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.) - (correct 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? - (correct 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.) - (correct 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.
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? - (correct Answer) - "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? - (correct Answer) - "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? - (correct Answer) - The 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? - (correct Answer) - Let 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? - (correct Answer) -
Clamp 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? -
(correct Answer) - Ensure 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? - (correct Answer) - The client's face should be turned toward
Mecca.
Rationality:
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.) - (correct 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? - (correct 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.) - (correct 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.
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? - (correct Answer) - "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? - (correct Answer) - "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? - (correct Answer) - The 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? - (correct Answer) - Let 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? - (correct Answer) -
Clamp 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? -
(correct Answer) - Ensure 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? - (correct Answer) - The client's face should be turned toward
Mecca.
Rationality:
