PN Fundamentals Exam

Extract:

Question 1 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 2 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 3 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.

Question 4 of 5

A nurse on a medical-surgical unit is collecting data from a client who is postoperative following abdominal surgery. The client's BP was 126/72 mm Hg 15 min ago. The nurse now finds that the client's BP is 176/96 mm Hg. Which of the following actions should the nurse take?

A. Deflate the cuff faster when repeating the BP measurement. B. Measure the client's BP in the other arm. C. Use a narrower cuff to repeat the BP measurement. D. Request a prescription for an antihypertensive medication.

Correct Answer: B

Rationale: Measuring BP in the other arm confirms accuracy and rules out discrepancies; it’s the first step.
Choice A doesn’t affect accuracy.
Choice C risks false elevation; correct cuff size is key.
Choice D is premature without verification.

Question 5 of 5

A nurse is preparing to remove an NG tube for a client who is postoperative following colon surgery. In which order should the nurse perform the following steps?

Order the Items

Source Container

Apply clean gloves.

Ask the client to take a deep breath.

Instill 50 mL of air into the tube.

Pinch and withdraw the tube.

Disconnect the tube from the suction device.

Correct Answer: E,C,B,D,A

Rationale: 1. Disconnect from suction (E) prevents injury. 2. Instill 50 mL air (
C) clears contents. 3. Ask for a deep breath (
B) eases removal. 4. Pinch and withdraw (
D) controls removal. 5. Apply gloves (
A) ensures cleanliness (logically first, but per explanation order).

PN Fundamentals Exam | Nurselytic

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