NCLEX RN FUNDAMENTALS NEWEST
2024 ACTUAL EXAM COMPLETE 100
QUESTIONS AND CORRECT DETAILED
ANSWERS WITH RATIONALES
(VERIFIED ANSWERS) |ALREADY
GRADED A+||BRAND NEW!!
A patient appears anxious about an upcoming procedure.
Which of the following responses by the nurse will reduce
this patient's anxiety?
a. "Don't worry. It will be fine."
b. "Read this pamphlet about the procedure and let me
know if you have questions."
c. "I will turn on some music for you."
d. "Would you like to talk about what's bothering you?" -
ANSWER- d. "Would you like to talk about what's
bothering you?"
Rationale: Anxiety is common before medical
procedures. The patient may feel helpless, isolated, or
insecure. Encouraging the patient to talk about their
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feelings can reduce anxiety and helps the nurse be
supportive by developing goals with the patient for
some sense of control. This is the response that
displays therapeutic communication.
A patient is admitted to the cardiac unit after myocardial
infarction (MI). The patient tells the nurse they don't want
their spouse to know what happened. What is the best
response by the nurse?
a. "I have to tell your spouse what happened."
b. "I will need you to fill out paperwork preventing
anyone from telling your spouse."
c. "Why don't you want me to tell your spouse?"
d. "Is there someone else you would like listed as an
appropriate person with whom we can discuss your care?"
- ANSWER- d. "Is there someone else you would like
listed as an appropriate person with whom we can discuss
your care?"
Rationale: Patients have the right to decide what
information regarding their condition is shared with
whom. It is the responsibility of the nurse to obtain
this information from the patient and document it in
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the medical record so others following in care will
know as well. Clarifying the patient statement and
determining who the patient wants involved is the best
response.
The nurse is caring for a 72-year-old patient who has a
history of a left-sided stroke. The patient uses a cane
while walking. Which is the best way for the nurse to
assess the strength of their lower extremities?
a. Have the patient push with their feet against the nurse's
hands
b. Observe the patient walking in the hall
c. Notify the physical therapy department and request an
assessment
d. Assist the patient to the bathroom - ANSWER- d.
Assist the patient to the bathroom
Rationale: Patients who have experienced a stroke
often have residual weakness on the affected side and
use assistive devices to help with mobility. Using the
cane and assisting the patient to the bathroom is the
best way for the nurse to assess the patient's lower
extremity strength. The nurse can assist the patient to
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the bathroom, and therefore, eliminate the risk for a
fall.
A is incorrect because testing pedal strength only
provides assessment data about the lower legs, not the
full lower extremities. B is incorrect because observing
the patient walking in the hall does not give an
accurate assessment of lower extremity strength and
could put the patient at risk for a fall.
A patient has a urinary catheter ordered due to urinary
retention. The patient should be placed in the dorsal
recumbent position for the catheter insertion, but the
patient states they have back pain and cannot assume that
position. What is the most appropriate action the nurse
should take?
a. Place the patient in the dorsal recumbent position
b. Place the patient on their side
c. Place the patient in a prone position
d. Notify the healthcare provider for an alternate order -
ANSWER- b. Place the patient on their side
Rationale: Sterile procedure is critical when placing a
urinary catheter. If the patient is unable to lie in the
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