PN 106 Foundations of Nursing Fundamentals
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Free PN 106 Foundations of Nursing Fundamentals Questions
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 preparing to administer medications through a nasogastric (NG) tube. What must the nurse do first?
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Crush medications, mix with 5 mL of water, and instill without flushing
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Crush medications as appropriate, flush the tube with 30 mL of water, then give the medications
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Administer medications directly into the tube without dilution
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Give all medications together in one syringe without flushing between them
Explanation
Correct Answer:
B. Crush medications as appropriate, flush the tube with 30 mL of water, then give the medications
Explanation of Correct Answer
Before administering medications via an NG tube, the nurse must crush medications that can safely be crushed, dilute them with water, and flush the tube with 30 mL of water. This ensures the tube is patent, prevents clogging, and allows proper medication delivery. Each medication should be given separately with additional flushing between drugs to maintain tube patency and accurate dosing.
A client has been prescribed eye drops for the treatment of glaucoma. The nurse is observing the client self-administer the eye drops. Which action by the client requires further teaching?
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The client looks upward toward the ceiling and administers the eye drops in the conjunctival sac
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While administering the eye drops, a drop lands on the client's outer lid, so the client administers another drop.
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The client cleans the eye from the inner to the outer canthus
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The client touches the conjunctival sac with the eyedropper to make sure she is in the correct location
Explanation
Correct Answer:
D. The client touches the conjunctival sac with the eyedropper to make sure she is in the correct location.
Explanation of Correct Answer
The tip of the eyedropper must never touch the eye or conjunctival sac because it contaminates the dropper and increases the risk of introducing infection into the eye. Sterility of the medication container is essential in preventing complications, especially in clients with glaucoma who are already at risk for vision loss. The dropper should be held just above the conjunctival sac without making contact.
Which medication administration activity can be delegated to a UAP?
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Application of a skin barrier cream to the perineal area
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Inserting vaginal medications
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Application of a transdermal patch
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Inserting rectal medications
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Instillation of ear drops
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Instillation of eye drops
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Use of MDIs
Explanation
Correct Answer:
A. Application of a skin barrier cream to the perineal area
Explanation of Correct Answer
Unlicensed assistive personnel (UAP) may provide basic comfort and hygiene care but cannot administer medications that require assessment, evaluation, or direct therapeutic effect. Applying a skin barrier cream to the perineal area is considered a comfort and protective measure, not a medication requiring nursing judgment, so it is within the scope of tasks that can be delegated to UAPs.
A nurse is assessing a patient with frequent diarrhea. Which finding would be the greatest concern and require prompt intervention?
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Dehydration
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Decreased skin turgor
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Dry mucous membranes with thick saliva
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Increased thirst
Explanation
Correct Answer:
A. Dehydration
Explanation of Correct Answer
The most concerning complication of diarrhea is dehydration, which can quickly develop due to excessive fluid loss. Dehydration can lead to electrolyte imbalance, hypovolemia, and impaired organ function if not corrected promptly. While decreased skin turgor, dry mucous membranes, and increased thirst are all signs of dehydration, the overall condition of dehydration itself represents the most urgent clinical concern requiring immediate management.
A nurse is teaching a patient about different types of surgical procedures. How should the nurse describe exploratory surgery?
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Surgery done to permanently treat a known condition
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Surgery done strictly for cosmetic purposes
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Surgery done to provide further data and determine a diagnosis for a problem
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Surgery done only to relieve symptoms without curing the disease
Explanation
Correct Answer:
C. Surgery done to provide further data and determine a diagnosis for a problem
Explanation of Correct Answer
Exploratory surgery is performed when the cause of a patient’s symptoms is unclear and further information is needed for diagnosis. It allows direct visualization and assessment of internal structures, often leading to identification of disease processes such as tumors, infections, or internal bleeding. Unlike curative or palliative surgery, the primary purpose is diagnostic rather than treatment-focused.
A nurse is teaching a patient how to use an incentive spirometer after abdominal surgery. Which instruction should the nurse give?
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Exhale forcefully into the mouthpiece to move the ball upward
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Take a deep breath in, watching the ball rise as they inhale
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Breathe rapidly in and out until the ball stays at the top
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Hold their breath first, then exhale slowly into the device
Explanation
Correct Answer:
B. Take a deep breath in, watching the ball rise as they inhale
Explanation of Correct Answer
The correct technique for using an incentive spirometer is to place the lips around the mouthpiece and inhale slowly and deeply. As the patient inhales, the ball or piston rises, providing visible feedback of lung expansion. This helps prevent atelectasis, improves ventilation, and promotes recovery by encouraging sustained deep breaths after surgery.
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.
A nurse is teaching a group of students about risk factors for acid–base imbalances. Which conditions can place a patient at greater risk?
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Hypertension, seasonal allergies, and mild arthritis
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Kidney disease, diarrhea, severe vomiting, electrolyte disturbances, certain drugs or toxins, and metabolic diseases
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Sprains, fractures, and minor infections
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Nearsightedness, hearing loss, and skin rashes
Explanation
Correct Answer:
B. Kidney disease, diarrhea, severe vomiting, electrolyte disturbances, certain drugs or toxins, and metabolic diseases
Explanation of Correct Answer
Acid–base imbalances can result from conditions that disrupt normal renal, gastrointestinal, or metabolic function. Kidney disease impairs the body’s ability to excrete acids or conserve bicarbonate. Diarrhea and severe vomiting cause significant loss of bicarbonate or gastric acid, respectively. Electrolyte disturbances alter buffering systems, while ingestion of drugs or toxins and metabolic diseases interfere with normal acid–base regulation. These conditions require close monitoring to prevent life-threatening imbalances.
The ear canal should be straightened when instilling eardrops to provide direct access to deeper ear structures. In what direction should the auricle be pulled in an infant to straighten the ear canal?
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Downward and inward
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Downward and back
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Upward and outward
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Upward and back
Explanation
Correct Answer:
B. Downward and back
Explanation of Correct Answer
In infants and children under 3 years old, the ear canal curves upward and is shorter and straighter than in adults. To straighten this canal for proper medication administration, the auricle should be gently pulled downward and back. This maneuver aligns the canal to allow the eardrops to reach deeper structures effectively, ensuring optimal absorption and therapeutic action.
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