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
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 lungsThe nurse obtains the blood pressure of several adult clients. Which client's blood pressure result causes the most concern?
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140/90
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102/70
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125/85
- 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. 140/90Which 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 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 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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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
What step should the nurse ensure when setting up an aquathermia pad for a client?
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A Keep water temperature between 98°F and 105°F
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B Keep the client lying in bed at all times
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C Keep the pad wrapped tightly around the limb
- D Keep the water reservoir chamber empty
Explanation
Explanation
When using an aquathermia pad, the nurse must ensure that the water temperature remains within the safe range of 98°F to 105°F to prevent thermal injury. Temperatures above this range increase the risk of burns, while lower temperatures may be ineffective. Maintaining the correct temperature promotes therapeutic heat transfer while protecting the client’s skin integrity and circulation.Correct Answer Is:
A Keep water temperature between 98°F and 105°FThe 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 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 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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Give oral care
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Lower the head of the bed
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Flush the tube with water
- 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 placementHow to Order
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