Fundamentals of Nursing NCLEX RN Exam Practice Q&A Set 3
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NCLEX RN
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NCLEX RN
Fundamentals of Nursing NCLEX RN Practice Questions| 75 Questions
1. 1. Question
The charge nurse asks the nursing assistive personnel (NAP) to give a bag bath to a patient with end-stage chronic obstructive pulmonary disease. How should the NAP proceed?
o A. Bathe the patient's entire body ...
fundamentals of nursing nclex rn practice questions| 75 questions 1 1 question the charge nurse asks the nursing assistive personnel nap to give a bag bath to a patient with end stage chronic obs
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Fundamentals of Nursing NCLEX RN Practice Questions| 75
Questions
1. 1. Question
The charge nurse asks the nursing assistive personnel (NAP) to give a
bag bath to a patient with end-stage chronic obstructive pulmonary
disease. How should the NAP proceed?
o A. Bathe the patient's entire body using 8 to 10 washcloths.
o B. Assist the patient to a chair and provide bathing supplies.
o C. Saturate a towel and blanket in a plastic bag, and then bathe the
patient.
o D. Assist the patient to the bathtub and provide a bath chair.
Incorrect
Correct Answer: A. Bathe the patient’s entire body using 8 to
10 washcloths.
A towel bath is a modification of the bed bath in which the NAP places
a large towel and a bath blanket into a plastic bag, saturates them with
a commercially prepared mixture of moisturizer, non rinse cleaning
agent, and water; warms in them in a microwave, and then uses them
to bathe the patient. A bag bath is a modification of the towel bath, in
which the NAP uses 8 to 10 washcloths instead of a towel or blanket.
Each part of the patient’s body is bathed with a fresh cloth.
Option B: A bag bath is not given in a chair or in the tub. The
bag bath is one alternative to the traditional bed bath used in
some nursing homes. The bath is performed with a series of 10
washcloths and a no-rinse liquid cleanser. Close the door and
windows to prevent cold drafts and wash hands with warm water
before beginning.
Option C: Moisten the washcloths with water and put in a plastic
bag with the cleanser. Warm the bag in the microwave for 60 to
90 seconds. Test the temperature of the clothes before touching
a resident with them and be careful when you open the bag, as
steam can burn.
, Option D: Take the bag to the resident’s bedside. When you are
not cleaning a body part, keep it covered. Only expose as much
of the resident’s body as necessary to adequately clean him or
her. Be especially sensitive to exposing genitals, buttocks, and
breasts. Bathing can be an extremely stressful experience for
residents, so try to make it as easy as possible.
2. 2. Question
For a morbidly obese patient, which intervention should the nurse
choose to counteract the pressure created by the skin folds?
A. Cover the mattress with a sheepskin.
B. Keep the linens wrinkle free.
C. Separate the skin folds with towels.
D. Apply petrolatum barrier creams.
Incorrect
Correct Answer: C. Separate the skin folds with towels.
Separating the skin folds with towels relieves the pressure of skin
rubbing on skin. Skin folds, in particular, may be difficult for the patient
to clean thoroughly; the abdominal folds and groins may be ignored,
leading to an increased risk of skin breakdown in these areas.
Option A: Sheepskins are not recommended for use at all. Skin
folds present a challenge in the management of patients who are
morbidly obese. The weight from excess adipose tissue in
skinfold areas can have an increased risk of skin injury such as
friction, maceration, skin tears and pressure ulcer development.
Option B: Skin folds and areas vulnerable to skin injury should
be cleaned and dried several times a day. Alcohol-based lotions
and harsh soaps, as well as talcum powders, should be avoided in
these areas. If necessary, dry cloths to absorb moisture can be
left in skin folds in between washing and drying of the skin folds.
Option D: Petrolatum barrier creams are used to minimize
moisture caused by incontinence. Patient hydration should also
be considered in the nutrition plan for the patients and the health
of their skin.
3. 3. Question
, A client exhibits all of the following during a physical assessment.
Which of these is considered a primary defense against infection?
A. Fever
B. Intact skin
C. Inflammation
D. Lethargy
Incorrect
Correct Answer: B. Intact skin
Intact skin is considered a primary defense against infection. Usually,
the skin prevents invasion by microorganisms unless it is damaged (for
example, by an injury, insect bite, or burn). Mucous membranes, such
as the lining of the mouth, nose, and eyelids, are also effective
barriers. Typically, mucous membranes are coated with secretions that
fight microorganisms. For example, the mucous membranes of the
eyes are bathed in tears, which contain an enzyme called lysozyme
that attacks bacteria and helps protect the eyes from infection. Fever,
the inflammatory response, and phagocytosis (a process of killing
pathogens) are considered secondary defenses against infection.
Option A: Body temperature increases as a protective response
to infection and injury. An elevated body temperature (fever)
enhances the body’s defense mechanisms, although it can cause
discomfort. A part of the brain called the hypothalamus controls
body temperature. Fever results from an actual resetting of the
hypothalamus’s thermostat. The body raises its temperature to a
higher level by moving (shunting) blood from the skin surface to
the interior of the body, thus reducing heat loss.
Option C: Any injury, including an invasion by microorganisms,
causes inflammation in the affected area. Inflammation, a
complex reaction, results from many different conditions. During
inflammation, the blood supply increases, helping carry immune
cells to the affected area. Because of the increased blood flow, an
infected area near the surface of the body becomes red and
warm. The walls of blood vessels become more porous, allowing
fluid and white blood cells to pass into the affected tissue. The
increase in fluid causes the inflamed tissue to swell. The white
, blood cells attack the invading microorganisms and release
substances that continue the process of inflammation.
Option D: Lethargy refers to a state of lacking energy. People
who are experiencing fatigue or tiredness can also be said to be
lethargic because of low energy. The same medical conditions
that can lead to tiredness or fatigue can also lead to lethargy.
4. 4. Question
A client with a stage 2 pressure ulcer has methicillin-resistant
Staphylococcus aureus (MRSA) cultured from the wound. Contact
precautions are initiated. Which rule must be observed to follow
contact precautions?
A. A clean gown and gloves must be worn when in contact
with the client.
B. Everyone who enters the room must wear a N-95 respirator
mask.
C. All linen and trash must be marked as contaminated and send to
biohazard waste.
D. Place the client in a room with a client with an upper respiratory
infection.
Incorrect
Correct Answer: A. A clean gown and gloves must be worn
when in contact with the client.
A clean gown and gloves must be worn when any contact is anticipated
with the client or with contaminated items in the room. Visitors might
also be asked to wear a gown and gloves. Patients are asked to stay in
their hospital rooms as much as possible. They should not go to
common areas, such as the gift shop or cafeteria. They may go to
other areas of the hospital for treatments and tests.
Option B: A respirator mask is required only with airborne
precautions, not contact precautions. Healthcare providers will
put on gloves and wear a gown over their clothing while taking
care of patients with MRSA.
Option C: All linen must be double-bagged and clearly marked
as contaminated. When leaving the room, healthcare providers
and visitors remove their gown and gloves and clean their hands.
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