which they are capable.”

FNDNRS-02-068

This is characterized by severe symptoms relatively of short duration.

• A. Chronic Illness
• B. Acute Illness
• C. Pain
• D. Syndrome

Correct Answer: B. Acute Illness

Acute illnesses are different than chronic illnesses in that they usually develop quickly and they only last a short time – usually a few days or weeks. Acute illnesses are often caused by viral or bacterial infections. 

• Option A: Chronic Illness (Choice A) are illnesses that are persistent or long-term. A chronic illness is a condition that develops over time and is present for a long period of time. Some people have chronic conditions for many years. Technically, a chronic disease is defined as a health condition that lasts anywhere from three months to a lifetime. Chronic conditions may get worse over time. 
• Option C: Pain refers to the product of higher brain center processing; it entails the actual unpleasant emotional and sensory experience generated from nervous signals.
• Option D: A syndrome is a set of medical signs and symptoms which are correlated with each other and often associated with a particular disease or disorder. The word derives from the Greek σύνδρομον, meaning “concurrence”.

FNDNRS-02-069

Which of the following is the nurse’s role in health promotion?

• A. Health risk appraisal
• B. Teach client to be effective health consumer
• C. Worksite wellness
• D. None of the above

Correct Answer: B. Teach client to be effective health consumer

Nurses play a huge role in illness prevention and health promotion. Nurses assume the role of ambassadors of wellness. The World Health Organization (WHO) defines health promotion as a process of enabling people to increase control over and to improve their health (WHO, 1986). Nurses are best qualified to take on the job of health promoter due to their expertise. There are few health care occupations that have the high level of health education knowledge, skills, theory, and research to be able to focus on prevention because it is considered part of their professional development focus.

• Option A: An HRA may be a simple questionnaire eliciting self-reported information on risk factors, behaviors, or diagnoses. Questionnaires may be supplemented with clinical examinations to obtain data on variables such as height, weight, body mass index (BMI), heart rate, or blood pressure. Some HRAs may include performance tests such as grip strength, timed-up-and-go, chair rise, or four-meter walk test.
• Option C: Studies show that employees are more likely to be on the job and performing well when they are in optimal health. Benefits of implementing a wellness program include: improved disease management and prevention, and a healthier workforce in general, both of which contribute to lower health care costs.
• Option D: One of the most critical roles that nurses have in health promotion and disease preventions is that of an educator. Nurses spend the most time with the patients and provide anticipatory guidance about immunizations, nutrition, dietary, medications, and safety.

FNDNRS-02-070

It is described as a collection of people who share some attributes of their lives.

• A. Family
• B. Illness
• C. Community
• D. Nursing

Correct Answer: C. Community

A community is defined by the shared attributes of the people in it, and/or by the strength of the connections among them. When an organization is identifying communities of interest, the shared attribute is the most useful definition of a community.

• Option A: In human society, family is a group of people related either by consanguinity (by recognized birth) or affinity (by marriage or other relationship). The purpose of families is to maintain the well-being of its members and of society. Ideally, families would offer predictability, structure, and safety as members mature and participate in the community.
• Option B: Illness is a condition of being unhealthy in the body or mind; a specific condition that prevents the body or mind from working normally; a sickness or disease.
• Option D: Nursing encompasses autonomous and collaborative care of individuals of all ages, families, groups, and communities, sick or well, and in all settings. Nursing includes the promotion of health, prevention of illness, and the care of ill, disabled, and dying people.

FNDNRS-02-071

Five teaspoons is equivalent to how many milliliters (ml)?

• A. 30 ml
• B. 25 ml
• C. 12 ml
• D. 22 ml

Correct Answer: B. 25 ml

One teaspoon is equal to 5ml. Drug calculations require the use of conversion factors, for example, when converting from pounds to kilograms or liters to milliliters. Simplistic in design, this method allows clinicians to work with various units of measurement, converting factors to find the answer. These methods are useful in checking the accuracy of the other methods of calculation, thus acting as a double or triple check. 

• Option A: 30 ml is equal to 6 teaspoons. When clinicians are prepared and know the key conversion factors, they will be less anxious about the calculation involved. This is vital to accuracy, regardless of which formula or method employed.
• Option C: 12 ml is equal to 2.4 teaspoons. Units of measurement must match, for example, milliliters and milliliters, or one needs to convert to like units of measurement. 
• Option D: 22 ml is equal to 4.4 teaspoons. Medication errors can be detrimental and costly to patients. Drug calculation and basic mathematical skills play a role in the safe administration of medications.

FNDNRS-02-072

1800 ml is equal to how many liters?

• A. 1.8
• B. 18000
• C. 180
• D. 2800

Correct Answer: A. 1.8

1,800 ml is equal to 1.8 liters.

• Option B: 18000 liters is equal to 18,000,000 ml.
• Option C: 180 liters is equal to 180,000 ml.
• Option D: 2800 liters is equal to 280,000 ml.

FNDNRS-02-073

Which of the following is the abbreviation of drops?

• A. Gtt.
• B. Gtts.
• C. Dp.
• D. Dr.

Correct Answer: B. Gtts.

Gtt (Choice A) is an abbreviation for drop. Dp and Dr are not recognized abbreviations for measurement. Standardization and uniform use of codes, symbols, and abbreviations can improve communication and understanding between health care practitioners, leading to safer and more effective care for patients. 

• Option A: Appropriate use of abbreviations is particularly important. Numerous studies have focused on health care practitioners’ understanding and interpretation of abbreviations in medical documents, such as medical records, discharge summaries, and medication orders. Findings indicate that it is not uncommon for practitioners to have difficulty understanding the abbreviations used in their hospitals.
• Option C: To prevent misunderstandings and potential risks to patient safety, MOI.4 requires hospitals to establish lists for approved and do-not-use abbreviations and monitor for appropriate abbreviation use. There are resources for identifying abbreviations for the do-not-use list, such as the Institute for Safe Medication Practices (ISMP), which publishes a list of dangerous abbreviations not to be used due to frequent misinterpretation and associated medication errors.
• Option D: When developing lists, hospitals need to ensure that abbreviations on the approved list are not also on the do-not-use list, and vice versa. In addition, abbreviations can have only one meaning within the entire organization—for example, the abbreviation NKDA could mean “no known drug allergies,” or it could mean “nonketotic diabetic acidosis,” but it cannot have both meanings in an organization. 

FNDNRS-02-074

The abbreviation for microdrop is…

• A. µgtt
• B. gtt
• C. mdr
• D. mgts

Correct Answer: A. µgtt

The abbreviation for microdrop is µgtt. When abbreviations are used in documents given to the patient, the potential for misunderstanding can increase. Information needs to be clear and unambiguous to improve patients’ comprehension.

• Option B: When abbreviations are used in documents given to the patient, the potential for misunderstanding can increase. Information needs to be clear and unambiguous to improve patients’ comprehension.
• Option C: As stated in MOI.4, ME 5, “Abbreviations are not used on informed consent and patient rights documents, discharge instructions, discharge summaries, and other documents patients and families receive from the hospital about the patient’s care.”
• Option D: No abbreviations of any kind should appear in informed consent documents, patient rights documents, and discharge instructions. These documents are meant for the patient and every effort should be made to increase the readability and clarity of the documents.

FNDNRS-02-075

Which of the following is the meaning of PRN?

• A. When advice
• B. Immediately
• C. When necessary
• D. Now.

Correct Answer: C. When necessary

PRN comes from the Latin “pro re nata” meaning, “for an occasion that has arisen or as circumstances require”. When an abbreviation is less known outside of the organization or clinical specialty, it is necessary to spell out the abbreviation throughout the discharge summary to prevent misunderstanding and confusion by the physician or health care organization that receives the summary.

• Option A: The practice of spelling out an abbreviation when first mentioned, then using the abbreviation thereafter in the document is acceptable only in discharge summaries. Abbreviations are not to be used in the other types of documents listed in the measurable element.
• Option B: Laboratory test results sometimes go to patients, but it is not the intent of the standard for the abbreviations of the laboratory tests to be spelled out. When test results are given to patients, they are shared with their physician who can help explain the results.
• Option D: Hospitals may want to consider providing a separate form or resource to patients for information about the tests — such as a handout or website that has the names of common laboratory tests along with their definitions or descriptions. Results of diagnostic imaging studies also go to a patient’s physician, after interpretation by a radiologist.