PN FUNDAMENTALS ONLINE PRACTICE
TEST A 2023 PERFECTLY SOLVED
AplnurseplisplcaringplforplaplclientplwhoplisplreceivingplcontinuousplNGpltubeplfeedings.plTheplnur
sepllistenspltopltheplclient'splbowelplsounds.plWhichplofpltheplfollowingplactionsplshouldpltheplnur
sepltake?pl(Clickplonpltheplaudioplbuttonpltopllistenpltopltheplclip.)pl-plANS--
Decreasepltheplrateplofpltheplfeeding
-
Rationality:plTheplnurseplshouldplexpectpltoplhearplbowelplsoundspleverypl5pltopl35plseconds.pl
pl
Thisplaudioplclipplindicatesplhypermotilityplbecauseplthereplareplgreaterplthanpl40plbowelplsoun
ds/
min.plHypermotilityplleadspltopldiarrheaplandplisplanplindicationplofplintolerancepltopltheplenteralpl
feeding.plTherefore,pltheplnurseplshouldplslowpltheplrateplofpltheplfeedingpltoplpromotepltheplclie
nt'spltoleranceplofpltheplfeeding.
TheplnurseplshouldplmaintainplaplclientplwhoplisplreceivingplcontinuousplNGpltubeplfeedingsplinpl
aplpositionplwithpltheplheadplofpltheplbedplelevatedpl30°pltopl45°pltoplpreventplaspirationplofpltheplf
ormula.
Aplnurseplisplpreparingpltopladministerploxygenpltoplaplclientplwhoplhasplheartplfailureplandplisplha
vingplseverepldifficultyplbreathing.plWhichplofpltheplfollowingploxygenpldeliveryplequipmentplsh
ouldpltheplnurseplselectpltoplprovidepltheplhighestplconcentrationplofploxygenpltopltheplclient?pl-
plANS--Nonrebreatherplmask
Rationality:
Aplnonrebreatherplmaskplprovidespltheplhighestplpercentageplofploxygenplconcentrationplwith
outplintubationplandplmechanicalplventilation.
AplVenturiplmaskplcanplbepladjustedpltoplprovideplaplconsistentpllowerploxygenplconcentration.
Aplsimpleplfaceplmaskplcanplbepladjustedplforplshort-
termpldeliveryplofpllowpltoplmediumploxygenplconcentration.
Aplnasalplcannulaplprovidesplapllowploxygenplconcentration.
Aplchargeplnurseplsmellsplsmoke,plenterspltheplvisitorplrestroom,plandplseesplflamesplinplthepltra
shplcan.plWhatplispltheplsequenceplofplactionsplthatpltheplnurseplshouldpltake?
pl(Movepltheplstepsplintopltheplboxplonpltheplright,plplacingplthemplinpltheplselectedplorderplofplperf
ormance.plUseplallpltheplsteps.)pl-plANS--Evacuateplclientsplfrompltheplareaplispltheplfirstplstep.pl
Rationality:plTheplfirstplactionpltheplnurseplshouldpltakeplwhenplusingpltheplRACEplprotocolplisplt
opl"rescue"plorplevacuatepltheplclientsplfrompltheplareapltoplpreventplharm.
,Pullpltheplleverplonpltheplfireplalarmplboxplispltheplsecondplstep.pl
Rationality:plForpltheplnextplstep,pl"alarm,"pltheplnurseplshouldplactivatepltheplfacilityplfireplalarm
plandplcallpltoplreportpltheplfirepltopltheplfacilityplemergencyplextension.
Closepltheplfirepldoorsplonpltheplunitplispltheplthirdplstep.pl
Rationality:plClosepltheplfirepldoorsplonpltheplunitplispltheplthirdplstep.plForpltheplthirdplstep,pl"confi
ne,"pltheplnurseplshouldplclosepltheplunitplfirepldoorspltoplpreventpltheplfireplfromplspreading.
Useplaplfireplextinguisherpltoplputploutpltheplfireplispltheplfourthplstep.
Rationality:plForpltheplfinalplstep,pl"extinguish,"pltheplnurseplshouldpluseplaplfireplextinguisherplto
plputploutpltheplfireplbyplaimingpltheplnozzleplatpltheplbaseplofpltheplfireplandplusingplaplsweepingplm
otion.
AplnurseplisplcaringplforplaplclientplwhoplhasplmetastaticplcancerplandplpracticesplCatholicism.plT
heplclientplaskspltheplnursepltopldiscusspltheplafterlifeplwithplthem.plWhichplofpltheplfollowingplstat
ementsplbypltheplnurseplassistsplinplmeetingpltheplclient'splspiritualplneeds?pl-
plANS--"Tellplmeplwhatpltheplafterlifeplmeanspltoplyou."
Rationale:plThisplstatementplrespectspltheplclient'splspiritualplneedsplbyplusingplopen-
endedpltherapeuticplcommunicationpltoplassistpltheplclientpltopltalkplaboutpltheirplconcerns.
Aplnurseplisplreinforcingplteachingplwithplaplclientplaboutpltheplpreventionplofplstressplinjuries.plW
hichplofpltheplfollowingplinstructionsplshouldpltheplnurseplinclude?pl-
plANS--"Whenplliftingplaplheavyplobject,plkeepplitplclosepltoplyourplbody."
Rationality:plTheplnurseplshouldplinstructpltheplclientpltoplkeeppltheplobjectplasplclosepltopltheirplb
odyplasplpossiblepltoplincreaseplstabilityplandpldecreaseplbackplstrainplwhenplliftingplaplheavyplo
bject.
Aplnurseplisplreinforcingplteachingplwithplaplclientplaboutplthepluseplofplcrutches.plWhichplofpltheplf
ollowingplactionsplbypltheplclientplindicatesplanplunderstandingplofpltheplteaching?pl-plANS--
Theplclientpladvancespltheplunaffectedpllegplfirstplwhileplclimbingplstairs.
Rationality:plWhenplascendingplstairs,pltheplclientplshouldplfirstpladvancepltheplunaffectedplleg.
Theplnurseplshouldplreinforceplwithpltheplclientplthatpltheirplaxillaplshouldplnotplbearplanyplweight
plwhileplinplthepltripodplpositionplbecauseplthisplcanplcauseplpressureplinjuryplformation.plTheplcli
entplshouldplbearpltheirplweightplwithpltheirplarmsplandplhands.
Aplclientplwhoplhaspladvancedplcancerpltellspltheplnurseplthatpltheyplhaveplapldifficultpltimepltalkin
gpltoplanyoneplaboutpltheplillness.plWhichplofpltheplfollowingplactionsplshouldpltheplnursepltakeplt
, oplencouragepltherapeuticplcommunication?pl-plANS--
Letpltheplclientplknowplthat,plaspltheirplnurse,pltheyplareplavailableplandplwillingpltopllisten.
-
plRationality:plActivepllisteningplconveyspltheplnurse'splrespectplandplacceptanceplforpltheplclien
t'splfeelingsplandplgivespltheplclientplanplopportunitypltoplexpresspltheirplthoughtsplandplneeds.
Aplnurseplisplpreparingpltoplremoveplaplclient'splperipheralplIVplcatheter.plAfterplperformingplhan
dplhygieneplandplapplyingplcleanplgloves,plwhichplofpltheplfollowingplactionsplshouldpltheplnurse
pltakeplfirst?pl-plANS--Clamppltheplinfusionpltubing.
Rationality:plEvidence-
basedplpracticeplindicatesplthatpltheplnurseplshouldplfirstplclamppltheplinfusionpltubingplafterplap
plyingplcleanplgloves.plThisplactionplstopspltheplflowplofpltheplIVplfluidplandplpreventsplitplfrompllea
kingploutplduringpltheplIVplremoval.
Aplnurseplisplcontributingpltopltheplplanplofplcareplforplaplclientplwhoplhasplaplpositiveplthroatplcultu
replforplstreptococci.plWhichplofpltheplfollowingplinterventionsplshouldpltheplnurseplrecommendp
ltoplbeplincludedplinpltheplplanplofplcare?pl-plANS--
Ensureplthatpltheplclientplwearsplaplsurgicalplmaskplduringpltransportationplthroughoutpltheplfaci
lity.
rationality:
Streptococcalplpharyngitisplrequirespldropletplprecautions.plTheplnurseplshouldplinstructplthepl
clientpltoplwearplaplsurgicalplmaskplwhenploutsideplofpltheplroompltoplpreventpltheplspreadplofplinf
ection.plStaffplshouldplmakepleveryplattemptpltopllimitpltheplclient'splmovementploutsideplofplthepl
room.
Theplnurseplshouldplprovideplaplroomplwithplnegative-
pressureplairflowplforplclientsplwhoplrequireplairborneplprecautions.
AplnurseplisplcaringplforplaplclientplwhoplhaspljustpldiedplandplpracticedpltheplIslamicplfaith.plWhich
plofpltheplfollowingplculturalplpracticesplshouldpltheplnurseplexpect?pl-plANS--
Theplclient'splfaceplshouldplbeplturnedpltowardplMecca.
Rationality:
Followingpldeath,plitplcanplbeplaplpracticeplofpltheplIslamicplfaithpltoplturnpltheplfaceplofplapldeceas
edplpersonpltowardplMecca.
ItplcanplbeplaplHispanicplandplLatinoplculturalplpracticepltopladornpltheplbodyplofplapldeceasedplpe
rsonplwithplamuletsplorplrosaryplbeads.
ItplcanplbeplaplChineseplculturalplpracticeplforpltheploldestplchildpltoplbathepltheplbodyplofplapldece
asedplpersonplunderplthepldirectionplofplanplolderplrelativeplorplpriest.
TEST A 2023 PERFECTLY SOLVED
AplnurseplisplcaringplforplaplclientplwhoplisplreceivingplcontinuousplNGpltubeplfeedings.plTheplnur
sepllistenspltopltheplclient'splbowelplsounds.plWhichplofpltheplfollowingplactionsplshouldpltheplnur
sepltake?pl(Clickplonpltheplaudioplbuttonpltopllistenpltopltheplclip.)pl-plANS--
Decreasepltheplrateplofpltheplfeeding
-
Rationality:plTheplnurseplshouldplexpectpltoplhearplbowelplsoundspleverypl5pltopl35plseconds.pl
pl
Thisplaudioplclipplindicatesplhypermotilityplbecauseplthereplareplgreaterplthanpl40plbowelplsoun
ds/
min.plHypermotilityplleadspltopldiarrheaplandplisplanplindicationplofplintolerancepltopltheplenteralpl
feeding.plTherefore,pltheplnurseplshouldplslowpltheplrateplofpltheplfeedingpltoplpromotepltheplclie
nt'spltoleranceplofpltheplfeeding.
TheplnurseplshouldplmaintainplaplclientplwhoplisplreceivingplcontinuousplNGpltubeplfeedingsplinpl
aplpositionplwithpltheplheadplofpltheplbedplelevatedpl30°pltopl45°pltoplpreventplaspirationplofpltheplf
ormula.
Aplnurseplisplpreparingpltopladministerploxygenpltoplaplclientplwhoplhasplheartplfailureplandplisplha
vingplseverepldifficultyplbreathing.plWhichplofpltheplfollowingploxygenpldeliveryplequipmentplsh
ouldpltheplnurseplselectpltoplprovidepltheplhighestplconcentrationplofploxygenpltopltheplclient?pl-
plANS--Nonrebreatherplmask
Rationality:
Aplnonrebreatherplmaskplprovidespltheplhighestplpercentageplofploxygenplconcentrationplwith
outplintubationplandplmechanicalplventilation.
AplVenturiplmaskplcanplbepladjustedpltoplprovideplaplconsistentpllowerploxygenplconcentration.
Aplsimpleplfaceplmaskplcanplbepladjustedplforplshort-
termpldeliveryplofpllowpltoplmediumploxygenplconcentration.
Aplnasalplcannulaplprovidesplapllowploxygenplconcentration.
Aplchargeplnurseplsmellsplsmoke,plenterspltheplvisitorplrestroom,plandplseesplflamesplinplthepltra
shplcan.plWhatplispltheplsequenceplofplactionsplthatpltheplnurseplshouldpltake?
pl(Movepltheplstepsplintopltheplboxplonpltheplright,plplacingplthemplinpltheplselectedplorderplofplperf
ormance.plUseplallpltheplsteps.)pl-plANS--Evacuateplclientsplfrompltheplareaplispltheplfirstplstep.pl
Rationality:plTheplfirstplactionpltheplnurseplshouldpltakeplwhenplusingpltheplRACEplprotocolplisplt
opl"rescue"plorplevacuatepltheplclientsplfrompltheplareapltoplpreventplharm.
,Pullpltheplleverplonpltheplfireplalarmplboxplispltheplsecondplstep.pl
Rationality:plForpltheplnextplstep,pl"alarm,"pltheplnurseplshouldplactivatepltheplfacilityplfireplalarm
plandplcallpltoplreportpltheplfirepltopltheplfacilityplemergencyplextension.
Closepltheplfirepldoorsplonpltheplunitplispltheplthirdplstep.pl
Rationality:plClosepltheplfirepldoorsplonpltheplunitplispltheplthirdplstep.plForpltheplthirdplstep,pl"confi
ne,"pltheplnurseplshouldplclosepltheplunitplfirepldoorspltoplpreventpltheplfireplfromplspreading.
Useplaplfireplextinguisherpltoplputploutpltheplfireplispltheplfourthplstep.
Rationality:plForpltheplfinalplstep,pl"extinguish,"pltheplnurseplshouldpluseplaplfireplextinguisherplto
plputploutpltheplfireplbyplaimingpltheplnozzleplatpltheplbaseplofpltheplfireplandplusingplaplsweepingplm
otion.
AplnurseplisplcaringplforplaplclientplwhoplhasplmetastaticplcancerplandplpracticesplCatholicism.plT
heplclientplaskspltheplnursepltopldiscusspltheplafterlifeplwithplthem.plWhichplofpltheplfollowingplstat
ementsplbypltheplnurseplassistsplinplmeetingpltheplclient'splspiritualplneeds?pl-
plANS--"Tellplmeplwhatpltheplafterlifeplmeanspltoplyou."
Rationale:plThisplstatementplrespectspltheplclient'splspiritualplneedsplbyplusingplopen-
endedpltherapeuticplcommunicationpltoplassistpltheplclientpltopltalkplaboutpltheirplconcerns.
Aplnurseplisplreinforcingplteachingplwithplaplclientplaboutpltheplpreventionplofplstressplinjuries.plW
hichplofpltheplfollowingplinstructionsplshouldpltheplnurseplinclude?pl-
plANS--"Whenplliftingplaplheavyplobject,plkeepplitplclosepltoplyourplbody."
Rationality:plTheplnurseplshouldplinstructpltheplclientpltoplkeeppltheplobjectplasplclosepltopltheirplb
odyplasplpossiblepltoplincreaseplstabilityplandpldecreaseplbackplstrainplwhenplliftingplaplheavyplo
bject.
Aplnurseplisplreinforcingplteachingplwithplaplclientplaboutplthepluseplofplcrutches.plWhichplofpltheplf
ollowingplactionsplbypltheplclientplindicatesplanplunderstandingplofpltheplteaching?pl-plANS--
Theplclientpladvancespltheplunaffectedpllegplfirstplwhileplclimbingplstairs.
Rationality:plWhenplascendingplstairs,pltheplclientplshouldplfirstpladvancepltheplunaffectedplleg.
Theplnurseplshouldplreinforceplwithpltheplclientplthatpltheirplaxillaplshouldplnotplbearplanyplweight
plwhileplinplthepltripodplpositionplbecauseplthisplcanplcauseplpressureplinjuryplformation.plTheplcli
entplshouldplbearpltheirplweightplwithpltheirplarmsplandplhands.
Aplclientplwhoplhaspladvancedplcancerpltellspltheplnurseplthatpltheyplhaveplapldifficultpltimepltalkin
gpltoplanyoneplaboutpltheplillness.plWhichplofpltheplfollowingplactionsplshouldpltheplnursepltakeplt
, oplencouragepltherapeuticplcommunication?pl-plANS--
Letpltheplclientplknowplthat,plaspltheirplnurse,pltheyplareplavailableplandplwillingpltopllisten.
-
plRationality:plActivepllisteningplconveyspltheplnurse'splrespectplandplacceptanceplforpltheplclien
t'splfeelingsplandplgivespltheplclientplanplopportunitypltoplexpresspltheirplthoughtsplandplneeds.
Aplnurseplisplpreparingpltoplremoveplaplclient'splperipheralplIVplcatheter.plAfterplperformingplhan
dplhygieneplandplapplyingplcleanplgloves,plwhichplofpltheplfollowingplactionsplshouldpltheplnurse
pltakeplfirst?pl-plANS--Clamppltheplinfusionpltubing.
Rationality:plEvidence-
basedplpracticeplindicatesplthatpltheplnurseplshouldplfirstplclamppltheplinfusionpltubingplafterplap
plyingplcleanplgloves.plThisplactionplstopspltheplflowplofpltheplIVplfluidplandplpreventsplitplfrompllea
kingploutplduringpltheplIVplremoval.
Aplnurseplisplcontributingpltopltheplplanplofplcareplforplaplclientplwhoplhasplaplpositiveplthroatplcultu
replforplstreptococci.plWhichplofpltheplfollowingplinterventionsplshouldpltheplnurseplrecommendp
ltoplbeplincludedplinpltheplplanplofplcare?pl-plANS--
Ensureplthatpltheplclientplwearsplaplsurgicalplmaskplduringpltransportationplthroughoutpltheplfaci
lity.
rationality:
Streptococcalplpharyngitisplrequirespldropletplprecautions.plTheplnurseplshouldplinstructplthepl
clientpltoplwearplaplsurgicalplmaskplwhenploutsideplofpltheplroompltoplpreventpltheplspreadplofplinf
ection.plStaffplshouldplmakepleveryplattemptpltopllimitpltheplclient'splmovementploutsideplofplthepl
room.
Theplnurseplshouldplprovideplaplroomplwithplnegative-
pressureplairflowplforplclientsplwhoplrequireplairborneplprecautions.
AplnurseplisplcaringplforplaplclientplwhoplhaspljustpldiedplandplpracticedpltheplIslamicplfaith.plWhich
plofpltheplfollowingplculturalplpracticesplshouldpltheplnurseplexpect?pl-plANS--
Theplclient'splfaceplshouldplbeplturnedpltowardplMecca.
Rationality:
Followingpldeath,plitplcanplbeplaplpracticeplofpltheplIslamicplfaithpltoplturnpltheplfaceplofplapldeceas
edplpersonpltowardplMecca.
ItplcanplbeplaplHispanicplandplLatinoplculturalplpracticepltopladornpltheplbodyplofplapldeceasedplpe
rsonplwithplamuletsplorplrosaryplbeads.
ItplcanplbeplaplChineseplculturalplpracticeplforpltheploldestplchildpltoplbathepltheplbodyplofplapldece
asedplpersonplunderplthepldirectionplofplanplolderplrelativeplorplpriest.
