PN
Fundamentals
Online
Practice
Test
A
2024
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.)
-
ANS
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
internal
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?
-
ANS
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.)
-
ANS
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?
-
ANS
"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?
-
ANS
"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?
-
ANS
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?
-
ANS
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?
-
ANS
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?
-
ANS
Ensures
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?
-
ANS
The
client's
face
should
be
turned
toward
Mecca.
Rationality:
Following
death,
it
can
be
a
practice
of
the
Islamic
faith
to
turn
the
face
of
a
deceased
person
toward
Mecca.
It
can
be
a
Hispanic
and
Latino
cultural
practice
to
adorn
the
body
of
a
deceased
person
with
amulets
or
rosary
beads.
It
can
be
a
Chinese
cultural
practice
for
the
oldest
child
to
bathe
the
body
of
a
deceased
person
under
the
direction
of
an
older
relative
or
priest.
It
can
be
a
practice
of
the
Hindu
faith
to
place
the
body
of
a
deceased
person
on
the
floor.
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?
-
ANS
Resolved
health
conditions
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