PN Fundamentals Online Practice 2020 A
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 - ANSWERDecrease 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 - ANSWERNonrebreather mask
A nonrebreather mask provides the highest percentage of oxygen concentration without
intubation and mechanical ventilation.
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. - ANSWEREvacuate 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.
, PN Fundamentals Online Practice 2020 A
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" - ANSWER"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." - ANSWER"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? -
ANSWERThe 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 - ANSWERLet
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 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 - ANSWERDecrease 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 - ANSWERNonrebreather mask
A nonrebreather mask provides the highest percentage of oxygen concentration without
intubation and mechanical ventilation.
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. - ANSWEREvacuate 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.
, PN Fundamentals Online Practice 2020 A
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" - ANSWER"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." - ANSWER"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? -
ANSWERThe 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 - ANSWERLet
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.
