Fundamentals of Nursing NCLEX RN Questions

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The following scenario applies to the next 1 items
The infection control nurse is reviewing transmission-based precautions for assigned clients.
Item 1 of 1
Client 1 Client 2 Client 3 Client 4 Client 5
• Admitted two days ago with fever, fatigue, hemoptysis, and pleuritic chest pain.
Purified protein derivative test: reactive.
Intravenous fluids and antipyretics prescribed.
Airborne precautions

The infection control nurse is reviewing transmission-based precautions for assigned clients. Client 1: Admitted two days ago with fever, fatigue, hemoptysis, and pleuritic chest pain. Purified protein derivative test: reactive. Intravenous fluids and antipyretics prescribed. Airborne precautions. Click to specify if the transmission-based precaution is appropriate or not appropriate for each client.

  • A. Client 1
  • B. Client 2
  • C. Client 3
  • D. Client 4
  • E. Client 5
  • F. Client 6
  • G. Client 7
Correct Answer: A

Rationale: Airborne precautions are appropriate for Client 1 due to symptoms and a reactive PPD test, suggesting possible tuberculosis, which requires airborne precautions.

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The nurse is working with a group of students and a student asks what cyanosis means. What is the nurse's best response?

  • A. Cyanosis is a condition characterized by a yellowish discoloration of the skin and mucous membranes due to excessive oxygenation.
  • B. Cyanosis is the blue coloring of the skin and mucous membranes in the presence of poorly oxygenated blood.
  • C. Cyanosis is the primary indication that the client has pneumonia.
  • D. Cyanosis is the bluish discoloration of the skin and mucous membranes due to poor peripheral circulation, even in the presence of normal oxygen levels.
Correct Answer: B

Rationale: Cyanosis is blue discoloration due to poorly oxygenated blood. Yellowish discoloration is jaundice, it’s not specific to pneumonia, and circulation issues alone don’t cause it if oxygen is normal.

The nurse is preparing a staff education program about physiological responses of stress. Which of the following is a physiological alteration that can occur with stress?

  • A. Decreased visual acuity
  • B. Increased peristalsis
  • C. Decreased glucocorticoids
  • D. Hyperglycemia
Correct Answer: D

Rationale: Stress triggers hyperglycemia via cortisol release. Visual acuity and peristalsis are not directly affected, and glucocorticoids increase, not decrease.

The nurse performs palpation and percussion during a head-to-toe assessment. Over which organ would the nurse expect to hear tympany when percussed?

  • A. Stomach
  • B. Liver
  • C. Normal lung tissue
  • D. Tympany is an abnormal finding
Correct Answer: A

Rationale: Tympany, a hollow sound, is expected over the stomach due to air in the gastric bubble. Liver produces dullness, lungs produce resonance, and tympany is normal in certain areas.

The nurse is performing a health assessment on a client. While performing percussion, which percussion sound would require follow-up?

  • A. Dull tone over the spleen
  • B. Hyperresonance over an adult's lung tissue
  • C. Flat tone over bone
  • D. Hyperresonance over a child's lung tissue
Correct Answer: B

Rationale: Hyperresonance in adult lungs suggests pneumothorax or emphysema, requiring follow-up. Dullness over spleen, flatness over bone, and hyperresonance in children are normal.

The nurse in the medical-surgical unit is preparing the room for a client being admitted with varicella-zoster (chickenpox). Which of the following infection control precautions should the nurse implement?

  • A. Place a surgical mask on the client during transport out of the client's room
  • B. Remove all alcohol-based hand rubs from the room
  • C. Wear a face shield while providing care
  • D. Asking the client to put on a clean mask each time someone enters the room
Correct Answer: A

Rationale: Varicella requires airborne and contact precautions, including a mask on the client during transport.

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