PN Fundamentals Online Practice Test A 2023

A nurse is caring for a client who is receiving continuous NG tube feedings. The nurse listens to the client's bowel sounds. Which of the following actions should the nurse take? (Click on the audio button to listen to the clip.) - Answer- Decrease the rate of the feeding - Rationality: The nurse should expect to hear bowel sounds every 5 to 35 seconds. This audio clip indicates hypermotility because there are greater than 40 bowel sounds/min. Hypermotility leads to diarrhea and is an indication of intolerance to the enteral feeding. Therefore, the nurse should slow the rate of the feeding to promote the client's tolerance of the feeding. The nurse should maintain a client who is receiving continuous NG tube feedings in a position with the head of the bed elevated 30° to 45° to prevent aspiration of the formula. A nurse is preparing to administer oxygen to a client who has heart failure and is having severe difficulty breathing. Which of the following oxygen delivery equipment should the nurse select to provide the highest concentration of oxygen to the client? - Answer- Nonrebreather mask Rationality: A nonrebreather mask provides the highest percentage of oxygen concentration without intubation and mechanical ventilation. A Venturi mask can be adjusted to provide a consistent lower oxygen concentration. A simple face mask can be adjusted for short-term delivery of low to medium oxygen concentration. A nasal cannula provides a low oxygen concentration. A charge nurse smells smoke, enters the visitor restroom, and sees flames in the trash can. What is the sequence of actions that the nurse should take? (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.) - Answer- Evacuate clients from the area is the first step. Rationality: The first action the nurse should take when using the RACE protocol is to "rescue" or evacuate the clients from the area to prevent harm. Pull the lever on the fire alarm box is the second step. Rationality: For the next step, "alarm," the nurse should activate the facility fire alarm and call to report the fire to the facility emergency extension.