PN FL Fundamentals Funds Exam 2 at Jersey College School of Nursing
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Free PN FL Fundamentals Funds Exam 2 at Jersey College School of Nursing Questions
Which tool is designed to assess a client's risk of falling in a healthcare setting?
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A FLACC
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B Braden scale
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C Morse scale
- D Barthel index
Explanation
Explanation
The Morse Fall Scale is specifically designed to assess a client’s risk of falling in healthcare settings. It evaluates factors such as history of falls, secondary diagnoses, use of ambulatory aids, IV therapy, gait, and mental status. The score helps nurses identify clients at low, moderate, or high risk for falls and guides the implementation of appropriate fall-prevention interventions.Correct Answer Is:
C Morse scaleWhich statement best describes the purpose of The Joint Commission (TJC) accreditation?
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A Ensures healthcare organizations meet established safety and quality standards
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B Monitors client billing and insurance claims for accuracy
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C Regulates healthcare provider licensing and scope of practice
- D Sets mandatory staff-to-client ratios in hospitals
Explanation
Explanation
The Joint Commission accreditation focuses on evaluating and ensuring that healthcare organizations comply with nationally recognized safety and quality standards. Accreditation promotes continuous performance improvement, patient safety, and quality of care through regular surveys and compliance with evidence-based standards designed to reduce risk and improve outcomes.Correct Answer Is:
A Ensures healthcare organizations meet established safety and quality standardsThe nurse is caring for a client with a history of falls. The nurse can select which restraint alternatives for this client? Select all that apply.
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A. Bed monitor
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B. Wrist
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C. Leg monitor
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D. Mittens
- E. Vest
Explanation
Explanation
A Bed monitorA bed monitor is an appropriate restraint alternative because it alerts staff when the client attempts to get out of bed. This allows timely assistance and reduces fall risk without restricting the client’s movement, supporting safety while preserving autonomy.
C Leg monitor
A leg monitor functions as a restraint alternative by signaling staff when the client attempts to stand or ambulate. This early warning system helps prevent falls while avoiding physical restraint and promoting safer mobility.
D Mittens
Mittens are considered a restraint alternative when used to prevent clients from pulling at tubes or devices while still allowing limited hand movement. They are less restrictive than wrist restraints and reduce injury risk without fully immobilizing the client.
Correct Answer Is:
A Bed monitorC Leg monitor
D Mittens
The nurse obtains the blood pressure of several adult clients. Which client's blood pressure result causes the most concern?
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A. 140/90
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B. 102/70
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C. 125/85
- D. 118/75
Explanation
Explanation
A blood pressure reading of 140/90 mmHg meets the clinical threshold for hypertension in adults. This level indicates persistently elevated systolic and diastolic pressures, which increase the risk for cardiovascular disease, stroke, kidney damage, and other complications if not managed. This finding warrants further assessment, monitoring, and possible medical intervention, making it the most concerning result among the options.Correct Answer Is:
A. 140/90The nurse is inserting a nasogastric tube. Which position should the client assume for the procedure?
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A High-Fowler's
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B Supine
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C Left lateral
- D Prone
Explanation
Explanation
High-Fowler’s position is the appropriate position for nasogastric tube insertion because it aligns the esophagus and stomach, making tube passage easier and safer. Sitting upright reduces the risk of aspiration, allows gravity to assist tube advancement, and enables the client to swallow during insertion, which helps guide the tube into the esophagus rather than the airway.Correct Answer Is:
A High-Fowler'sThe nurse is providing perineal care for a client. Which nursing actions are appropriate? Select all that apply.
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A Place soiled linens on the floor
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B Change gloves as they become soiled
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C Retract the foreskin of the uncircumcised male to cleanse the tip of the penis
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D Cleanse the client's vagina from front to back
- E Use ice-cold water and alcohol-based sanitizer to cleanse the perineum
Explanation
Explanation
B Change gloves as they become soiledChanging gloves as they become soiled is an essential infection-control practice during perineal care. This prevents the transfer of microorganisms from contaminated areas to clean areas and reduces the risk of introducing bacteria into the urinary or reproductive tract.
C Retract the foreskin of the uncircumcised male to cleanse the tip of the penis
For uncircumcised male clients, retracting the foreskin is necessary to properly cleanse the glans penis. This prevents the buildup of smegma and reduces the risk of infection. After cleansing, the foreskin must be returned to its normal position to prevent circulatory impairment.
D Cleanse the client's vagina from front to back
Cleaning from front to back prevents the spread of fecal bacteria from the rectal area to the urethra or vagina. This technique significantly reduces the risk of urinary tract infections and is a standard, evidence-based perineal care practice.
Correct Answer Is:
B Change gloves as they become soiledC Retract the foreskin of the uncircumcised male to cleanse the tip of the penis
D Cleanse the client's vagina from front to back
A nurse recognizes that the process in which food is broken down in the gastrointestinal (GI) tract, releasing nutrients for the body to use, is called
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A. Indigestion
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B. Peristalsis
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C. Absorption
- D. Digestion
Explanation
Explanation
Digestion is the process by which food is broken down into smaller molecules in the gastrointestinal tract, allowing the body to extract and absorb nutrients. It involves mechanical and chemical processes that begin in the mouth and continue through the stomach and intestines. The nutrients released during digestion are then available for the body to use in various functions, including energy production and cell repair.Correct Answer Is:
D. DigestionThe instructor is observing a nursing student provide a bed bath to an unconscious client. Which action by the student requires intervention by the instructor?
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A. The student leaves the side rail down while turning the client
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B. The student verbalizes each step before implementing it
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C. The student places soiled linens in a linen hamper
- D. The student checks the water temperature before starting the bath
Explanation
Explanation
Leaving the side rail down while turning an unconscious client requires intervention because it poses a safety risk. The side rail should be raised to ensure the client does not accidentally fall or experience injury during the bath. Proper safety precautions, including the use of side rails, should always be followed when performing care on an unconscious or immobile client to prevent falls and ensure their safety.Correct Answer Is:
A. The student leaves the side rail down while turning the clientWhich device should the nurse advise the client to use regularly to prevent atelectasis?
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A.
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B.
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C.
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D.
Explanation
Explanation
The device shown in option A is an incentive spirometer, which is specifically designed to prevent atelectasis. Regular use encourages the client to take slow, deep breaths, promoting lung expansion and keeping the alveoli open. This helps prevent collapse of lung tissue, improves oxygenation, and is especially important for postoperative or immobile clients who are at increased risk for atelectasis.Correct Answer Is:
A.What should the nurse consider the most reliable way to assess placement of a nasogastric tube (NGT) immediately after insertion before initiating tube feedings?
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A Aspirate gastric contents and assess a pH of less than 7
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B Measure the NGT from the tip of the nose to the xiphoid process prior to insertion
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C Obtain an x-ray to confirm location of the NGT tip
- D Observe for bubbling when the proximal end of the tube is placed in a cup of water
Explanation
Explanation
An x-ray is the most reliable and definitive method for confirming correct nasogastric tube placement immediately after insertion. It visually verifies that the tube is positioned in the stomach and not in the respiratory tract, which is critical before starting tube feedings. Other methods may be used as supplemental checks, but radiographic confirmation is the gold standard for initial placement.Correct Answer Is:
C Obtain an x-ray to confirm location of the NGT tipHow to Order
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