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
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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 of the following actions should the nurse take first upon spotting smoke coming from a client's room?
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The nurse rescues the client by safely moving them out of the room to a secure location
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The nurse shuts the door to the client's room to prevent the smoke from spreading
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The nurse puts out the fire with a nearby fire extinguisher
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The nurse activates the fire alarm system
Explanation
Explanation
The first priority when spotting smoke or fire is to rescue the client and move them to a secure location. This action prevents harm from potential smoke inhalation or burns and ensures the client's immediate safety. According to fire safety protocols, the rescue should come before actions like closing doors, using fire extinguishers, or activating alarms. The RACE (Rescue, Alarm, Confine, Extinguish) acronym outlines this priority order in fire safety.Correct Answer Is:
A. The nurse rescues the client by safely moving them out of the room to a secure locationThe 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
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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 packThe 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
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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 placementThe 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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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
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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 feedingWhich 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
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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 scaleA 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
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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 hypotensionThe use of heat applications should be contraindicated for which client?
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The client suffering from hypothermia
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The client with a bleeding wound
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The client with severe back spasm
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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 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
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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 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
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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'sHow to Order
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