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 physician asks if the client has remained afebrile. Which vital sign should the nurse assess in an afebrile client?
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Blood pressure 106/90 mmHg
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Temperature of 97.9 degrees Fahrenheit
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Numeric pain level less than 2 on a 0-10 scale
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Tachycardia at 105 beats per minute
Explanation
Explanation
An afebrile client is one who does not have a fever, meaning their body temperature is within the normal range, typically around 98.6°F (37°C). A temperature of 97.9°F indicates that the client is within a normal temperature range, which is a key assessment when confirming if a client remains afebrile. This temperature is considered acceptable and does not indicate a fever.Correct Answer Is:
B. Temperature of 97.9 degrees FahrenheitThe 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
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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 clientA 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. DigestionThe 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
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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
The 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
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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 mLThe 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 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 packWhich 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
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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 device should the nurse advise the client to use regularly to prevent atelectasis?
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.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
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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 tipHow to Order
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