FUNDAMENTALS LATEST
PROCTOR EXAM
A nurse is planning care for a client who has a single-lumen nasogastric
(NG) tube for gastric decompression. Which of the following actions
should the nurse include in the plan of care? (Select all that apply.) -
ANSWERS--Provide oral hygiene frequently.
-Measure the amount of drainage from the NG tube every shift.
-Secure the NG tube to the client's gown.
Rationale:
-Provide oral hygiene frequently is correct. Frequent oral hygiene
provides comfort for the client since mucous membranes easily become
dry and uncomfortable when a client cannot drink fluids.
-Measure the drainage from the NG tube every shift is correct.
Measuring the drainage at least every shift helps the provider to
calculate fluid loss and prescribe appropriate replacement therapy.
-Secure the NG tube to the client's gown is correct. An unsecured NG
tube can irritate the nares if the tube is pulled or caught on the bed or
other equipment. The tube can also be dislodged if not secured
appropriately.
A nurse in a provider's office is reviewing the laboratory findings of a
client who reports chills and aching joints. The nurse should identify
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PAGE
1
, FUNDAMENTALS LATEST
PROCTOR EXAM
which of the following findings as an indication that the client has an
infection? - ANSWERS-WBC 15,000 mm3
Rationale:
This finding is above the expected reference range and is an indication
of infection.
A nurse on a surgical unit is receiving a client who had abdominal
surgery from the postanesthesia care unit. Which of the following
assessments should the nurse make first? - ANSWERS-Airway
Rationale:
The nurse should apply the ABC priority-setting framework when caring
for this client. This framework emphasizes the basic core of human
functioning and prioritizes having an open airway, being able to breathe
in adequate amounts of oxygen, and circulating oxygen to the body's
organs via the blood. An alteration in any of these can indicate a threat
to life. Therefore, this is the nurse's priority concern. When applying the
ABC priority-setting framework, airway is always the highest priority
because the airway must be clear and open for oxygen exchange to
occur. Breathing is the second highest priority in the ABC priority-
setting framework because adequate ventilatory effort is essential in
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PAGE
2
, FUNDAMENTALS LATEST
PROCTOR EXAM
order for oxygen exchange to occur. Circulation is the third highest
priority in the ABC priority-setting framework because delivery of
oxygen to critical organs only occurs if the heart and blood vessels are
capable of efficiently carrying oxygen to them; therefore, the nurse
should first assess the client's airway.
A nurse is planning to perform passive range-of-motion exercises for a
client. Which of the following actions should the nurse take? -
ANSWERS-Repeat each joint motion five times during each session.
Rationale:
To maintain the client's joint mobility the nurse should repeat each
motion three to five times.
A nurse is caring for a client who has Clostridium difficile and is in
contact isolation. Which of the following actions should the nurse take?
- ANSWERS-Wear gloves when changing the client's gown.
Rationale:
The nurse should wear gloves when handling articles that have the
potential to contaminate the hands when caring for a client who is in
contact isolation.
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PAGE
3
PROCTOR EXAM
A nurse is planning care for a client who has a single-lumen nasogastric
(NG) tube for gastric decompression. Which of the following actions
should the nurse include in the plan of care? (Select all that apply.) -
ANSWERS--Provide oral hygiene frequently.
-Measure the amount of drainage from the NG tube every shift.
-Secure the NG tube to the client's gown.
Rationale:
-Provide oral hygiene frequently is correct. Frequent oral hygiene
provides comfort for the client since mucous membranes easily become
dry and uncomfortable when a client cannot drink fluids.
-Measure the drainage from the NG tube every shift is correct.
Measuring the drainage at least every shift helps the provider to
calculate fluid loss and prescribe appropriate replacement therapy.
-Secure the NG tube to the client's gown is correct. An unsecured NG
tube can irritate the nares if the tube is pulled or caught on the bed or
other equipment. The tube can also be dislodged if not secured
appropriately.
A nurse in a provider's office is reviewing the laboratory findings of a
client who reports chills and aching joints. The nurse should identify
END OF
PAGE
1
, FUNDAMENTALS LATEST
PROCTOR EXAM
which of the following findings as an indication that the client has an
infection? - ANSWERS-WBC 15,000 mm3
Rationale:
This finding is above the expected reference range and is an indication
of infection.
A nurse on a surgical unit is receiving a client who had abdominal
surgery from the postanesthesia care unit. Which of the following
assessments should the nurse make first? - ANSWERS-Airway
Rationale:
The nurse should apply the ABC priority-setting framework when caring
for this client. This framework emphasizes the basic core of human
functioning and prioritizes having an open airway, being able to breathe
in adequate amounts of oxygen, and circulating oxygen to the body's
organs via the blood. An alteration in any of these can indicate a threat
to life. Therefore, this is the nurse's priority concern. When applying the
ABC priority-setting framework, airway is always the highest priority
because the airway must be clear and open for oxygen exchange to
occur. Breathing is the second highest priority in the ABC priority-
setting framework because adequate ventilatory effort is essential in
END OF
PAGE
2
, FUNDAMENTALS LATEST
PROCTOR EXAM
order for oxygen exchange to occur. Circulation is the third highest
priority in the ABC priority-setting framework because delivery of
oxygen to critical organs only occurs if the heart and blood vessels are
capable of efficiently carrying oxygen to them; therefore, the nurse
should first assess the client's airway.
A nurse is planning to perform passive range-of-motion exercises for a
client. Which of the following actions should the nurse take? -
ANSWERS-Repeat each joint motion five times during each session.
Rationale:
To maintain the client's joint mobility the nurse should repeat each
motion three to five times.
A nurse is caring for a client who has Clostridium difficile and is in
contact isolation. Which of the following actions should the nurse take?
- ANSWERS-Wear gloves when changing the client's gown.
Rationale:
The nurse should wear gloves when handling articles that have the
potential to contaminate the hands when caring for a client who is in
contact isolation.
END OF
PAGE
3
