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
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 tipWhich action should the nurse take next after checking the residual gastric volume of a client receiving an intermittent tube feeding and obtaining 100 milliliters (mL)?
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A. Hold the feeding and notify the healthcare provider immediately
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B. Reinstill the aspirated contents and continue with the feeding
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C. Dispose of the aspirated contents in a medical waste bin
- D. Lay the client supine and restart the feeding
Explanation
Explanation
When a nurse checks the residual gastric volume and obtains 100 mL, the appropriate next step is to reinstate the aspirated contents and then continue the feeding, as long as the residual volume is within the acceptable range (usually less than 250 mL). Reinstating the aspirated contents helps maintain the client's electrolyte balance and prevents loss of nutrients. The nurse should assess the client's tolerance to the feeding and monitor for any signs of complications such as distention or discomfort.Correct Answer Is:
B. Reinstill the aspirated contents and continue with the feedingThe client is NPO in preparation for surgery and is receiving IV fluids at 100 mL/hour. The client has not taken anything by mouth and voided 250 mL over the past 4 hours. What is the client's total intake during this 4-hour period?
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A 250 mL
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B 300 mL
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C 400 mL
- D 650 mL
Explanation
Explanation
Total intake includes all fluids received by the client, regardless of output. The client is receiving IV fluids at a rate of 100 mL per hour. Over a 4-hour period, the intake is calculated as 100 mL/hour multiplied by 4 hours, which equals 400 mL. Urine output is not subtracted when calculating intake, as intake and output are recorded separately.Correct Answer Is:
C 400 mLWhich 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 use of heat applications should be contraindicated for which client?
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A. The client suffering from hypothermia
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B. The client with a bleeding wound
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C. The client with severe back spasm
- D. The client with edema in the lower extremities
Explanation
Explanation
Heat applications should be contraindicated for clients with a bleeding wound because heat can increase blood flow to the area, potentially leading to further bleeding and swelling. Applying heat to an active or recent wound can exacerbate the bleeding and impede proper healing. Cold applications are usually preferred in such cases to constrict blood vessels and minimize blood flow to the affected area.Correct Answer Is:
B. The client with a bleeding woundThe nurse is administering a bolus enteral feeding via a nasogastric tube (NGT). What should be the first action of the nurse?
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A. Give oral care
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B. Lower the head of the bed
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C. Flush the tube with water
- D. Check placement
Explanation
Explanation
Before administering a bolus enteral feeding, the nurse must first verify correct placement of the nasogastric tube to ensure it is positioned in the stomach and not displaced into the airway. Checking placement is a critical safety step that helps prevent aspiration, respiratory complications, and serious injury. Tube placement is typically verified by checking gastric aspirate pH or by reviewing radiographic confirmation per facility policy.Correct Answer Is:
D. Check placementWhich 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.The nurse checks the residual gastric volume of a client receiving an intermittent tube feeding and obtains 100 milliliters (mL). Which action should the nurse take next?
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A. Hold the feeding and notify the healthcare provider immediately
-
B. Reinstill the aspirated contents and continue with the feeding
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C. Dispose of the aspirated contents in a medical waste bin
- D. Lay the client supine and restart the feeding
Explanation
Explanation
When the residual gastric volume is within an acceptable range (usually less than 250 mL), the nurse should reinstill the aspirated contents and continue the feeding. This action helps maintain the client's electrolyte balance and nutritional intake. Reinstating the aspirate is important to avoid unnecessary loss of nutrients and to maintain the feeding schedule. The nurse should continue monitoring the client for any signs of intolerance or discomfort during the feeding.Correct Answer Is:
B. Reinstill the aspirated contents and continue with the feedingThe 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 applied a cold pack to a client's right wrist. The client begins to complain of numbness and tingling in the right hand. Which of the following actions should the nurse implement first?
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A Inform the healthcare provider
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B Assess the client's circulation
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C Remove the cold pack
- D Assess the skin for signs of damage
Explanation
Explanation
Numbness and tingling are signs of excessive cold exposure that may indicate impaired circulation or nerve compression. The nurse’s first priority is to remove the cold pack immediately to prevent further tissue injury, such as frostbite or nerve damage. Once the cold source is removed, circulation and skin integrity can then be assessed and additional interventions implemented if needed.Correct Answer Is:
C Remove the cold packHow to Order
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