PN Fundamentals Online Practice Test A Questions & Answers

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.) - ANSWERSDecrease 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? - ANSWERSNonrebreather 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.) - ANSWERSEvacuate 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. Close the fire doors on the unit is the third step. Rationality: Close the fire doors on the unit is the third step. For the third step, "confine," the nurse should close the unit fire doors to prevent the fire from spreading. Use a fire extinguisher to put out the fire is the fourth step. Rationality: For the final step, "extinguish," the nurse should use a fire extinguisher to put out the fire by aiming the nozzle at the base of the fire and using a sweeping motion. A nurse is caring for a client who has metastatic cancer and practices Catholicism. The client asks the nurse to discuss the afterlife with them. Which of the following statements by the nurse assists in meeting the client's spiritual needs? - ANSWERS"Tell me what the afterlife means to you." Rationale: This statement respects the client's spiritual needs by using open-ended therapeutic communication to assist the client to talk about their concerns. A nurse is reinforcing teaching with a client about the prevention of stress injuries. Which of the following instructions should the nurse include? - ANSWERS"When lifting a heavy object, keep it close to your body." Rationality: The nurse should instruct the client to keep the object as close to their body as possible to increase stability and decrease back strain when lifting a heavy object. A nurse is reinforcing teaching with a client about the use of crutches. Which of the following actions by the client indicates an understanding of the teaching? - ANSWERSThe client advances the unaffected leg first while climbing stairs. Rationality: When ascending stairs, the client should first advance the unaffected leg. The nurse should reinforce with the client that their axilla should not bear any weight while in the tripod position because this can cause pressure injury formation. The client should bear their weight with their arms and hands. A client who has advanced cancer tells the nurse that they have a difficult time talking to anyone about the illness. Which of the following actions should the nurse take to encourage therapeutic communication? - ANSWERSLet the client know that, as their nurse, they are available and willing to listen. - Rationality: Active listening conveys the nurse's respect and acceptance for the client's feelings and gives the client an opportunity to express their thoughts and needs. A nurse is preparing to remove a client's peripheral IV catheter. After performing hand hygiene and applying clean gloves, which of the following actions should the nurse take first? - ANSWERSClamp the infusion tubing. Rationality: Evidence-based practice indicates that the nurse should first clamp the infusion tubing after applying clean gloves. This action stops the flow of the IV fluid and prevents it from leaking out during the IV removal. A nurse is contributing to the plan of care for a client who has a positive throat culture for streptococci. Which of the following interventions should the nurse recommend to be included in the plan of care? - ANSWERSEnsure that the client wears a surgical mask during transportation throughout the facility. rationality: Streptococcal pharyngitis requires droplet precautions. The nurse should instruct the client to wear a surgical mask when outside of the room to prevent the spread of infection. Staff should make every attempt to limit the client's movement outside of the room. The nurse should provide a room with negative-pressure airflow for clients who require airborne precautions. A nurse is caring for a client who has just died and practiced the Islamic faith. Which of the following cultural practices should the nurse expect? - ANSWERSThe client's face should be turned toward Mecca. Rationality: Following death, it can be a practice of the Islamic faith to turn the face of a deceased person toward Mecca. It can be a Hispanic and Latino cultural practice to adorn the body of a deceased person with amulets or rosary beads. It can be a Chinese cultural practice for the oldest child to bathe the body of a deceased person under the direction of an older relative or priest. It can be a practice of the Hindu faith to place the body of a deceased person on the floor.