*N3632 FOUNDATIONS | NCLEX REVIEW Practice
Questions Care Final
. Indirect care measureA 34-year-old client had a surgical repair
of an abdominal hernia in the morning. At 12 noon, the nurse
records the client's vital signs on the recovery room flow sheet.
What is this an example of?
A) Psychomotor skill
B) Indirect care measure
C) Physical care technique
D) Anticipating complications Correct Answers B. Indirect
care measures
Recording vital signs is an example of indirect care. Taking vital
signs is an example of a psychomotor skill. Anticipating
complications is a cognitive skill that is an assessment skill.
Recording vital signs is a direct care measure and not a physical
care technique.
"Unhappy and worried about health" is not a scientifically-based
nursing diagnosis, and it can lead to error in:
A) Data collection
B) Date clustering
C) Diagnostic label
D) Medical diagnosis Correct Answers C. Diagnostic label
The diagnostic label is the name of the nursing diagnosis as
approved by the North American Nursing Diagnosis Association
(NANDA) International. The question does not discuss data
collection, medical diagnosis, or data clustering.
,10. A nurse teaches the importance of folic acid intake to a
group of pregnant women. This is considered which level of
preventive care?
A) Illness behavior
B) Primary prevention
C) Tertiary prevention
D) Secondary prevention Correct Answers B. Primary
prevention
Primary prevention is considered true prevention. It aims at
maintaining physical and emotional health in an already healthy
individual.Primary prevention is considered true prevention. It
aims at maintaining physical and emotional health in an already
healthy individual.
11. A person's ideas, convictions, and attitudes about health and
illness can be described as:
A) Moral beliefs
B) Health beliefs
C) Holistic views
D) Negative health behaviors Correct Answers B. Health
beliefs
Health beliefs are an individual's perceptions of health or illness,
which may be based on factual information or misinformation,
common sense or myths, or reality or false expectations. Moral
beliefs are learned behaviors that are in accordance with the
principles of right or wrong. Holistic views consider the
emotional and spiritual well-being of the individual. Negative
health behaviors include behaviors that are typically harmful to
,health, such as smoking, drug or alcohol abuse, poor diet, and
refusal to take appropriate medications.
12. For which airborne disease(s) would the nurse be required to
use gloves, respiratory devices, and gown when in close contact
with the client?
A) Herpes simplex, scabies
B) Viral pneumonia, atelectasis
C) Chickenpox, pulmonary tuberculosis
D) Multidrug-resistant respiratory syncytial virus Correct
Answers C) Chickenpox, pulmonary tuberculosis
Airborne precautions are required for chickenpox and
tuberculosis, because in these diseases small particles float in the
air and a barrier is required to prevent contamination of the
nurse. A respiratory protection device is form-fitted to the face
to prevent the escape of air around the seal. Gloves and gown
are also worn to prevent contamination and transport of infective
particles to other clients. For viral pneumonia a regular mask is
used as a barrier because the particles do not float in the air and
are more likely to be found on surfaces unless coughing or
spitting is occurring. Atelectasis is the collapse of alveoli, and
airborne precautions are not needed. Herpes and scabies are
spread by contact, and gloves and gown would be necessary;
masks would not be needed. For multidrug-resistant respiratory
syncytial virus the protection of the client would be as important
as preventing the spread of these disorders. Therefore, gown,
gloves, and mask would be used as in reverse isolation to
prevent cross contamination of the client.
, 12. The client who is most ready to begin a client teaching
session is the client who has:
A) Experienced nausea and vomiting for the past 24 hours
B) Just been told that he needs to have major surgery
C) Voiced a concern about how insulin injections will affect her
lifestyle
D) Complained bitterly about the low-fat, low-cholesterol diet
he must follow after his heart attack Correct Answers C.
Voiced a concern about how insulin injections will affect her
lifestyle
14. The nurse is setting up a sterile field for the physician.
Which of the following statements concerning a sterile field is
correct?
A) The sides of the drape over the table are still sterile until they
are touched.
B) Reaching over the field is not a source of contamination if the
nurse has on a clean gown and gloves.
C) One inch around the border should be considered to be the
barrier between the sterile field and under the table.
D) A liquid spill onto the sterile field is a source of
contamination from the table below the drape, even if the barrier
is waterproof. Correct Answers C) One inch around the border
should be considered to be the barrier between the sterile field
and under the table.
A 1-inch margin is considered unsterile and is the barrier
spacing between the sterile field in the center of the drape and
the edge of the drape. Liquids spilled on a waterproof drape will
not absorb from or be contaminated from the surface beneath.
Although such a situation could be messy, bacteria would not
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