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
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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Indigestion
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Peristalsis
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Absorption
- 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. DigestionWhich electrolyte does water follow?
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Calcium
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Potassium
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Magnesium
- Sodium
Explanation
Explanation
Water primarily follows sodium due to the principle of osmosis. When sodium is present in higher concentrations in the extracellular fluid, water will move towards the sodium to balance the concentration of solutes across the membrane. This process helps regulate fluid balance in the body. Sodium plays a key role in maintaining fluid volume, blood pressure, and cellular hydration.Correct Answer Is:
D. SodiumThe 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
Which electrolyte is the most abundant cation in the extracellular fluid compartments, including the blood, with serum levels ranging from 135 to 145 mEq/L?
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Sodium
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Potassium
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Magnesium
- Chloride
Explanation
Explanation
Sodium is the most abundant cation in the extracellular fluid compartments, including the blood. It plays a crucial role in maintaining fluid balance, blood pressure, and nerve and muscle function. The normal serum sodium levels range from 135 to 145 mEq/L, and sodium helps regulate osmotic pressure in the body, ensuring proper hydration and electrolyte balance.Correct Answer Is:
A. SodiumThe nurse is caring for a client who is alert and oriented to self only. Which of the following should the nurse implement to aid in the prevention of a client fall? Select all that apply.
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A Remove all mobility aids from the room
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B Place the bed in the lowest position
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C Use a bed alarm
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D Turn off all lights to maintain a calm environment
- E Leave all four side rails up
Explanation
Explanation
B Place the bed in the lowest positionPlacing the bed in the lowest position reduces the risk of injury if the client attempts to get out of bed independently. It shortens the distance to the floor, improves stability when sitting or standing, and is a standard fall-prevention intervention for clients with altered orientation.
C Use a bed alarm
A bed alarm alerts nursing staff when the client attempts to get out of bed without assistance. This allows staff to respond promptly and provide help, reducing the risk of falls while avoiding physical restraints. Bed alarms are especially useful for clients with cognitive impairment or disorientation.
Correct Answer Is:
B Place the bed in the lowest positionC Use a bed alarm
The 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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The student leaves the side rail down while turning the client
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The student verbalizes each step before implementing it
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The student places soiled linens in a linen hamper
- 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 clinical manifestations should be possible observations related to fluid volume deficit? Select all that apply.
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A Strong, bounding pulse
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B Increased urine output
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C Flushed, pale, hot, dry skin
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D Low blood pressure
- E Decreased urine output
Explanation
Explanation
D Low blood pressureLow blood pressure is a common manifestation of fluid volume deficit because there is a reduced circulating blood volume. When intravascular volume decreases, venous return to the heart is reduced, leading to decreased cardiac output and hypotension. This finding reflects inadequate fluid levels to maintain normal blood pressure.
E Decreased urine output
Decreased urine output occurs in fluid volume deficit as the kidneys conserve water to maintain circulating volume. Reduced renal perfusion triggers hormonal responses, such as activation of antidiuretic hormone and the renin-angiotensin-aldosterone system, resulting in less urine production. This is an important indicator of dehydration or hypovolemia.
Correct Answer Is:
D Low blood pressureE Decreased urine output
The 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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Bed monitor
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Wrist
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Leg monitor
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Mittens
- 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 checks the residual gastric volume before administering a tube feeding. What is the primary purpose of this nursing action?
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To assess the patency of the nasogastric tube
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To verify the nutritional content of the formula
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To prevent aspiration of feeding formula into the lungs
- To evaluate whether the client needs additional hydration
Explanation
Explanation
Checking the residual gastric volume helps determine how much food or liquid remains in the stomach from the previous feeding. If the residual volume is too high (usually over 250 mL), it can indicate delayed gastric emptying, increasing the risk of aspiration. Aspiration occurs when the formula is regurgitated into the airways and can lead to serious complications such as pneumonia. Therefore, the primary purpose of checking the residual volume is to prevent aspiration by ensuring the stomach is adequately empty before administering a new feeding.Correct Answer Is:
C. To prevent aspiration of feeding formula into the lungsHow to Order
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