PN 106 Foundations of Nursing Fundamentals at Nightgale College PN
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Free PN 106 Foundations of Nursing Fundamentals at Nightgale College PN Questions
A client is attempting to put pills in his mouth from a medicine cup and drops one pill on the bed sheet. The nurse should:
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retrieve the pill from the linens and allow the client to take it.
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discard the pill and get another from the dose pack.
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scoop up the pill in a souffle cup and hand the cup to the client.
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report the loss of the pill as a medication error.
Explanation
Correct Answer:
B. discard the pill and get another from the dose pack.
Explanation of Correct Answer
A pill that has fallen onto bed linens is considered contaminated and unsafe to administer. To ensure infection control and medication safety, the nurse must discard the dropped pill and obtain a new one from the original supply or dose pack. This protects the client from potential pathogens while ensuring the correct medication is given as prescribed.
A nurse is explaining different types of surgical procedures to a group of students. How should the nurse describe palliative surgery?
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A surgery performed to permanently cure a disease
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A surgery done only for diagnostic purposes
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A surgery that alleviates symptoms and provides comfort but does not necessarily cure the disease or heal the injury
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A surgery performed strictly for cosmetic enhancement
Explanation
Correct Answer:
C. A surgery that alleviates symptoms and provides comfort but does not necessarily cure the disease or heal the injury
Explanation of Correct Answer
Palliative surgery is performed to relieve symptoms, improve quality of life, and provide comfort when curing the disease is not possible. Examples include removing part of a tumor to reduce pain or obstruction. Unlike curative surgery, it does not aim to eliminate the underlying condition but focuses on symptom management and patient well-being, especially in advanced or terminal illness.
A nurse is teaching a student about recognizing dehydration. Which assessment finding is most consistent with dehydration?
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Weight gain and elevated blood pressure
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Crackles in lungs and possible edema
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Slow, bounding pulse
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Weight loss and low blood pressure
Explanation
Correct Answer:
D. Weight loss and low blood pressure
Explanation of Correct Answer
Dehydration results from fluid volume deficit, which causes weight loss and a drop in blood pressure due to reduced circulating volume. Other expected signs include dry mucous membranes, poor skin turgor, tachycardia, and concentrated urine. In contrast, weight gain, elevated blood pressure, crackles, edema, and a bounding pulse are signs of fluid volume overload, not dehydration.
A nurse is teaching a group of students about the World Health Organization (WHO) three-step ladder approach for pain management. What are the correct steps?
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Begin with opioids for severe pain, then taper to mild analgesics, then discontinue therapy
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Start with nonopioid drugs with or without adjuvants; if pain persists, add opioids for mild to moderate pain; if pain still persists, switch to opioids for moderate to severe pain
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Use adjuvant therapy alone first, then nonopioids, then opioids only if all else fails
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Begin with surgical interventions, then add nonopioids, then opioids if needed
Explanation
Correct Answer: B. Start with nonopioid drugs with or without adjuvants; if pain persists, add opioids for mild to moderate pain; if pain still persists, switch to opioids for moderate to severe pain
Explanation of Correct Answer
The WHO three-step ladder provides a structured approach to pain management. Step 1 begins with nonopioid drugs such as acetaminophen or NSAIDs, possibly combined with adjuvant therapies. Step 2 adds an opioid appropriate for mild to moderate pain if control is inadequate. Step 3 advances to stronger opioids for moderate to severe pain. This progression ensures safe, effective, and individualized pain relief.
If you find your patient on the floor, not breathing, has no pulse, and unconscious, what do you do first?
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Check blood pressure
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Call for help or activate EMS
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Place the patient in recovery position
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Begin CPR
Explanation
Correct Answer:
B. Call for help or activate EMS
Explanation of Correct Answer
The first step when encountering an unresponsive patient with no breathing and no pulse is to call for help or activate emergency medical services (EMS). Early activation ensures that advanced life support and emergency equipment can be mobilized while you begin CPR. This action maximizes the patient’s chance of survival by combining immediate resuscitation with timely advanced interventions.
A nurse is inserting a Foley catheter for a patient. While inflating the retention balloon, what should the nurse observe?
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The patient’s urine output in the drainage tubing
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The patient’s facial expressions for signs of discomfort
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The color of the patient’s urine in the drainage bag
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The position of the catheter tubing on the bed
Explanation
Correct Answer:
B. The patient’s facial expressions for signs of discomfort
Explanation of Correct Answer
When inflating the Foley catheter balloon, the nurse must carefully observe the patient’s facial expressions for discomfort or pain. Discomfort may indicate the balloon is being inflated while still in the urethra rather than the bladder, which can cause trauma. If pain is noted, inflation should stop immediately and the catheter repositioned. Monitoring the patient’s response ensures correct placement and prevents injury.
A nurse is preparing to complete a mental status exam on a patient. Which areas should be included in this assessment?
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Vital signs, skin integrity, and reflexes
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Appearance and behavior, level of awareness and reality orientation, thinking/content of thought, memory, speech and ability to communicate, mood and affect, judgment, and perception
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Pain scale rating, mobility, and nutrition status
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Vision, hearing, and peripheral pulses
Explanation
Correct Answer:
B. Appearance and behavior, level of awareness and reality orientation, thinking/content of thought, memory, speech and ability to communicate, mood and affect, judgment, and perception
Explanation of Correct Answer
A mental status exam is a structured way of assessing a patient’s cognitive, emotional, and psychological functioning. Key areas include appearance and behavior, level of consciousness and orientation, thought processes and content, memory, speech, mood and affect, judgment, and perception. These findings help nurses and providers evaluate mental health conditions, monitor changes, and guide appropriate interventions.
A nurse is preparing a patient for diagnostic testing and explains that ultrasound can be used to assess which areas of the body?
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Bones and spinal cord
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Female reproductive organs, thyroid
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Lungs and alveoli directly
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Teeth and jaw structures
Explanation
Correct Answer:
B. Female reproductive organs, thyroid
Explanation of Correct Answer
Ultrasound is best for assessing soft tissues and glands. It is widely used to examine female reproductive organs, including the uterus and ovaries, and the thyroid gland in the neck. Sound waves do not penetrate bone or air-filled spaces effectively, so it cannot directly visualize bones, the spinal cord, lungs, alveoli, or teeth structures. This makes option B the correct choice.
A nurse is teaching a patient how to perform routine colostomy care at home. Which steps should the nurse include in the instructions?
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Cut the wafer opening ½ inch larger than the stoma, remove old appliance, apply new one without cleaning the skin
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Remove the old pouch, clean and dry the skin, cut the wafer opening 1/8 inch larger than the stoma, and apply the new pouch
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Remove the old pouch, cut the wafer opening 1 inch larger than the stoma, and apply directly over soiled skin
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Cleanse the stoma only with alcohol, then apply the new pouch without measuring
Explanation
Correct Answer:
B. Remove the old pouch, clean and dry the skin, cut the wafer opening 1/8 inch larger than the stoma, and apply the new pouch
Explanation of Correct Answer
Colostomy care involves removing the old pouching system, gently cleansing the skin around the stoma with warm water, and drying it thoroughly. The opening of the wafer or skin barrier should be cut about 1/8 inch larger than the stoma to avoid constriction while still protecting the skin. Once prepared, the new pouch is applied securely to maintain a proper seal and prevent leakage.
A nurse is teaching older adults about normal age-related changes in the digestive tract. Which change is expected with aging?
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Increased gastric secretion and faster peristalsis
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Decreased sense of taste and smell
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Stronger gag reflex and increased muscle tone
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Improved chewing ability and reduced dental caries
Explanation
Correct Answer:
B. Decreased sense of taste and smell
Explanation of Correct Answer
With aging, the digestive system undergoes several changes, including an increased risk of dental caries and tooth loss, decreased sense of taste and smell, reduced gag reflex, diminished muscle tone, decreased gastric secretions, and slowed peristalsis. These changes affect appetite, digestion, and nutrition. The decreased sense of taste and smell is particularly significant, as it reduces food enjoyment and may contribute to poor intake and weight loss in older adults.
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