RN Fundamentals Proctored Exam: Assessment Questions with Certified Answers (Part 1), Exams of Nursing

Download RN Fundamentals Proctored Exam: Assessment Questions with Certified Answers (Part 1) and more Exams Nursing in PDF only on Docsity! RN Fundamentals Proctored Exam Assessment Questions with Certified Answer Success Guaranteed. Can an RN delegate to the LPN to provide tracheostomy care to a client with pneumonia? - Answer Yes. A nurse on a med-surg unit has received change-of-shift report & will care for 4 clients. Which of the following client's needs may the nurse assign to an assistive personnel (AP)? A. Feeding a client who was admitted 24 hrs ago w/aspiration pneumonia B. Reinforcing teaching w/a client who is learning to walk using a quad cane C. Reapplying a condom catheter for a client who has urinary incontinence RN Fundamentals Proctored Exam Assessment Questions with Certified Answer Success Guaranteed. D. Applying a sterile dressing to a pressure ulcer - Answer C. Reapplying a condom catheter for a client who has urinary incontinence Rationale: The application of a condom catheter is a noninvasive, routine procedure that the nurse may delegate to the AP A nurse is delegating the ambulation of a client who had knee arthroplasty 5 days ago to an AP. Which of the following information should the nurse share with the AP? Select All. A. The roommate is up independently. B. The client ambulates w/his slippers on over his antiembolic stockings C. The client uses a front-wheeled walker when ambulating D. The client had pain medication 30 min ago E. The client is allergic to codeine F. The client ate 50% of his breakfast this morning - Answer B, C, D RN Fundamentals Proctored Exam Assessment Questions with Certified Answer Success Guaranteed. C. LPN D. AP - Answer B. RN A client returning from surgery requires assessment and establishment of a plan of care. RNs are responsible for this, especially if the client is potentially unstable. A nurse observes an AP reprimanding a client for not using the urinal properly. The AP tells him she will put a diaper on him if he does not use the urinal more carefully next time. Which of the following torts is the AP committing? A. Assault B. Battery C. False imprisonment D. Invasion of privacy - Answer A. Assault RN Fundamentals Proctored Exam Assessment Questions with Certified Answer Success Guaranteed. By threatening the client, the AP is committing assault. An adult client who is competent tells the nurse that he is thinking about leaving the hospital against medical advice. The nurse believes that this is not in the client's best interest, so she administers a PRN sedative med that the client has not requested along w/his usual meds. Which of the following tort has the nurse committed? A. Assault B. False imprisonment C. Negligence D. Breach of confidentiality - Answer B. False imprisonment The nurse gave the med as a chemical restraint to keep the client from leaving the facility against medical advice. The client did not consent. RN Fundamentals Proctored Exam Assessment Questions with Certified Answer Success Guaranteed. A client who will undergo neurosurgery the following week tells the nurse in the surgeon's office that he will prepare his advance directives before he goes to the hospital. Which of the following statements by the client indicates to the nurse that he understands advance directives? A. "I'd rather have my brother make decisions for me, but I know it has to be my wife." B. "I know they won't go ahead w/the surgery unless I prepare these forms." C. "I plan to write that I don't want them to keep me on a breathing machine." D. "I will get my regular doctor to approve my plan before I hand it in at the hospital." - Answer C. The client has the right to decide and specify which medical procedures he wants when a life-threatening situation arrives RN Fundamentals Proctored Exam Assessment Questions with Certified Answer Success Guaranteed. A. The client's input & output for the shift B. The client's BP from the previous day C. A bone scan that is scheduled for today D. The med routine from the med administration record - Answer C. A bone scan that is scheduled for today This is important because the nurse might have to modify the client's care to accommodate them leaving the unit A nurse enters a client's room & finds him sitting in his chair. He states, "I fell in the shower, but I got myself back up & into my chair." How should the nurse document this in the client's chart? A. The client fell in the shower. B. The client states he fell in the shower & was able to get himself back into his chair RN Fundamentals Proctored Exam Assessment Questions with Certified Answer Success Guaranteed. C. The nurse should not document this info because she did not witness the fall D. The client fell in the shower & is now resting comfortably - Answer B. By writing what the client states, the info is subjective data A nursing instructor is reviewing documentation w/a group of nursing students. Which of the following legal guidelines should they follow when documenting a client's record? Select all. A. Cover errors w/correction fluid, & write in the correct info B. Put the date & time on all entries C. Document objective data, leaving out opinions D. Use as many abbreviations as possible E. Wait until the end of the shift to document - Answer B, C RN Fundamentals Proctored Exam Assessment Questions with Certified Answer Success Guaranteed. The skin barrier covering a client's intestinal fistula keeps falling off when she stands up to ambulate. The nurse has reapplied it twice during the shift, but it remains intact only when the client is supine in bed. The nurse telephoned the physical therapist about the difficulties containing the drainage from the fistula, so the therapist didn't ambulate the client today. The client sat in a chair during lunch w/an absorbent pad over the fistula. The client ate all the food on her tray. The wound care nurse confirmed that she will see the client later today. The client states she feels frustrated at not having physical therapy, but the nurse thinks the client welcomed having a day to rest. Which of the following information should the nurse include in the change-of-shift report? Select all. A. The physical therapist didn't ambulate the client today B. The skin barrier's seal stays on in bed but loosens when the - Answer A, B, D RN Fundamentals Proctored Exam Assessment Questions with Certified Answer Success Guaranteed. C. Registered dietitian D. Occupational therapist - Answer D. An occupational therapist can assist clients who have physical challenges to use adaptive devices & strategies to help w/self-care activities A client who is postop following a knee arthroplasty is concerned about the adverse effects of the medication he is receiving for pain management. Which of the following members of the interprofessional care team may assist the client in understanding the medication's effects? Select all. A. Provider B. CNA C. Pharmacist D. RN RN Fundamentals Proctored Exam Assessment Questions with Certified Answer Success Guaranteed. E. Respiratory therapist - Answer A, C, D A client who has had a cerebrovascular accident has persistent problems w/dysphagia. The nurse caring for the client should initiate a referral w/which of the following members of the interprofessional care team? A. Social worker B. CNA C. Occupational therapist D. Speech-language pathologist - Answer D A speech-language pathologist can initiate specific therapy for clients who have difficulty feeding due to swallowing difficulties A nursing instructor is acquainting a group of nursing students w/the roles of the various members of the health care team they will RN Fundamentals Proctored Exam Assessment Questions with Certified Answer Success Guaranteed. encounter on a medical-surgical unit. When she gives examples of the types of tasks CNAs may perform, which of the following client activities should she include? Select all. A. Bathing B. Ambulating C. Toileting D. Determining pain level E. Measuring vital signs - Answer A, B, C, E Determining pain level requires assessment, which is the job of the licensed personnel. A nurse in a provider's office is preparing to assess a young adult male client's musculoskeletal system as part of a comprehensive physical RN Fundamentals Proctored Exam Assessment Questions with Certified Answer Success Guaranteed. A nurse is preforming a neurosensory examination for a client. Which of the following tests should the nurse preform to test the client's balance? Select all. A. Romberg test B. Heel-to-toe walk C. Snellen test D. Spinal accessory function E. Rosenbaum test - Answer A, B C and E test visual acuity , D tests cranial nerve XI is intact by asking the client to shrug shoulders without complication. A nurse is collecting data from an older adult client as part of a neurosensory examination. Which of the following findings should the nurse expect as changes associated w/aging? Select all. RN Fundamentals Proctored Exam Assessment Questions with Certified Answer Success Guaranteed. A. Slower light touch sensation B. Some vision & hearing decline C. Slower fine finger movement D. Some short-term memory decline E. Slower superficial pain sensation - Answer B, C, D A nurse is providing discharge instructions to a client who has a prescription for the use of oxygen in his home. Which of the following should the nurse teach the client about using oxygen safely in his home? Select all. A. Family members who smoke must be at least 10 ft from the client when the oxygen is in use B. Nail polish should not be used near a client who is receiving oxygen C. A "No smoking" sign should be placed on the front door RN Fundamentals Proctored Exam Assessment Questions with Certified Answer Success Guaranteed. D. Cotton bedding & clothing should be replaced w/items made from wool E. A fire extinguisher should be readily available in the home - Answer B, C, E Family members that smoke should do so outside, and wool creates static electricity so it should be avoided. A nurse educator is conducting a parenting class for new parents. Which of the following statements made by a participant indicates a need for further clarification & instruction? A. "I will begin swimming lessons as soon as my baby can close her mouth under water." B. "Once my baby can sit up, he should be safe in the bathtub." C. "I will test the temp of the water before placing my baby in the bath." RN Fundamentals Proctored Exam Assessment Questions with Certified Answer Success Guaranteed. A home health nurse is discussing the dangers of food poisoning w/a client. Which of the following info should the nurse include in her counseling? Select all. A. Most food poisoning is caused by a virus B. Immunocompromised individuals are at risk for complications from food poisoning C. Clients who are especially at risk are instructed to eat or drink only pasteurized milk, yogurt, cheese, or other dairy products D. Healthy individuals usually recover from the illness in a few weeks E. Handling raw & fresh food separately to avoid cross contamination may prevent food poisoning - Answer B, C, E Most food poisoning is caused by a bacteria such as E. coli. Healthy individuals usually recover in a few days. RN Fundamentals Proctored Exam Assessment Questions with Certified Answer Success Guaranteed. A nurse is caring for a client diagnosed w/severe acute respiratory syndrome (SARS). The nurse is aware that health care professionals are required to report communicable & infectious diseases. Which of the following illustrate the rationale for reporting? Select all. A. Planning & evaluating control & prevention strategies B. Determining public health priorities C. Ensuring proper medical treatment D. Identifying endemic disease E. Monitoring for common-source outbreaks - Answer A, B, C, E Not D because endemic disease is already prevalent within a population, so reporting is not necessary RN Fundamentals Proctored Exam Assessment Questions with Certified Answer Success Guaranteed. A nurse is contributing to the plan of care for a client who is being admitted to the facility w/a suspected diagnosis of pertussis. Which of the following should the nurse include in the plan of care? Select all. A. Place the client in a room that has negative air pressure of at least 6 exchanges/hr B. Wear a mask when providing care within 3 ft of the client C. Place a surgical mask on the client if transportation to another dept is unavoidable D. Use sterile gloves when handling soiled linens E. Wear a gown when preforming care that may result in contamination from secretions - Answer B, C, E Private room w/droplet precautions indicated for this client. The nurse should wear a gown when contamination from body fluids might happen RN Fundamentals Proctored Exam Assessment Questions with Certified Answer Success Guaranteed. E. Increase in pulse & respiratory rate - Answer A, B, E Edema and pain and tenderness is localized A nurse is teaching a young adult client about health promotion & illness prevention. Which of the following statements by the client indicates an understanding of the teaching? A. "I already had my immunizations as a child, so I'm protected in that area." B. "It is important to schedule routine health care visits even if I'm feeling well." C. "If I'm having any discomfort, I'll just got to an urgent care center." D. "If I am felling stressed, I will remind myself that this is something I should expect." - Answer B. routine health screenings are important at any age RN Fundamentals Proctored Exam Assessment Questions with Certified Answer Success Guaranteed. A nursing instructor is explaining the various stages of the lifespan to a group of nursing students. The nurse should offer which of the following behaviors by a young adult as an example of appropriate psychosocial development? A. Becoming actively involved in providing guidance to the next generation B. Adjusting to major changes in roles and relationships due to losses C. Devoting a great deal of time to establishing an occupation D. Finding oneself "sandwiched" in between & being responsible for 2 generations - Answer C. Exploring and establishing career options & establishing oneself is important developmental task in a young adult A nurse is counseling a young adult who describes having difficulty dealing w/several issues. Which of the following problems the client RN Fundamentals Proctored Exam Assessment Questions with Certified Answer Success Guaranteed. verbalized should the nurse identify as the priority for further assessment & intervention? A. "I have my own apartment now, but it's not easy living away from my parents." B. "It's been so stressful for me to even think about having my own family." C. "I don't even know who I am yet, & now I'm supposed to know what to do." D. "My girlfriend is pregnant, & I don't think I have what it takes to be a good father." - Answer C. Applying Erikson stages of development, knowing oneself is done in adolescence, and this requires the most urgent help A nurse is reviewing safety precautions w/a group of young adults at a community health fair. Which of the following recommendations should the nurse include specifically for this age group? Select all. RN Fundamentals Proctored Exam Assessment Questions with Certified Answer Success Guaranteed. The nurse should prevent shivering & encourage the client to increase fluids. Why E-Oral hygiene helps prevent cracking of dry mucous membranes of the mouth & lips. A nurse is instructing an AP in caring for a client who has a low platelet count as a result of chemo. Which of the following is the nurse's priority instruction for measuring vital signs for this client? A. "Don't measure the client's temp rectally." B. "Count the client's radial pulse for 30 sec & multiply by 2." C. "Don't let the client know you are counting her respirations." D. "Let the client rest for 5 mins before you measure her BP." - Answer A. "Don't measure the client's temp rectally." RN Fundamentals Proctored Exam Assessment Questions with Certified Answer Success Guaranteed. The greatest risk to a client w/a low platelet count is injury that results in bleeding, obtaining a temp this way increases the risk for bleeding. A nurse is instructing a group of nursing students in measuring a client's RR. Which of the following guidelines should the nurse include? Select all. A. Place the client in semi-Fowler's position B. Have the client rest an arm across the abdomen C. Observe 1 full respiratory cycle before counting the rate D. Count the rate for 1 min if it is regular E. Count & report any signs the client demonstrates - Answer A, B, C For D, this is if the rate is irregular after initial count, for E, sighs are expected & don't need to be reported RN Fundamentals Proctored Exam Assessment Questions with Certified Answer Success Guaranteed. A nurse who is admitting a client who has a fractured femur obtains a BP reading of 140/94 mmHg. The client denies any history of HTN. Which of the following actions should the nurse take next? A. Request a prescription for an antihypertensive med B. Ask the client if she is having pain C. Request a prescription for an anti-anxiety med D. Return in 30min to recheck the client's BP - Answer B Perform a pain assessment would be the appropriate action to take next A nurse is performing an admission assessment on a client. When measuring her vital signs, the nurse finds that her radial pulse rate 68/min & her simultaneous apical pulse rate is 84/min. What is the client's pulse deficit? - Answer 16/min RN Fundamentals Proctored Exam Assessment Questions with Certified Answer Success Guaranteed. C. Fever D. Poor skin turgor E. Peripheral edema - Answer B, C, D fever=caused by dehydration tachycardia not brady hypotension because of decreased BP from dehydration fluid overload=peripheral edema A nurse is preparing to administer a cleansing enema to an adult client in preparation for a diagnostic procedure. Which of the following are appropriate steps for the nurse to take? Select all. A. Warm the enema prior to instillation B. Position the client on the left side w/the right leg flexed forward C. Lubricate the rectal tube or nozzle RN Fundamentals Proctored Exam Assessment Questions with Certified Answer Success Guaranteed. D. Slowly insert the rectal tube about 2 inches E. Hang the enema container 24 inches above the client's anus - Answer A, B, C -D is the appropriate length of insertion for a child, 3-4 for an adult. -24 inches is too high & will cause it to run to fast & possible painful distention of the colon, 18 inches is the recommended height While a nurse is administering a cleansing enema, the client reports abdominal cramping. Which of the following is the appropriate intervention? A. Have the client hold his breath briefly B. Discontinue the fluid instillation C. Remind the client that cramping is common at this time D. Lower the enema fluid container - Answer D. RN Fundamentals Proctored Exam Assessment Questions with Certified Answer Success Guaranteed. This will slow the rate of instillation & relieve some discomfort A nurse is caring for a client who has been sitting in a chair for 3 hrs. Which of the following problems is the client at risk for developing? A. Stasis of secretions B. Muscle atrophy C. Pressure ulcer D. Fecal impaction - Answer Answer: C Unrelieved pressure over a bony prominence for too long increases the risk of a pressure ulcer A-sitting will help prevent stasis of secretions B and D-these are from prolonged bed rest RN Fundamentals Proctored Exam Assessment Questions with Certified Answer Success Guaranteed. C. "With this thing on, my leg muscles won't get weak." D. "This device is going to keep my joints in good shape." - Answer B. sequential pressure devices promote venous return in the deep veins of the legs & thus help prevent thrombus formation To promote the safe use of a cane for a client who is recovering from a minor musculoskeletal injury of the left lower extremity, which of the following instructions should the nurse provide? Select all. A. Hold the cane on the right side B. Keep 2 points of support on the floor C. Place the cane 15in in front of the feet before advancing D. After advancing the cane, move the weaker leg forward E. Advance the stronger leg so that it aligns evenly w/the cane - Answer A, B, D RN Fundamentals Proctored Exam Assessment Questions with Certified Answer Success Guaranteed. C-the client should place the cane 6-10 inches in front before advancing not 15 E-the client should advance the stronger leg past the cane not aligned w/it A nurse is assessing the pain level of a client who has come to the ER reporting severe abd. pain. The nurse asks the client whether he has nausea & has been vomiting. The nurse is assessing which of the following? A. Presence of associated symptoms B. Location of the pain C. Pain quality D. Aggravating & relieving factors - Answer A. this is a common symptom people have when experiencing pain RN Fundamentals Proctored Exam Assessment Questions with Certified Answer Success Guaranteed. A nurse is assessing a client who is reporting severe pain despite analgesia. The nurse can best assess the intensity of the client's pain by: A. asking what precipitates the pain B. questioning the client about the location of the pain C. offering the client a pain scale to measure his pain D. using open-ended questions to identify the situation - Answer C. pain scale can measure the amount and intensity of the pain A nurse is obtaining hx from a client who has pain. The nurse's guiding principle throughout this process should be that: A. some clients exaggerate their level of pain B. pain must have an identifiable source to justify the use of opioids. C. objective data are essential in assessing pain D. pain is whatever the client says it is - Answer D RN Fundamentals Proctored Exam Assessment Questions with Certified Answer Success Guaranteed. A. Orthostatic hypotension B. Fine motor tremors C. Acute dystonias D. Decreased level of consciousness E. Uncontrollable restlessness - Answer B, C, E A and D are adverse effects, but not EPS A nurse is providing teaching about managing anticholinergic effects for a client who has a new prescription for oxybutunin (Ditropan XL). Which of the following are appropriate to include in the teaching? Select all. A. Take frequent sips of water B. Wear sunglasses when exposed to sunlight RN Fundamentals Proctored Exam Assessment Questions with Certified Answer Success Guaranteed. C. Use a soft toothbrush when brushing teeth D. Take the medication w/an antacid E. Urinate prior to taking the med - Answer A, B, E side effects of this med include: dry mouth, photophobia, and urinary retention A nurse is reviewing the reported meds of a client who was recently admitted. The meds include cimetidine (Tagamet) & imipramine hydrochloride (Tofranil). Knowing that cimetidine decreases the metabolism of imipramine hydrochloride, the nurse should identify that this combination is likely to result in which of the following effects? A. Decreased therapeutic effects of cimetidine B. Increased risk of imipramine hydrochloride toxicity C. Decreased risk of adv effects of cimetidine RN Fundamentals Proctored Exam Assessment Questions with Certified Answer Success Guaranteed. D. Increased therapeutic effects of imipramine hydrochloride - Answer B. A med that decreases the metabolism of a 2nd med increases the serum level of the 2nd med, increasing risk for toxicity A nurse in an outpatient clinic is caring for a client who states she is trying to get pregnant. The client currently takes a Category D pregnancy risk med for the control of seizures. Which of the following statements by the nurse is appropriate? A. "This med is prescribed if necessary but it is known to cause adverse effects to the fetus." B. "This med has evidence indicating that it is safe to take during pregnancy & will not harm the fetus." C. "This med cannot be taken during pregnancy because the risk outweighs the potential benefits." RN Fundamentals Proctored Exam Assessment Questions with Certified Answer Success Guaranteed. A. Give the client thin liquids. B. Instruct the client to tuck her chin when swallowing. C. Have the client use a straw. D. Encourage the client to lie down & rest after meals. - Answer B. Tucking when swallowing allows food to pass down esophagus more easily. A nurse is preparing a presentation about basic nutrients for a group of high school athletes. She should explain that which of the following is the body's priority energy reserve? A. Fat B. Protein C. Glycogen D. Carbohydrates - Answer D. carbs provide glucose RN Fundamentals Proctored Exam Assessment Questions with Certified Answer Success Guaranteed. A nurse is caring for a client who is on a low-residue diet. The nurse should expect to see which of the following foods on the client's meal tray? A. Cooked barley B. Pureed broccoli C. Vanilla custard D. Lentil soup - Answer C. low-residue diets are low in fiber and easy to digest: dairy products especially A nurse is caring for a client who weighs 80 kg (176 lb) and is 1.6 m ( 5 ft 3 in) tall. Calculate her BMI & determine whether this client is obese based on her BMI. - Answer BMI=30 above 30 equals obese so yes. RN Fundamentals Proctored Exam Assessment Questions with Certified Answer Success Guaranteed. A nurse in a senior center is counseling a group of older adults about their nutritional needs & considerations. Which of the following info should the nurse include? Select all. A. Older adults are more prone to dehydration than younger adults are B. Older adults need the same amount of most vitamins & minerals as younger adults do C. Many older men & women need calcium supplementation D. Older adults need more calories than they did when they were younger E. Older adults should consume a diet low in carbs - Answer A, B, C D-they need fewer calories not more E-they need more carbs & fiber RN Fundamentals Proctored Exam Assessment Questions with Certified Answer Success Guaranteed. D. "Mix all the crushed meds prior to dissolving in water." - Answer A The client should flush the tube w/15-30 mL of water to prevent clogging of the tube A nurse educator is teaching a module on pharmacokinetics to a group of newly licensed nurses. Which of the following statements by a newly licensed nurse indicates an understanding of the 1st-pass effecct? A. "Some meds block normal receptor activity regulated by endogenous compounds or receptor activity caused by other meds." B. "Some meds may have to be administered by a nonenteral route to avoid inactivation as they travel through the liver." C. "Some meds leave the body more slowly & therefore have a greater risk of accumulation & toxicity." D. "Some meds have a wide safety margin, so there is no need for routine serum medication level monitoring." - Answer B. first pass deals with the liver RN Fundamentals Proctored Exam Assessment Questions with Certified Answer Success Guaranteed. A nurse is teaching an adult client how to administer ear drops. Which of the following statements by the client indicates understanding of the proper technique? A. "I will straighten my ear canal by pulling my ear down & back." B. "I will gently apply pressure w/my finger to the tragus of my ear after putting in the drops." C. "I will insert the nozzle of the ear drop bottle snug into my ear before squeezing the drops in." D. "After the drops are in, I will place a cotton ball all the way into my ear canal." - Answer B. The client should apply gentle pressure w/the finger to the tragus of the ear after administering the drops to help the drops go into the ear canal. RN Fundamentals Proctored Exam Assessment Questions with Certified Answer Success Guaranteed. A nurse prepares to administer an injection of morphine (Duramorph) to a client who reports pain. Prior to administering, the nurse is called to another room to assist another client onto a bedpan. She asks a 2nd nurse to give the injection. Which of the following actions should the 2nd nurse take? A. Offer to assist the client needing the bedpan. B. Administer the injection prepared by the other nurse C. Prepare another syringe & administer the injection D. Tell the client needing the bedpan she will have to wait for her nurse - Answer A. A nurse is preparing to administer a med to a client. The med was scheduled for administration at 0900. Which of the following are acceptable administration times for this med? Select all. A. 0905 RN Fundamentals Proctored Exam Assessment Questions with Certified Answer Success Guaranteed. A nurse is preparing to administer digoxin (Lanoxin) to a client who states, "I don't want to take that med. I do not want one more pill." Which of the following responses by the nurse is appropriate in this situation? A. "Your physician prescribed it for you, so you really should take it." B. "Well, let's just get it over w/quickly then." C. "Okay, I'll just give you your other meds." D. "Tell me your concerns w/taking this med." - Answer D. A nurse is assessing a client who has an acute resp. infection that puts her at risk for hypoxemia. Which of the following findings are early indications that should alert the nurse that the client is developing hypoxemia? Select all. A. Restlessness RN Fundamentals Proctored Exam Assessment Questions with Certified Answer Success Guaranteed. B. Tachypnea C. Bradycardia D. Confusion E. Pallor - Answer A, B, E C and D are late manifestations of hypoxemia. A nurse is caring for a client who is having difficulty breathing. The client is lying in bed & is already receiving oxygen therapy via nasal cannula. Which of the following interventions is the nurse's priority? A. Increase the oxygen flow B. Assist the client to Fowler's position C. Promote removal of pulmonary secretions D. Obtain a specimen for arterial blood gases - Answer B Fowler's facilitates better breathing RN Fundamentals Proctored Exam Assessment Questions with Certified Answer Success Guaranteed. A nurse is preparing to preform endotracheal suctioning for a client. Which of the following are appropriate guidelines for the nurse to follow? Select all. A. Apply suction while withdrawing the catheter B. Perform suctioning on a routine basis, Q2-3 hours C. Maintain medical asepsis during suctioning D. Use a new catheter for each suctioning attempt E. Limit suctioning to 2-3 attempts - Answer A, D, E B-Suctioning is not w/out risk so it should be done as needed, not routinely. C-endotracheal suctioning requires surgical asepsis RN Fundamentals Proctored Exam Assessment Questions with Certified Answer Success Guaranteed. A. "Water helps clear the tube so it doesn't get clogged." B. "Flushing helps make sure the tube stays in place." C. "This will help you get enough fluids." D. "Adding water makes the formula less concentrated." - Answer A this action clears the excess formula preventing any clumps/clogging A nurse is preparing to instill an enteral feeding to a client who has an NG tube in place. Which of the following is the nurse's highest assessment priority before performing this procedure? A. Check how long the feeding container has been opened B. Verify the placement of the NG tube C. Confirm that the client doesn't have diarrhea D. Make sure the client is alert & oriented - Answer B the greatest risk is aspiration so verifying the placement of the tube is most important RN Fundamentals Proctored Exam Assessment Questions with Certified Answer Success Guaranteed. A nurse is caring for a client who is receiving continuous enteral feedings. Which of the following nursing interventions is the highest priority when the nurse suspects aspiration of the feeding? A. Auscultate breath sounds B. Stop the feeding C. Obtain a chest xray D. Initiate oxygen therapy - Answer B. Stop the feeding A nurse is caring for a client in a long-term care facility who is receiving enteral feedings via NG tube. Which of the following is an appropriate nursing action prior to administering the tube feeding? Select all. A. Auscultate bowel sounds. B. Assist the client to an upright position. RN Fundamentals Proctored Exam Assessment Questions with Certified Answer Success Guaranteed. C. Test the pH of gastric aspirate. D. Warm the formula to body temp. E. Discard any residual gastric contents. - Answer A, B, C D-the formula should be room temp not body E-unless the volume of the contents is more than 250 mL, the nurse should return the residual content to the client's stomach A nurse is preparing to insert an NG tube for a client who requires gastric decompression. Which of the following actions should the nurse perform prior to beginning the procedure? Select all. A. Review a signal the client can use if feeling any distress B. Lay a towel across the client's chest C. Administer oral pain meds D. Obtain a Dobhoff tube for insertion RN Fundamentals Proctored Exam Assessment Questions with Certified Answer Success Guaranteed. A. Stage III pressure ulcer B. Sutured surgical incision C. Casted bone fracture D. Laceration sealed w/adhesive E. Open burn area - Answer A, E B and D are healed w/primary intention C is not a skin wound unless bone has pierced the skin A client who had abd. surgery 24 hr ago reports a pulling sensation & pain in his surgical incision. The nurse checks the client's surgical wound & finds the wound separated w/viscera protruding. Which of the following interventions is appropriate? Select all. A. Cover the area w/saline-soaked sterile dressings B. Apply an abdominal binder snugly around the abd. RN Fundamentals Proctored Exam Assessment Questions with Certified Answer Success Guaranteed. C. Use sterile gloves to apply gentle pressure to the exposed tissues D. Position the client supine w/his hips & knees bent E. Offer the client a warm beverage, such as herbal tea - Answer A, D A nurse is caring for an older adult client who is at risk for developing pressure ulcers. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin? Select all. A. Keep the head of the bed elevated 30 degrees B. Massage the client's bony prominences often C. Apply cornstarch liberally to the skin after bathing D. Have the client sit on a gel cushion when in a chair E. Reposition the client at least Q 3 hr while in bed - Answer A, D not E because it should be at least every 2 hours RN Fundamentals Proctored Exam Assessment Questions with Certified Answer Success Guaranteed. 102 - Answer