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 collecting a social history from a patient and learns the patient lives in an egalitarian household. How should the nurse understand this type of household?
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One spouse holds authority over all major decisions
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Children have primary responsibility for decision-making
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Extended family elders control household rules
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Spouses share responsibilities and decision-making equally
Explanation
Correct Answer:
D. Spouses share responsibilities and decision-making equally
Explanation of Correct Answer
An egalitarian household is one in which both spouses share responsibilities, authority, and decision-making equally. Neither partner dominates; instead, household duties, financial management, and family roles are balanced. This approach emphasizes equality and cooperation, supporting mutual respect between partners. In contrast, patriarchal or matriarchal households designate one partner as the primary authority figure.
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.
When you suction your patient through the nasopharyngeal route, what amount of suction do you use?
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40 to 60 mm Hg
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80 to 120 mm Hg
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140 to 160 mm Hg
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180 to 200 mm Hg
Explanation
Correct Answer:
B. 80 to 120 mm Hg
Explanation of Correct Answer
The recommended suction pressure for nasopharyngeal suctioning is 80 to 120 mm Hg. This level is strong enough to effectively remove secretions without causing trauma to the delicate mucosal tissues. Using pressures higher than this increases the risk of airway injury, hypoxia, and discomfort, while lower pressures may be ineffective at clearing secretions.
A nurse is caring for a patient receiving continuous tube feeding. What should the nurse do to avoid complications?
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Increase the feeding rate if the patient complains of hunger
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Monitor frequently for constipation, nausea, diarrhea, hyperglycemia, and electrolyte imbalance
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Administer all medications at once through the feeding tube without flushing
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Stop checking residual volumes once feeding is established
Explanation
Correct Answer:
B. Monitor frequently for constipation, nausea, diarrhea, hyperglycemia, and electrolyte imbalance
Explanation of Correct Answer
To avoid complications of continuous tube feeding, the nurse must monitor the patient frequently for gastrointestinal issues such as constipation, nausea, and diarrhea, as well as metabolic problems like hyperglycemia and electrolyte imbalance. Continuous monitoring allows for early detection of feeding intolerance or complications, enabling prompt intervention. Proper flushing, medication administration, and monitoring residuals are also key parts of safe tube feeding management.
A nurse is caring for a patient who has just started on continuous tube feeding. Which assessment finding should the nurse report to the provider?
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Active bowel sounds present in all four quadrants
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Abdomen distention, nausea, or diarrhea
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Stable blood glucose within normal limits
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Tolerating the feeding without discomfort
Explanation
Correct Answer:
B. Abdomen distention, nausea, or diarrhea
Explanation of Correct Answer
After initiating continuous tube feeding, concerning assessment findings include abdominal distention, nausea, vomiting, or diarrhea. These symptoms may indicate feeding intolerance, delayed gastric emptying, or complications such as aspiration risk. Monitoring bowel sounds and blood glucose is important, but distention and gastrointestinal symptoms are critical to report promptly to prevent further complications and adjust feeding as necessary.
A nurse is teaching a patient how to collect a mid-stream urine specimen. Which instruction should the nurse include?
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Collect the first portion of urine directly into the container
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Cleanse the urethral area, begin urinating, stop, then collect the mid-portion of urine
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Save the last portion of urine voided for the specimen
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Collect all urine during a 24-hour period for analysis
Explanation
Correct Answer:
B. Cleanse the urethral area, begin urinating, stop, then collect the mid-portion of urine
Explanation of Correct Answer
A mid-stream urine specimen requires cleaning the urethral opening, discarding the initial flow of urine, and then collecting the middle portion. This method reduces contamination from bacteria normally present at the urethral opening and external genitalia. It is the preferred technique for bacterial culture and routine urine screening to ensure accurate results.
After a cardiac catheterization, a patient is being cared for by a nurse. In the first hour following the surgery, how frequently should the nurse check the location where the catheter was inserted?
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Every 30 minutes for the first hour, then every 2 hours
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Every 5 minutes for the first hour, then every hour
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Every 10 to 15 minutes for the first hour, while temperature is checked every 6 hours
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Every 60 minutes for the first hour, then every 4 hours
Explanation
Correct Answer:
C. Every 10 to 15 minutes for the first hour, while temperature is checked every 6 hours
Explanation of Correct Answer
After a cardiac catheterization, the catheter insertion site must be closely monitored for bleeding, hematoma, or compromised circulation. The standard is to assess the site every 10 to 15 minutes for the first hour, then less frequently as the patient stabilizes. In addition, body temperature is monitored every 6 hours to detect possible infection. These steps ensure early recognition of complications.
A nurse is assessing the stoma of a patient with an ascending colostomy. Where should the nurse expect the stoma to be located?
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In the left lower abdomen
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In the low to middle right side of the abdomen
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In the upper left abdomen
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In the midline of the lower abdomen
Explanation
Correct Answer:
B. In the low to middle right side of the abdomen
Explanation of Correct Answer
An ascending colostomy is typically located on the low to middle right side of the abdomen, where the ascending colon lies. The stool from this portion of the colon is usually liquid to semi-liquid because little water has been absorbed. Knowing the correct stoma location helps the nurse assess, educate, and provide appropriate care for the patient with an ascending colostomy.
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.
A nurse is preparing to administer a cleansing enema to a patient. Which steps demonstrate proper procedure?
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Place the patient in right Sims’ position, use cold water, insert 2 inches, and hold container at hip level
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Place the patient in left Sims’ position, use water at 100–105°F, lubricate tip, insert 4 inches, and hold container 12–18 inches above rectum
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Place the patient supine, use hot water, insert 1 inch, and hold container at shoulder height
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Place the patient in Fowler’s position, use lukewarm water, insert 6 inches, and hold container at waist level
Explanation
Correct Answer:
B. Place the patient in left Sims’ position, use water at 100–105°F, lubricate tip, insert 4 inches, and hold container 12–18 inches above rectu
Explanation of Correct Answer
The correct procedure for administering an enema includes positioning the patient in left Sims’ position to allow the solution to follow the natural curve of the sigmoid colon. The water should be warmed to 100–105°F to avoid cramping. The enema tip must be lubricated and inserted 4 inches into the rectum. The enema container is held 12–18 inches above the rectum, allowing the solution to flow for 5–10 minutes to achieve effective cleansing.
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