PN FUNDAMENTALS 2023/2024 CORRECT AND VERIFIED ANSWERS GRADED A+
1.A nurse is preparing to collect data bout the function of a client's trigeminal nerve or cranial
nerve (CNV). Which of the following items should the nurse gather for the test?
1. sugar
2. coffee
3. cotton wisps
4. snellen chart
Cotton wisps ; trigeminal nerve has sensory and motor capabilities. Use cotton to test sensation,
ask client to clench teeth to test motor abilities.
2.A nurse is collecting data regarding a client's nutritional status during a community health
screening. The client is consuming 500 calories per day more than his energy level requires.
When will the client have gained 4.5 kg (10lb)?
1. 10 months
2. 5 months
3. 5 weeks
4. 10 weeks
10 weeks ; 1 lb of fat is equivalent to 3,500 calories. 500 calories/day for 7 days = 1 lb gain each
week.
3.A nurse is collecting data about a client's pulses. Which of the following descriptions should
the nurse use to document the findings?
1. peripheral pulses equal bilaterally at a rate of 60/min
2. radial, brachial, and pedal pulses bilaterally weak
3. peripheral pulses bilaterally symmetric, equal, and strong in all 4 extremities
4. brachial, radial, popliteal, and dorsalis pedis pulses regular, 58, and bilaterally palpable
Peripheral pulses bilaterally symmetric, equal, and strong in all 4 extremities ; documentation of
peripheral pulse evaluation should include strength, equality, and symmetry in all 4 extremities.
HR is not a component of peripheral pulse evaluation.
4.A nurse at an ophthalmology clinic is collecting data from a client who was referred by the
provider for a potential cataract. Which of the following client reports is consistent with
cataracts?
1. Halos when looking at lights
2. Loss of peripheral vision
3. Bright flashes of light and floaters
4. Eyestrain and headaches with close work
, Halos when looking at lights ; other manifestations of cataracts are difficulty seeing at night,
glare sensitivity, and decreased visual acuity even in daylight.
5.A nurse is caring for a client who has a hearing impairment. Which of the following
interventions should the nurse use when speaking with the client?
1. speak directly toward the client's impaired ear
2. exaggerate lip movements
3. speak loudly
4. face the client when speaking
Face the client when speaking ; also stand or sit at the same level, and speak toward the client's
best ear, enunciate and avoid mumbling. Speaking loudly or shouting can distort sounds.
6.A nurse is assisting a client who has dysphagia at mealtime. Which of the following actions
should the nurse take?
1. assist the client into a semi-sitting position
2. have the client lean slightly backeard
3. advise the client to tuck his chin downward
4. instruct the client to tilt his head slightly backward
Advise the client to tuck his chin downward ; the client should sit upright, lean slightly forward,
tilt his head forward, and tuck his chin in.
7.A nurse is reinforcing teaching with a client who is postop following a knee arthroplasty about
the muscles he will need to strengthen in physical therapy. Which of the following muscle groups
are responsible for movement at the knee joint?
1. antigravity
2. antagonistic
3. synergistic
4. skeletal
Antagonistic ; the antagonistic group is responsible for the movement of the knee joint by
contracting while other muscles relax.
8.A nurse is preparing to administer a tap water enema to a client. Which of the following actions
should the nurse take?
1. raise the enema bag if the client experiences cramping
2. lubricate 2.54 cm (1 in) of the tip of the rectal tube prior to insertion
3. place the client in a left Sims' position
4. don sterile gloves prior to the procedure
1.A nurse is preparing to collect data bout the function of a client's trigeminal nerve or cranial
nerve (CNV). Which of the following items should the nurse gather for the test?
1. sugar
2. coffee
3. cotton wisps
4. snellen chart
Cotton wisps ; trigeminal nerve has sensory and motor capabilities. Use cotton to test sensation,
ask client to clench teeth to test motor abilities.
2.A nurse is collecting data regarding a client's nutritional status during a community health
screening. The client is consuming 500 calories per day more than his energy level requires.
When will the client have gained 4.5 kg (10lb)?
1. 10 months
2. 5 months
3. 5 weeks
4. 10 weeks
10 weeks ; 1 lb of fat is equivalent to 3,500 calories. 500 calories/day for 7 days = 1 lb gain each
week.
3.A nurse is collecting data about a client's pulses. Which of the following descriptions should
the nurse use to document the findings?
1. peripheral pulses equal bilaterally at a rate of 60/min
2. radial, brachial, and pedal pulses bilaterally weak
3. peripheral pulses bilaterally symmetric, equal, and strong in all 4 extremities
4. brachial, radial, popliteal, and dorsalis pedis pulses regular, 58, and bilaterally palpable
Peripheral pulses bilaterally symmetric, equal, and strong in all 4 extremities ; documentation of
peripheral pulse evaluation should include strength, equality, and symmetry in all 4 extremities.
HR is not a component of peripheral pulse evaluation.
4.A nurse at an ophthalmology clinic is collecting data from a client who was referred by the
provider for a potential cataract. Which of the following client reports is consistent with
cataracts?
1. Halos when looking at lights
2. Loss of peripheral vision
3. Bright flashes of light and floaters
4. Eyestrain and headaches with close work
, Halos when looking at lights ; other manifestations of cataracts are difficulty seeing at night,
glare sensitivity, and decreased visual acuity even in daylight.
5.A nurse is caring for a client who has a hearing impairment. Which of the following
interventions should the nurse use when speaking with the client?
1. speak directly toward the client's impaired ear
2. exaggerate lip movements
3. speak loudly
4. face the client when speaking
Face the client when speaking ; also stand or sit at the same level, and speak toward the client's
best ear, enunciate and avoid mumbling. Speaking loudly or shouting can distort sounds.
6.A nurse is assisting a client who has dysphagia at mealtime. Which of the following actions
should the nurse take?
1. assist the client into a semi-sitting position
2. have the client lean slightly backeard
3. advise the client to tuck his chin downward
4. instruct the client to tilt his head slightly backward
Advise the client to tuck his chin downward ; the client should sit upright, lean slightly forward,
tilt his head forward, and tuck his chin in.
7.A nurse is reinforcing teaching with a client who is postop following a knee arthroplasty about
the muscles he will need to strengthen in physical therapy. Which of the following muscle groups
are responsible for movement at the knee joint?
1. antigravity
2. antagonistic
3. synergistic
4. skeletal
Antagonistic ; the antagonistic group is responsible for the movement of the knee joint by
contracting while other muscles relax.
8.A nurse is preparing to administer a tap water enema to a client. Which of the following actions
should the nurse take?
1. raise the enema bag if the client experiences cramping
2. lubricate 2.54 cm (1 in) of the tip of the rectal tube prior to insertion
3. place the client in a left Sims' position
4. don sterile gloves prior to the procedure
