PN Fundamentals Online Practice 2020 A With Complete Solution

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? Replace the NG tube place Place the client in the sims position Decrease the rate of feeding Check the clients blood glucose Decrease the rate of the feeding 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. 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? Nasal cannula Simple face mask Venturi mask Nonrebreather mask Nonrebreather mask A nonrebreather mask provides the highest percentage of oxygen concentration without intubation and mechanical ventilation. 00:02 01:34 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.) Evacuate clients from the area is the first step. Pull the lever on the fire alarm box is the second step. Close the fire doors on the unit is the third step. Use a fire extinguisher to put out the fire is the fourth step. Evacuate clients from the area is the first step. 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. 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. 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. 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? "Tell me what the afterlife means to you." "You should discuss the afterlife with your priest." "Keep praying. A miracle could happen" "Maybe your condition will lead you closer to God" "Tell me what the afterlife means to you." 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? "Keep your knees in a locked position when standing for prolonged periods" "Bend at the waist when lifting a heavy object" "Keep your feet close together when lifting a heavy object" ""When lifting a heavy object, keep it close to your body." "When lifting a heavy object, keep it close to your body." 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? The client advances the unaffected leg first while climbing stairs. 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? Keep the conversation moving by asking about the client's family Let the client know that, as their nurse, they are available and willing to listen. Ask if the client understands what to expect in the advanced stages of the illness Ask the clients visitors not to say anything about the advanced disease Let the client know that, as their nurse, they are available and willing to listen. 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? Clamp the infusion tubing. Remove the dressing. Withdraw the catheter from the vein. Ensure the catheter is intact. Clamp the infusion tubing. 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? Place the client in a room with another who has pharyngitis Ensure that the client wears a surgical mask during transportation throughout the facility. Limit the client's visitors to visitations of 30 min Provide the client a room with negative-pressure airflow of six exchanges per hour Ensure that the client wears a surgical mask during transportation throughout the facility. 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. 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? The clients body should be placed on the floor The clients oldest child will bathe the body The client's face should be turned toward Mecca The clients body will be adorned with amulets The client's face should be turned toward Mecca Following death, it can be a practice of the Islamic faith to turn the face of a deceased person toward Mecca. 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? Discontinued medications Resolved health conditions Resolved health conditions The nurse should report both unresolved and resolved health conditions to promote continuity of care. A nurse is contributing to the plan of care for a client who has a prescription for elastic bandages to the lower extremities. Which of the following actions should the nurse recommend for the plan of care? Check for capillary refill proximally to the elastic bandages every 12 hr Compare the client's pedal pulses bilaterally every 4 hr. Place the clients legs in a dependent position for 30 min before applying the elastic bandages Remove the elastic bandages every other day to inspect the skin Compare the client's pedal pulses bilaterally every 4 hr. The nurse should compare the pedal pulses bilaterally every 4 hr to check for adequate circulation for a client who has elastic bandages on their lower extremities.