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 nurse is reviewing arterial blood gas (ABG) results and clinical symptoms for a patient with suspected respiratory alkalosis. Which findings would the nurse expect?
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pH less than 7.35, PaCO₂ greater than 45 mm Hg, bradypnea, lethargy
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pH greater than 7.45, PaCO₂ less than 35 mm Hg, hyperventilation, confusion, lightheadedness
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pH 7.35–7.45, PaCO₂ 35–45 mm Hg, normal respirations, stable mentation
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pH less than 7.35, PaCO₂ less than 35 mm Hg, tachypnea, drowsiness
Explanation
Correct Answer:
B. pH greater than 7.45, PaCO₂ less than 35 mm Hg, hyperventilation, confusion, lightheadedness
Explanation of Correct Answer
Respiratory alkalosis occurs when hyperventilation, often caused by anxiety or pain, leads to excessive exhalation of carbon dioxide. This reduces PaCO₂ below 35 mm Hg and raises blood pH above 7.45. Clinical signs include hyperventilation, confusion, and lightheadedness due to cerebral vasoconstriction from low CO₂ levels. Recognizing these findings helps guide interventions such as encouraging slow, controlled breathing.
A nurse is caring for a postoperative patient. When is it appropriate to start the patient on a clear liquid diet?
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As soon as the patient is fully awake from anesthesia
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When the patient expresses hunger
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When bowel sounds are detected by auscultation
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Immediately after the surgical procedure ends
Explanation
Correct Answer:
C. When bowel sounds are detected by auscultation
Explanation of Correct Answer
A clear liquid diet should begin only after bowel sounds are detected by auscultation, indicating the return of gastrointestinal motility. Starting oral intake too early, before peristalsis returns, increases the risk of nausea, vomiting, and abdominal distention. Confirming bowel sounds ensures the GI tract can tolerate fluids and helps prevent postoperative complications such as ileus.
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.
A nurse is preparing to perform digital removal of stool for a patient with severe constipation. Which assessment finding would be most important to monitor during the procedure?
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Signs of dehydration
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Vagal response
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Abdominal distention
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Presence of hemorrhoids
Explanation
Correct Answer:
B. Vagal response
Explanation of Correct Answer
During digital removal of stool, stimulation of the vagus nerve can occur, leading to a vagal response. This may cause bradycardia, hypotension, dizziness, or even syncope, which can be dangerous for the patient. The nurse must closely monitor the patient’s heart rate and overall response during the procedure. If symptoms of vagal stimulation appear, the procedure should be stopped immediately and the patient stabilized.
A nurse is preparing to draw a patient’s blood sample. Which patient identifiers should the nurse verify before proceeding?
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Room number and diagnosis
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Patient’s name and date of birth, checked against the wristband
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Patient’s bed number and initials
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Patient’s provider name and procedure type
Explanation
Correct Answer:
B. Patient’s name and date of birth, checked against the wristband
Explanation of Correct Answer
Before drawing blood, at least two patient identifiers must be used to ensure safety and accuracy. The standard practice is to verify the patient’s full name and date of birth, comparing this information to the wristband and the lab requisition form. Room and bed numbers are not reliable identifiers. This process prevents errors such as mislabeling or drawing the wrong patient’s blood.
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.
Which change occurs in the respiratory system of an older person?
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Increased elasticity of lung tissue
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Airway cilia experience impairment
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Alveolar membrane becomes thinner
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Greater respiratory reserve is available
Explanation
Correct Answer:
B. Airway cilia experience impairment
Explanation of Correct Answer
With aging, the airway cilia become less effective in clearing mucus and foreign particles from the respiratory tract. This impairment compromises pulmonary defense mechanisms, leading to a higher risk of infections and reduced clearance of secretions
A nurse is explaining diagnostic kidney function tests to a patient. How should the nurse describe the glomerular filtration rate (GFR)?
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A measure of the amount of protein excreted in urine in 24 hours
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A test that measures the volume of urine filtered by the kidney in 1 minute
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A measure of how much sodium is excreted by the kidneys per hour
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A test that determines how concentrated urine is after water deprivation
Explanation
Correct Answer:
B. A test that measures the volume of urine filtered by the kidney in 1 minute
Explanation of Correct Answer
Glomerular filtration rate (GFR) reflects how well the kidneys are filtering blood by measuring the volume of fluid filtered through the glomeruli each minute. It is a key indicator of renal function. A normal GFR is about 90–120 mL/min, and decreases may indicate kidney disease or impaired renal perfusion. Monitoring GFR helps guide diagnosis and treatment of renal disorders.
A nurse is providing dietary counseling to an overweight Hispanic patient. Which recommendation is most appropriate to support healthier eating habits?
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Eliminate all carbohydrates from meals
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Reduce fried foods and sugar intake
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Follow a high-protein, high-fat diet
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Avoid all traditional cultural foods
Explanation
Correct Answer:
B. Reduce fried foods and sugar intake
Explanation of Correct Answer
For an overweight patient, especially within cultural dietary patterns that may include fried foods and sugary drinks or desserts, reducing fried foods and limiting sugar intake are key recommendations. These changes lower excess calorie consumption, improve heart health, and support gradual weight loss. The goal is to encourage healthier preparation methods and balanced meals rather than complete elimination of cultural food preferences.
A nurse is reviewing proper care of an indwelling urinary catheter with a student nurse. Which of the following should be included in the procedure?
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Keep the drainage bag above the level of the bladder to promote flow
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Maintain a closed drainage system at all times
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Disconnect the tubing regularly to measure urine output
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Provide perineal care only once daily
Explanation
Correct Answer:
B. Maintain a closed drainage system at all times
Explanation of Correct Answer
Maintaining a closed drainage system is a critical step in preventing infection with an indwelling catheter. Along with this, the nurse should measure urine output regularly, observe drainage and urine characteristics at each encounter, keep the drainage bag below the bladder to prevent backflow, provide perineal and insertion site care twice daily, and secure the catheter to the leg. These measures promote comfort, accurate monitoring, and infection prevention.
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