PN Fundamentals Exam

Extract:

Question 1 of 5

A nurse is caring for a client who is dying. One of the client's family members tells the nurse, 'I need to help. What can I do?' Which of the following actions should the nurse take?

A. Include the family member in providing care for the client. B. Describe a personal experience with the death of a family member. C. Ask if they have had prior experience with the death of a family member. D. Suggest that the family member contact a grief counselor.

Correct Answer: C

Rationale: Asking about prior experience helps tailor support to the family member’s comfort level and needs.
Choice A may overwhelm them if unprepared.
Choice B shifts focus inappropriately.
Choice D delays addressing their immediate desire to help.

Question 2 of 5

A nurse in a long-term care facility is caring for a client who has a gastrostomy feeding tube. Prior to administering medications, which of the following findings should the nurse report to the provider?

A. Stomach contents are yellowish green in color. B. Aspirated stomach contents' pH measures 6.5. C. Residual volume of stomach contents measures 90 mL. D. Hyperactive bowel sounds are present.

Correct Answer: C

Rationale: A 90 mL residual volume indicates delayed gastric emptying, requiring reporting for potential care adjustments.
Choice A is normal due to bile.
Choice B isn’t significantly abnormal.
Choice D isn’t urgent unless paired with other issues.

Question 3 of 5

A nurse is collecting data from a client who reports feeling short of breath and notes that the client's SaO2 level is 88% while on room air. Which of the following actions should the nurse take first?

A. Recheck the client's SaO2 level after having the client cough and clear their throat. B. Review the client's most recent SaO2 level in the medical record. C. Notify the charge nurse of the client's condition. D. Check the client's medical records to see which medications were recently administered.

Correct Answer: A

Rationale: Rechecking SaO2 after coughing ensures accuracy, as secretions may affect readings; it’s the priority action.
Choice B delays immediate assessment.
Choice C is premature before verification.
Choice D is secondary to confirming the current status.

Question 4 of 5

A nurse is coordinating care of a group of clients with an assistive personnel (AP). Which of the following tasks should the nurse assign to the AP?

A. Measure the intake and output of a client who has received furosemide. B. Reinforce teaching with a client about crutch-gait walking. C. Check a client's peripheral IV site for redness or swelling. D. Assess the pain level of a client who has received acetaminophen.

Correct Answer: A

Rationale: Measuring intake and output is within an AP’s scope, requiring documentation, not judgment.
Choice B involves teaching, a nursing role.
Choice C requires assessment skills beyond AP scope.
Choice D involves subjective pain assessment, reserved for nurses.

Question 5 of 5

A nurse is collecting a urine specimen for culture and sensitivity from a client who has an indwelling urinary catheter. Which of the following actions should the nurse take?

A. Remove 45 mL of urine from the catheter with a syringe. B. Clamp the catheter tubing for 60 min. C. Clamp the catheter tubing below the needleless port D. Place the specimen in a clean specimen cup.

Correct Answer: A

Rationale: Removing 45 mL with a syringe ensures a sterile sample from the catheter, minimizing contamination.
Choice B risks retention and discomfort.
Choice C disrupts drainage unnecessarily.
Choice D is incorrect as sterile aspiration, not pouring, is required.

PN Fundamentals Exam | Nurselytic

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