PNR 105 Foundations of Nursing
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Free PNR 105 Foundations of Nursing Questions
A nurse is reviewing proper care of an indwelling urinary catheter with a student nurse. Which of the following should be included in the procedure?
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Keep the drainage bag above the level of the bladder to promote flow
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Maintain a closed drainage system at all times
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Disconnect the tubing regularly to measure urine output
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Provide perineal care only once daily
Explanation
Maintaining a closed drainage system is a critical step in preventing infection with an indwelling catheter. Along with this, the nurse should measure urine output regularly, observe drainage and urine characteristics at each encounter, keep the drainage bag below the bladder to prevent backflow, provide perineal and insertion site care twice daily, and secure the catheter to the leg. These measures promote comfort, accurate monitoring, and infection prevention.
A nurse is preparing to perform digital removal of stool for a patient with severe constipation. Which assessment finding would be most important to monitor during the procedure?
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Signs of dehydration
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Vagal response
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Abdominal distention
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Presence of hemorrhoids
Explanation
During digital removal of stool, stimulation of the vagus nerve can occur, leading to a vagal response. This may cause bradycardia, hypotension, dizziness, or even syncope, which can be dangerous for the patient. The nurse must closely monitor the patient’s heart rate and overall response during the procedure. If symptoms of vagal stimulation appear, the procedure should be stopped immediately and the patient stabilized.
A nurse is attending a cultural competence seminar and hears the term ethnocentrism. How should the nurse understand this concept?
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The belief that all cultures are equally valid and should be respected
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The belief that one’s own cultural group determines the standards by which other groups’ behavior should be judged
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The ability to adapt to different cultural practices without judgment
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The process of blending aspects of multiple cultures into one’s lifestyle
Explanation
Ethnocentrism is the belief that one’s own culture is superior and that its values, customs, and practices are the standard for judging other cultures. This viewpoint can create bias, prejudice, and misunderstandings in healthcare settings. Recognizing ethnocentrism helps nurses avoid imposing personal cultural norms on patients, instead fostering cultural sensitivity and delivering care that respects diverse beliefs and practices
A nurse begins a shift on a busy medical-surgical unit and will be caring for multiple clients. Which client does the nurse assess first?
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A client who would like some acetaminophen (Tylenol) for a mild headache
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A client who needs discharge teaching about an antibiotic
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A client who just received nitroglycerin for chest pain
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A client who has a question about her daily medications
Explanation
The priority for the nurse is to assess the client who just received nitroglycerin for chest pain. Chest pain may indicate myocardial ischemia or infarction, which is a life-threatening condition. After giving nitroglycerin, it is essential to quickly reassess the client’s pain level, vital signs, and response to the medication. This ensures that the treatment is effective and identifies if additional interventions are needed.
A nurse is caring for a patient who is passing continuous small amounts of stool, suggesting possible fecal impaction. Which type of enema would the nurse anticipate being ordered?
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Tap water enema
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Oil retention enema
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Fleet enema
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Soap suds enema
Explanation
A Fleet enema is a hypertonic solution commonly used to relieve constipation and clear fecal impaction. In patients passing continuous small amounts of stool, this often indicates overflow around an impaction. The Fleet enema works by drawing water into the bowel, stimulating peristalsis, and softening stool, making it effective for clearing impactions and restoring normal bowel function.
A nurse is assessing a patient who reports occasional urinary leakage because they cannot reach the bathroom in time. The nurse recognizes this as which type of urinary incontinence?
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Stress incontinence
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Urge incontinence
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Functional incontinence
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Overflow incontinence
Explanation
Functional incontinence occurs when a patient has normal bladder control but cannot reach the bathroom in time due to physical limitations, environmental barriers, or cognitive impairment. The problem is not with the urinary tract itself but with the ability to access toileting facilities. Addressing mobility, environment, or support needs can help reduce episodes of functional incontinence.
A client complains about the taste of the sublingual nitroglycerin and admits that he swallows it rather than holding it under his tongue. The nurse explains that sublingual medications:
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can be taken between the cheek and tongue to diminish taste.
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can be held against the roof of the mouth with the tongue to reduce taste.
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should not be swallowed because it alters the absorption potential.
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can be inserted rectally without loss of absorption potential.
Explanation
Sublingual medications, such as nitroglycerin, are designed to dissolve under the tongue, where they are absorbed rapidly into the bloodstream through the oral mucosa. Swallowing the medication subjects it to first-pass metabolism in the liver, which reduces its bioavailability and effectiveness. Therefore, clients should be instructed never to swallow sublingual tablets, as doing so alters absorption and delays therapeutic action.
A nurse is assessing a postoperative patient for signs of uncontrolled pain. Which findings would indicate the patient is experiencing poor pain control?
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Smiling, relaxed posture, and normal movement
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Grimacing with movement, holding the body rigid, and guarded behavior
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Steady respiratory rate, normal blood pressure, and calm affect
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Engaging in conversation, walking comfortably, and laughing
Explanation
Signs of uncontrolled pain often include nonverbal cues such as facial grimacing, guarding, or holding the body rigid to avoid movement. Patients may also limit mobility and appear tense or restless. These behaviors signal that pain is not adequately managed and require prompt nursing intervention, even if the patient is not verbally expressing discomfort.
A nurse is reviewing arterial blood gas (ABG) results and clinical symptoms for a patient with suspected respiratory alkalosis. Which findings would the nurse expect?
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pH less than 7.35, PaCO₂ greater than 45 mm Hg, bradypnea, lethargy
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pH greater than 7.45, PaCO₂ less than 35 mm Hg, hyperventilation, confusion, lightheadedness
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pH 7.35–7.45, PaCO₂ 35–45 mm Hg, normal respirations, stable mentation
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pH less than 7.35, PaCO₂ less than 35 mm Hg, tachypnea, drowsiness
Explanation
Respiratory alkalosis occurs when hyperventilation, often caused by anxiety or pain, leads to excessive exhalation of carbon dioxide. This reduces PaCO₂ below 35 mm Hg and raises blood pH above 7.45. Clinical signs include hyperventilation, confusion, and lightheadedness due to cerebral vasoconstriction from low CO₂ levels. Recognizing these findings helps guide interventions such as encouraging slow, controlled breathing.
A nurse is inserting a Foley catheter for a patient. While inflating the retention balloon, what should the nurse observe?
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The patient’s urine output in the drainage tubing
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The patient’s facial expressions for signs of discomfort
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The color of the patient’s urine in the drainage bag
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The position of the catheter tubing on the bed
Explanation
When inflating the Foley catheter balloon, the nurse must carefully observe the patient’s facial expressions for discomfort or pain. Discomfort may indicate the balloon is being inflated while still in the urethra rather than the bladder, which can cause trauma. If pain is noted, inflation should stop immediately and the catheter repositioned. Monitoring the patient’s response ensures correct placement and prevents injury.
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