PN FUNDAMENTALS PROCTORED EXAM

Question 1: View

A nurse is planning to provide postmortem care for a client who requires an autopsy. Which of the following actions should the nurse plan to take?

A. Ask the assist personnel to document the client's time of death. B. Place an identification tag on the outside of the client's shroud. C. Wear sterile gloves when cleaning the client's body. D. Remove the client's dentures and give them to the client's family.

Explanation

A. Asking the assist personnel to document the client's time of death is not correct. While accurate documentation of the time of death is important, the responsibility typically falls on the healthcare provider or physician who confirms the death, not necessarily the assist personnel involved in postmortem care. B. Place an identification tag on the outside of the client's shroud is correct. This action ensures proper identification throughout the postmortem process and aligns with standard procedures for maintaining identification integrity during autopsy procedures. Identifying the client accurately is crucial to prevent any errors or mix-ups. C. Wearing sterile gloves when cleaning the client's body is incorrect. Sterile gloves are not typically required for postmortem care. While gloves are important for infection control, they don't necessarily need to be sterile for handling deceased patients unless there are specific infectious concerns. D. Removing the client's dentures and give them to the client's family is incorrect. In most cases, the client's personal belongings, including dentures, are typically handled according to specific protocols or the family's wishes. However, removing the dentures and giving them to the family isn't typically part of postmortem care. The family might be informed about the presence of dentures and their disposition, but the decision to give them to the family should follow established procedures or the family's preferences.

Question 2: View

A nurse is preparing to insert an indwelling urinary catheter and is verifying the client's express consent for this procedure. Which of the following actions should the nurse take?

A. Check the medical record for the client's signature on a previous consent form. B. Have another nurse co-sign the client's consent. C. Obtain verbal consent from the end. D. Witness the client's signature on a consent form.

Explanation

Choice A Reason:

Checking the medical record for the client's signature on a previous consent form is incorrect. While a previous consent form might exist in the medical records, for certain procedures or situations, specific, current consent for each instance is often necessary. Verifying a previous consent form may not ensure the client's informed consent for the current procedure.

Choice B Reason:

Having another nurse co-sign the client's consent is incorrect. Co-signing a client's consent by another nurse doesn't substitute for the client's own signature and may not adequately verify the client's informed decision and understanding of the procedure.

Choice C Reason:

Obtaining verbal consent from the client is incorrect. While obtaining verbal consent is important, for invasive procedures like catheter insertion, it's essential to have written, witnessed consent to ensure proper documentation and confirmation that the client is fully informed and agrees to the procedure.

Choice D Reason:

Witnessing the client's signature on a consent form is correct. Express consent for medical procedures typically involves the client signing a consent form after being adequately informed about the procedure, its potential risks, benefits, and alternatives. Witnessing the client's signature on a consent form ensures that the client has provided informed consent for the specific procedure.

Question 3: View

A nurse is preparing to administer a medication from an ampule. Which of the following is an appropriate action for the nurse to take?

A. Use a filter needle to aspirate the medication B. Add 0.5 ml of diluent to the medication, C. Cleanse the tip of the ampule with an alcohol swab after opening. D. Inject air into the ampule prior to drawing the medication into a syringe.

Explanation

Choice A Reason:

This is the correct action. A filter needle should be used when drawing medication from an ampule to prevent glass particles from being aspirated into the syringe and subsequently administered to the patient.

Choice B Reason:

Adding 0.5 ml of diluent to the medication is incorrect. Adding diluent to medication from an ampule is not a standard practice. Ampules usually contain pre-measured doses of medication and are designed for direct withdrawal without dilution. Adding diluent could alter the concentration and effectiveness of the medication.

Choice C Reason:

This is not necessary. Once the ampule is opened, it should be handled with care to avoid contamination, but cleansing the tip with an alcohol swab is not a standard practice since it does not effectively remove glass particles.

Choice D Reason:

This is incorrect. Ampules are not pressurized containers, and injecting air into an ampule is unnecessary and could cause the medication to spill out or create bubbles that interfere with accurate dosing.

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Question 4: View

A nurse is preparing to administer a medication from an ampule. Which of the following is an appropriate action for the nurse to take?

A. Use a filter needle to aspirate the medication B. Add 0.5 ml of diluent to the medication, C. Cleanse the tip of the ampule with an alcohol swab after opening. D. Inject air into the ampule prior to drawing the medication into a syringe.

Explanation

Choice A Reason:

A filter needle is used to prevent any glass particles from entering the syringe when drawing medication from an ampule, as ampules are made of glass that can sometimes break and leave shards.

Choice B Reason:

Adding 0.5 ml of diluent to the medication is incorrect. Adding diluent to medication from an ampule is not a standard practice. Ampules usually contain pre-measured doses of medication and are designed for direct withdrawal without dilution. Adding diluent could alter the concentration and effectiveness of the medication.

Choice C Reason:

The ampule should be cleansed before opening to remove any potential contaminants. Once the ampule is opened, the inside of the ampule and the medication should be considered sterile, so there is no need to cleanse the tip after opening.

Choice D Reason:

Injecting air into the ampule prior to drawing the medication into a syringe is incorrect. This action is not typically necessary when withdrawing medication from an ampule. Some medications may require air to equalize pressure, but it's crucial to follow specific guidelines for each medication. In most cases, creating positive pressure by injecting air into the ampule is not recommended, as it could affect the stability or integrity of the medication.

Question 5: View

A nurse is caring for a client who is postoperative following a laminectomy. Which of the following actions should the nurse take when repositioning the client?

A. Place the bed in the lowest position before logrolling the client. B. Place the client in semi-Fowler's position prior to logrolling. C. Place the client's arms above her head prior to logrolling. D. Place a pillow between the client's legs prior to logrolling.

Explanation

Choice A Reason:

Placing the bed in the lowest position before logrolling the client is incorrect. Lowering the bed position isn't directly related to the safety or comfort of the client during logrolling. It's more important to focus on proper body alignment and support for the surgical site.

Choice B Reason:

Placing the client in semi-Fowler's position prior to logrolling is incorrect. Semi-Fowler's position (a reclined position with the head of the bed elevated at a 30-45-degree angle) might be used for comfort, but it's not specifically necessary before logrolling, which is a technique used to move the client while maintaining spinal alignment.

Choice C Reason:

Placing the client's arms above her head prior to logrolling is incorrect. Placing the client's arms above the head isn't typically necessary or recommended before logrolling a postoperative client. It's crucial to prioritize maintaining proper body alignment and minimizing stress on the surgical site during movement.

Choice D Reason:

Placing a pillow between the client's legs prior to logrolling is correct. This action helps maintain proper alignment of the spine and reduces pressure on the surgical site during logrolling. Placing a pillow between the legs provides support and helps prevent excessive twisting or stress on the back.

Question 6: View

A nurse is caring for a client who is postoperative following a laminectomy. Which of the following actions should the nurse take when repositioning the client?

A. Place the bed in the lowest position before logrolling the client. B. Place the client in semi-Fowler's position prior to logrolling. C. Place the client's arms above her head prior to logrolling. D. Place a pillow between the client's legs prior to logrolling.

Explanation

Choice A Reason:

Placing the bed in the lowest position before logrolling the client is incorrect. Lowering the bed position isn't directly related to the safety or comfort of the client during logrolling. It's more important to focus on proper body alignment and support for the surgical site.

Choice B Reason:

Placing the client in semi-Fowler's position prior to logrolling is incorrect. Semi-Fowler's position (a reclined position with the head of the bed elevated at a 30-45-degree angle) might be used for comfort, but it's not specifically necessary before logrolling, which is a technique used to move the client while maintaining spinal alignment.

Choice C Reason:

Placing the client's arms above her head prior to logrolling is incorrect. Placing the client's arms above the head isn't typically necessary or recommended before logrolling a postoperative client. It's crucial to prioritize maintaining proper body alignment and minimizing stress on the surgical site during movement.

Choice D Reason:

Placing a pillow between the client's legs prior to logrolling is correct. This action helps maintain proper alignment of the spine and reduces pressure on the surgical site during logrolling. Placing a pillow between the legs provides support and helps prevent excessive twisting or stress on the back.

Question 7: View

A nurse is reinforcing teaching with an older adult client who has urinary incontinence. Which of the following instructions should the nurse include?
Train the bladder by voiding every 5 hr.

A. Training the bladder by voiding every 5 hr. B. Applying adult diapers at bedtime is incorrect C. Performing pelvic-muscle exercises is correct. D. Drinking citrus juice with meals is incorrect

Explanation

Training the bladder by voiding every 5 hr. is incorrect. For individuals experiencing urinary incontinence, scheduled voiding at regular intervals might be a part of the management plan. However, the specific interval of every 5 hours might not suit everyone, as it depends on individual bladder capacity and function. Scheduled voiding should be tailored to the individual's needs and not solely based on a fixed time frame.

Choice B Reason:

Applying adult diapers at bedtime is incorrect. While using protective garments like adult diapers may manage urinary incontinence during sleep, it doesn't address the underlying issue or provide a solution to improve the condition.

Choice C Reason:

Performing pelvic-muscle exercises is correct. Pelvic floor muscle exercises, also known as Kegel exercises, can help strengthen the muscles that support the bladder and control urine flow. This can potentially improve urinary incontinence by enhancing bladder control.

Choice D Reason:

Drinking citrus juice with meals is incorrect. Citrus juices can irritate the bladder and potentially exacerbate urinary incontinence for some individuals. Advising the consumption of citrus juice might not be beneficial and could worsen symptoms in certain cases.

Question 8: View

A nurse is reinforcing discharge teaching about fecal occult blood testing with include in the teaching?

A. Discontinue supplements containing vitamin C 24 hr. before the test B. Refrain from consuming pork 7 days before the test. C. Place a thick layer of stool on the specimen card. D. Urinate prior to collecting the stool specimen

Explanation

Choice A Reason:

Discontinuing supplements containing vitamin C 24 hr. before the test is incorrect. While high doses of vitamin C might interfere with the accuracy of some laboratory tests, it typically doesn't impact fecal occult blood testing. However, it's always best to follow specific instructions provided by the healthcare provider or laboratory.

Choice B Reason:

Refraining from consuming pork 7 days before the test. There isn't typically a requirement to avoid specific foods, such as pork, before a fecal occult blood test. The test is designed to detect blood in the stool, regardless of the diet. However, some dietary restrictions might be advised based on specific instructions or conditions, but these are not universally applicable.

Choice C Reason:

Placing a thick layer of stool on the specimen card is incorrect. When collecting a sample for a fecal occult blood test, it's important to follow the specific instructions provided by the healthcare provider or laboratory. Generally, a small portion of stool is applied to the designated area on the specimen card as instructed, rather than applying a thick layer. Applying too much stool can affect the accuracy of the test.

Choice D Reason:

Urinating prior to collecting the stool specimen is correct. This instruction ensures that the urine doesn't contaminate the stool sample, which could potentially affect the accuracy of the test results.

Question 9: View

A nurse is preparing to provide tracheostomy care to a client who has a chronic tracheostomy. In which order should the nurse complete the following steps? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

A. Pour 2.54 cm (1 in) of 0.9% sodium chloride solution into the sterile basin. B. Cleanse the stoma site with 0.9% sodium chloride solution. C. Unlock and remove the inner cannula. D. Scrub the inside and outside of the inner cannula with a small brush. E. Wipe the inside of the inner cannula with a folded pipe cleaner.

Explanation

1. Unlock and remove the inner cannula (Step C). This is the initial step because it allows access to the inner cannula for cleaning. Removing it enables further cleaning of the inner cannula and ensures proper hygiene of the tracheostomy.

2. Scrub the inside and outside of the inner cannula with a small brush (Step D). Once the inner cannula is removed, it should be cleaned thoroughly to remove any secretions or debris. Scrubbing with a small brush helps in effectively cleaning both the inside and outside surfaces.

3. Wipe the inside of the inner cannula with a folded pipe cleaner (Step E). Using a pipe cleaner helps to reach areas that a brush might not access easily. It further ensures the removal of any remaining secretions or buildup inside the inner cannula.

4. Cleanse the stoma site with 0.9% sodium chloride solution (Step B). After addressing the inner cannula, the nurse moves to clean the stoma site to prevent infection or irritation. This step ensures the area around the tracheostomy is clean and free from contaminants.

5.Pour 2.54 cm (1 in) of 0.9% sodium chloride solution into the sterile basin (Step A). Lastly, preparing the sterile basin with the saline solution should be done at the start to ensure it's ready for use during the cleaning process. This solution will be utilized for cleaning the stoma site in step B and may also be needed for moistening the brush or pipe cleaner during steps D and E.

Question 10: View

A nurse is reviewing the laboratory results for a client who reports vomiting and diarrhea for 2 days. Which of the following laboratory findings should the nurse expect?

A. Hyperkalemia B. Hypocalcemia C. Hypermagnesemia D. Hyponatremia

Explanation

Choice A Reason:

Hyperkalemia is incorrect. Vomiting and diarrhea typically lead to a loss of potassium rather than an increase. These conditions often result in depletion of electrolytes, including potassium, due to the loss of fluids.

Choice B Reason:

Hypocalcemia is correct. While prolonged or severe diarrhea could potentially lead to some electrolyte imbalances, hypocalcemia is not typically a primary finding associated with vomiting and diarrhea. Calcium levels may not be significantly affected by these symptoms compared to sodium and potassium.

Choice C Reason:

Hypermagnesemia is incorrect. Similar to calcium, magnesium levels are not usually significantly impacted by vomiting and diarrhea alone. Hypermagnesemia is more commonly associated with excessive intake of magnesium-containing medications or renal dysfunction rather than acute gastrointestinal symptoms.

In a client experiencing vomiting and diarrhea, the loss of fluids and electrolytes due to these symptoms commonly leads to:

Choice D Reason:

Hyponatremia is correct. Vomiting and diarrhea can cause a loss of sodium and water, leading to decreased sodium levels in the blood, which manifests as hyponatremia. This electrolyte imbalance is a typical finding in individuals experiencing gastrointestinal issues with fluid loss.