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.) - ANSDecrease 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? - ANSNonrebreather 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.) - ANSEvacuate
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? - ANS"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? - ANS"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? - ANSThe 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? - ANSLet 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? -
ANSClamp 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? - ANSEnsure 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? - ANSThe 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.
A nurse is preparing to transfer a client from an acute care facility to a long-term care facility.
Which of the following information should the nurse plan to include in the transfer report? -
ANSResolved health conditions
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.) - ANSDecrease 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? - ANSNonrebreather 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.) - ANSEvacuate
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? - ANS"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? - ANS"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? - ANSThe 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? - ANSLet 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? -
ANSClamp 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? - ANSEnsure 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? - ANSThe 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.
A nurse is preparing to transfer a client from an acute care facility to a long-term care facility.
Which of the following information should the nurse plan to include in the transfer report? -
ANSResolved health conditions
