Fundamentals Of Nursing NCLEX Quiz 38

1.

The nurse is caring for an elderly woman who has had a fractured hip repaired. In the first few days following the surgical repair. which of the following nursing measures will best facilitate the resumption of activities for this client?

A.

Arranging for the wheelchair
B.

Asking her family to visit
C.

Assisting her to sit out of bed in a chair qid
D.

Encouraging the use of an overhead trapeze

Correct Answer
D. Encouraging the use of an overhead trapeze

Explanation
Exercise is important to keep the joints and muscles functioning and to prevent secondary complications. Using the overhead trapeze prevents hazards of immobility by permitting movement in bed and strengthening of the upper extremities in preparation for ambulation. Sitting in a wheelchair would require too great hip flexion initially. Asking her family to visit would not facilitate the resumption of activities. Sitting in a chair would cause too much hip flexion. The client initially needs to be in a low Fowler’s position or taking a few steps (as ordered) with the aid of a walker.

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2.

What do you think is the most important nursing order in a client with major head trauma who is about to receive bolus enteral feeding?

A.

Measure intake and output.
B.

Check albumin level.
C.

Monitor glucose levels.
D.

Increase enteral feeding.

Correct Answer
A. Measure intake and output.

Explanation
It is important to measure intake and output. which should equal. Enteral feeding are hyperosmotic agents pulling fluid from cells into vascular bed. Water given before feeding will present a hyperosmotic diuresis. I and O measures assess fluid balance.

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3.

The pathological process causing esophageal varices is:

A.

Ascites and edema.
B.

Systemic hypertension.
C.

Portal hypertension.
D.

Dilated veins and varicosities.

Correct Answer
C. Portal hypertension.

Explanation
Esophageal varices results from increased portal hypertension. In portal hypertension. the liver cannot accept all of the fluid from the portal vein. The excess fluid will back flow to the vessels with lesser pressure. such as esophageal veins or rectal veins causing esophageal varices or hemorrhoids.

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4.

Which of the following interventions will help lessen the effect of GERD (acid reflux)?

A.

Elevate the head of the bed on 4-6 inch blocks.
B.

Lie down after eating.
C.

Increase fluid intake just before bedtime.
D.

Wear a girdle.

Correct Answer
A. Elevate the head of the bed on 4-6 inch blocks.

Explanation
Elevation of the head of the bed allows gravity to assist in decreasing the backflow of acid into the esophagus. Fluid does not flow uphill. The other three options all increase fluid backflow into the esophagus through position or increasing abdominal pressure.

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5.

What is the main benefit of therapeutic massages is:

A.

To help a person with swollen legs to decrease the fluid retention.
B.

To help a person with duodenal ulcers feel better.
C.

To help damaged tissue in a diabetic to heal.
D.

To improve circulation and muscles tone.

Correct Answer
D. To improve circulation and muscles tone.

Explanation
Particularly in the elderly adults. therapeutic massage will help improve circulation and muscle tone as well as the personal attention and social interaction that a good massage provides. A massage is contraindicated in any condition where massage to damaged tissue can dislodge a blood clot.

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6.

Which of the following foods should be avoided by clients who are prone to develop heartburn as a result of gastroesophageal reflux disease (GERD)?

A.

Lettuce
B.

Eggs
C.

Chocolate
D.

Butterscotch

Correct Answer
C. Chocolate

Explanation
Ingestion of chocolate can reduce lower esophageal sphincter (LES) pressure leading to reflux and clinical symptoms of GERD. All of the other foods do not affect LES pressure.

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7.

Which of the following should be included in a plan of care for a client receiving total parenteral nutrition (TPN)?

A.

Withhold medications while the TPN is infusing.
B.

Change TPN solution every 24 hours.
C.

Flush the TPN line with water prior to initiating nutritional support.
D.

Keep client on complete bed rest during TPN therapy.

Correct Answer
B. Change TPN solution every 24 hours.

Explanation
TPN solutions should be changed every 24 hours in order to prevent bacterial overgrowth due to hypertonicity of the solution. Option 1 is incorrect; medication therapy can continue during TPN therapy. Option 3 is incorrect; flushing is not required because the initiation of TPN does not require a client to remain on bed rest during therapy. However. other clinical conditions of the client may affect mobility issues and warrant the client’s being on bed rest.

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8.

Which of the following should be included in a plan of care for a client who is lactose intolerant?

A.

Remove all dairy products from the diet.
B.

Frozen yogurt can be included in the diet.
C.

Drink small amounts of milk on an empty stomach.
D.

Spread out selection of dairy products throughout the day.

Correct Answer
B. Frozen yogurt can be included in the diet.

Explanation
Clients who are lactose intolerant can digest frozen yogurt. Yogurt products are formed by bacterial action. and this action assists in the digestion of lactose. The freezing process further stops bacterial action so that limited lactase activity remains. Option 1 is incorrect; elimination of all dairy products can lead to significant clinical deficiencies of other nutrients. Option 3 is incorrect because drinking milk on an empty stomach can exacerbate clinical symptoms. Drinking milk with a meal may benefit the client because other foods. (especially fat) may decrease transit time and allow for increased lactase activity. Option 4 is incorrect because although individual tolerance should be acknowledged. spreading out the use of known dairy products will usually exacerbate clinical symptoms.

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9.

Pain tolerance in an elderly patient with cancer would:

A.

Stay the same.
B.

Be lowered.
C.

Be increased.
D.

No effect on pain tolerance.

Correct Answer
B. Be lowered.

Explanation
There is potential for a lowered pain tolerance to exist with diminished adaptative capacity.

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10.

What is the main advantage of cutaneous stimulation in managing pain:

A.

Costs less.
B.

Restricts movement and decreases.
C.

Gives client control over pain syndrome.
D.

Allows the family to care for the patient at home.

Correct Answer
C. Gives client control over pain syndrome.

Explanation
Cutaneous stimulation allows the patient to have control over his pain and allows him to be in his own environment. Cutaneous stimulation increases movement and decreases pain.

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