Fundamentals NCLEX RN Questions

Fundamentals NCLEX RN Questions Related

Review Fundamentals NCLEX RN Questions related questions and content

Nurses’ Notes
1930 – Assessment completed

Peripheral pulses were all palpable. S1/S2 heart tones auscultated. No peripheral edema.

Lung sounds were clear in all fields. Client denied any cough or dyspnea. Respirations were regular and unlabored.

Bowel sounds were active in all quadrants, with no abdominal distention noted. Client only reports nausea after her prescribed acetaminophen-oxycodone.

Surgical incisions appeared approximated, reddened, and the surrounding area was hot to touch. Small amount of foul-smelling, purulent type of drainage was noted. The gauze dressing was changed, and a new gauze dressing was applied.

Client reported intermittent incisional pain of 3/10 described as ‘sore’. Vital Signs: Oral Temperature 100.4° F (38° C)

Pulse 93/minute

Respirations 18/minute

Blood pressure 111/69 mm Hg

O2 saturation 95% on room air

The nurse performs a physical assessment for a client three days post-operative following a radical hysterectomy.Select three (3) assessment and vital sign findings that are highly concerning.

  • A. Incisional pain
  • B. Approximated wounds
  • C. Pulse rate
  • D. Foul smelling drainage
  • E. Nausea after pain medication
  • F. Oral temperature
  • G. Purulent wound drainage
Correct Answer: D,F,G

Rationale: This client is demonstrating signs and symptoms of a surgical site infection. The findings requiring follow-up include the foul-smelling drainage that is purulent. Further, this client also has a concern for their oral temperature as it is a clinical fever.

Findings that are not highly concerning include the client’s incisional pain which is described as sore and is intermittent. This is an expected finding following surgery. The wounds being approximated is an optimal finding. The client’s pulse is within normal limits. Finally, nausea after pain medication is a common side-effect.

You may also like to solve these questions

The nurse is ambulating a client who is wearing a gait belt. The client begins to fall. The nurse should take which appropriate action to minimize injury?

  • A. Hold the gait belt, extend one leg, let the client slide against the leg, and lower the client to the floor.
  • B. Let go of the gait belt, grab the client under each arm, and gently lower the client to the floor.
  • C. Grasp the gait belt, and instruct the client to fall gently down to the floor in a side-lying position.
  • D. Hold the gait belt, and lower the client to the floor by using a narrow base of support.
Correct Answer: A

Rationale: Using the gait belt to guide the client against the nurse’s leg minimizes injury. Letting go, instructing a side-lying fall, or using a narrow base increases risk.

The nurse is counseling a client diagnosed with irritable bowel syndrome (IBS). The nurse should advise the client to increase their

  • A. Dairy intake.
  • B. Fiber intake.
  • C. Fat intake.
  • D. Calcium intake.
Correct Answer: B

Rationale: Fiber regulates bowel function in IBS. Dairy and fat may worsen symptoms, and calcium is unrelated to IBS management.

The nurse is assigned to multiple clients with fever. Taking a rectal temperature would be contraindicated in which of the following cases? Select all that apply.

  • A. A client who had rectal surgery and a post-operative abscess
  • B. A child who has pneumonia
  • C. An older client who is post-myocardial infarction (MI)
  • D. A teenager with leukemia, a neutrophil count of 500/microliter, and is receiving erythropoietin for anemia
  • E. An adult patient with acute pancreatitis and has disseminated intravascular coagulation (DIC)
Correct Answer: A,D,E

Rationale: Rectal temperature is contraindicated in rectal surgery/abscess (due to trauma risk), neutropenia (infection risk), and DIC (bleeding risk). Pneumonia and post-MI do not contraindicate rectal measurement.

The nurse is observing the surgical aseptic technique of a nursing student. Which observation by the nurse requires follow-up?

  • A. Spills sterile water onto the sterile field
  • B. Uses sterile gloves to handle sterile supplies on a sterile field
  • C. Has sterile gauze placed into the sterile field
  • D. Keeps the sterile field above their waist
Correct Answer: A

Rationale: Spilling sterile water contaminates the sterile field, requiring follow-up. Other actions are consistent with aseptic technique.

The nurse observes unlicensed assistive personnel (UAP) give a bed bath using 4% chlorhexidine (CHG) wipes. Which observation requires follow-up?

  • A. The UAP uses one wipe for washing each major body part
  • B. The UAP rinses the skin after bathing with the CHG solution
  • C. The UAP washes the client's face with warm water and mild soap
  • D. The UAP allows the CHG solution to dry on the client's skin
Correct Answer: B

Rationale: Rinsing CHG wipes removes their antimicrobial effect. Using separate wipes, washing the face separately, and allowing CHG to dry are correct.

Copyright © 2025 Nokea. All rights reserved.