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 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 clientThe 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 packWhat 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°FWhich nursing actions are appropriate when applying soft wrist restraints to ensure the client's safety? Select all that apply.
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Secure the restraint straps to the bed frame
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Remove the restraint every 2 hours
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Offer fluids to the client every 6 hours
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Tie the restraints using a quick-release knot
- Turn off distractors such as television or music
Explanation
Explanation
A. Secure the restraint straps to the bed frame
The restraint straps should be secured to a stationary part of the bed, such as the bed frame, to ensure the client's safety. This prevents movement of the client while allowing for secure restraint. Restraints should never be tied to movable parts of the bed, such as side rails, as this could lead to injury if the rails are adjusted or moved.
B. Remove the restraint every 2 hours
Restraints should be removed at least every 2 hours to assess the client’s circulation and provide comfort. Regular removal of restraints helps to prevent issues such as pressure ulcers, nerve compression, or circulation problems. The client should also be offered the opportunity to change position and to check for skin irritation.
D. Tie the restraints using a quick-release knot
A quick-release knot is essential when applying restraints to ensure that they can be removed quickly and safely in an emergency. This knot allows for rapid release of the restraint without causing further injury or difficulty. It is a key safety measure to ensure that staff can respond promptly to any changes in the client’s condition.
Correct Answer Is:
A. Secure the restraint straps to the bed frameB. Remove the restraint every 2 hours
D. Tie the restraints using a quick-release knot
Which 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 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'sA client's blood pressure (BP) while sitting was 130/82. Upon standing, the client became dizzy and the BP dropped to 108/68. The nurse identifies that the client is experiencing which condition?
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Essential hypotension
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Secondary hypotension
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Pulse pressure hypotension
- Orthostatic hypotension
Explanation
Explanation
Orthostatic hypotension, also known as postural hypotension, occurs when there is a significant drop in blood pressure upon standing. The normal response to standing is for the blood vessels to constrict and maintain blood pressure. However, in orthostatic hypotension, this process is impaired, leading to a drop in BP and symptoms such as dizziness or lightheadedness, as seen in this client. A drop of 20 mmHg or more in systolic BP or 10 mmHg or more in diastolic BP when standing is typically diagnostic of orthostatic hypotension.Correct Answer Is:
D. Orthostatic hypotensionWhich 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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Hold the feeding and notify the healthcare provider immediately
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Reinstill the aspirated contents and continue with the feeding
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Dispose of the aspirated contents in a medical waste bin
- 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 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 lungsWhich 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. SodiumHow to Order
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