Fundamentals Proctored Exam | Questions and Answers with Rationales | LATEST 2020/ 2021

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1. A nurse is planning to collect a stool specimen for ova and parasites from a client who has diarrhea. Which of the following actions should the nurse take when collecting the specimen? A. Instruc... t the client to defecate into the toilet bowl -incorrect: The nurse should have the client defecate into a bedpan or a container for stool collection. The toilet water can dilute and contaminate the liquid specimen. B. Transfer the specimen to a sterile container -incorrect: The nurse should place the stool specimen in a clean container using a tongue depressor. C. Refrigerate the collected specimen -incorrect: The nurse should send the collected stool specimen immediately to the laboratory after labeling the specimen properly to prevent contamination with microorganisms and keep the specimen from getting cold. D. Place the stool specimen collection container in a biohazard bag -The nurse should place the specimen collection container in a biohazard bag with the client label on the container and the bag for easy identification. This will also prevent contamination with microorganisms. 2. A nurse is caring for a client who has a tracheostomy and requires suctioning. Which of the following actions should the nurse take? A. Hyper oxygenate the client before suctioning -The nurse should use a manual resuscitation bag to hyper oxygenate the client for several minutes prior to suctioning. B. Insert the catheter during exhalation -incorrect: The nurse should insert the catheter during inhalation C. Apply suction during insertion of the catheter -incorrect: Applying suction while inserting the catheter increases the risk of damage to the tracheal mucosa and removes oxygen from the airways. D. Apply suction for no more than 15 secs -incorrect: The nurse should apply suction for no more than 10 seconds 3. A nurse is providing teaching to a client regarding protein intake. Which of the following foods should the nurse include as an example of an incomplete protein? A. Eggs -incorrect: this is a complete protein, contains all of the essential amino acids necessary for the synthesis of protein in the body. B. Soybeans -incorrect: this is a complete protein, contains all of the essential amino acids necessary for the synthesis of protein in the body. Stuvia.com - The Marketplace to Buy and Sell your Study Material Downloaded by: franklinalvarez16 | franklinalvarez16@hotmail.com Distribution of this document is illegal Stuvia.com - The Marketplace to Buy and Sell your Study Material C. Lentils -Incomplete proteins are missing 1 or more of the essential amino acids necessary for the synthesis of protein in the body. Examples of incomplete proteins include lentils, vegetables, grains, nuts, and seeds. D. Yogurt -incorrect: this is a complete protein, contains all of the essential amino acids necessary for the synthesis of protein in the body. 4. A nurse is caring for a client who was admitted to a long-term care facility for rehabilitation after a total hip arthroplasty. At which of the following times should the nurse begin discharge planning? A. One week prior to the client’s discharge -incorrect: Beginning to plan for the client’s discharge a week prior to the event might not allow sufficient time for planning. The nurse should begin discharge planning at the time of admission. B. Upon the client’s admission to the care facility -The nurse should begin discharge planning at the time that the client is admitted to the facility. C. Once the discharge date is identified -incorrect: Beginning to plan for the client’s discharge once the discharge date is identified might not allow sufficient time for planning. The nurse should begin discharge planning at the time of admission. D. When the client addresses the topic with the nurse -incorrect: Beginning to plan for the client’s discharge once the discharge date is identified might not allow sufficient time for planning. The nurse should begin discharge planning at the time of admission. 5. A nurse is preparing to administer a cleansing enema to a client. Which of the following actions should the nurse plan to take? A. Insert the rectal tube 15.2 cm (6 in) -incorrect: The nurse should insert the rectal tube 7 to 10 cm (3 to 4 in) B. Wear sterile gloves to insert the tubing -incorrect: The nurse should wear clean (nonsterile) gloves to prevent contamination. C. Position the client on his left side -Positioning is an important aspect of administering an enema. Having the client lie on his left side facilitates the flow of the enema solution into the sigmoid and descending colon. D. Hold the solution bag 91 cm (36 inch) above the client’s rectum -incorrect: The nurse should hold the solution bag 30 cm (12 in) above the client’s rectum for a low enema and 45 cm (18 in) for a high enema. If the nurse holds the solution bag too high, the solution might run in too fast, causing discomfort and spasms that make retaining the enema more difficult. 5. A nurse is caring for a client who has bilateral cats on her hands. Which of the following actions should the nurse take when assisting the client with feeding? A. Sit at the bedside when feeding the client -The nurse should avoid appearing to be in a hurry. Sitting at the bedside provides the client with the nurse’s full attention during the feeding Downloaded by: franklinalvarez16 | franklinalvarez16@hotmail.com Distribution of this document is illegal Stuvia.com - The Marketplace to Buy and Sell your Study Material B. Order pureed foods -incorrect: Without any mouth or throat injuries that make chewing or swallowing difficult, the client should be served foods of an appropriate variety of textures. Pureed foods are for clients who cannot chew, have difficulty swallowing, or do not have teeth. C. Make sure feedings are provided at room temperature -incorrect: The nurse should ask the client if the food is the correct temperature D. Offer the client a drink of fluid after every bite -incorrect: If the client is unable to communicate, the nurse should offer the client fluids after every 3 or 4 mouthfuls. However, there is no indication that this client is unable to communicate. Therefore, the client should tell the nurse when she would like a drink. 6. A nurse is administering an IM injection to a 5-month-old infant. Which of the following injection sites should the nurse use? A. Deltoid -incorrect: The nurse can use the deltoid muscle for injecting small volumes of medication for children 18 months of age or older, but its proximity to several nerves and arteries make it a riskier choice. B. Ventrogluteal -incorrect: This is a safe site for IM injections for clients older than 7 months. C. Vastus lateralis -The nurse should use the vastus lateralis site over the anterior thigh for IM injections for infants and children. D. Dorsogluteal -incorrect: This site is unsafe to use because of its proximity to the sciatic nerve and the superior gluteal nerve and artery. 7. A nurse is caring for a client who has major fecal incontinence and reports irritation in the perianal area. Which of the following actions should the nurse take first? A. Apply a fecal collection system -incorrect: The nurse should apply a fecal collection system to divert the feces away from the area of skin irritation; however, there is another action the nurse should take first. B. Apply a barrier cream -incorrect: The nurse should apply a barrier cream to decrease skin breakdown in the perianal area from the feces; however, there is another action the nurse should take first. C. Cleanse and dry the area -incorrect: The nurse should cleanse and dry the perianal area to decrease skin irritation; however, there is another action the nurse should take first. D. Check the client’s perineum -The nurse should apply the nursing process priority-setting framework to plan care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with an assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify a provider of a change in the client’s status, the nurse must first collect adequate data from the client. Assessing or collecting additional data will provide the nurse with knowledge to make an appropriate decision. The priority nursing action is for the nurse to collect more data by assessing the area of irritation. Downloaded by: franklinalvarez16 | franklinalvarez16@hotmail.com Distribution of this document is illegal Stuvia.com - The Marketplace to Buy and Sell your Study Material 9. A nurse is caring for a client who is receiving IV therapy via a peripheral catheter. The nurse should identify that which of the following findings is an indication of infiltration? A. Redness at the infusion site -incorrect: Redness at the infusion site is an indication of phlebitis or infection. B. Edema at the infusion site -Edema due to fluid entering subcutaneous tissue is an indication of infiltration. C. Warmth at the infusion site -incorrect: Warmth at the infusion site is an indication of phlebitis or infection. D. Oozing of blood at the infusion site -incorrect: Oozing of blood at the infusion site is an indication that the IV system is not intact. 10. A nurse is caring for a client who reports not sleeping at night, which interferes with her ability to function during the day. Which of the following interventions should the nurse suggest to this client? A. Avoid beverages that contain caffeine -Caffeine is a stimulant. The nurse should suggest that the client avoid caffeinated beverages. B. Take a sleep medication regularly at bedtime -incorrect: Sleep-promoting medication is a last resort. The nurse should not suggest this type of medication for the client before recommending other nonpharmacological interventions. C. Watch television for 30 minutes in bed to relax prior to falling asleep -incorrect: Clients should associate going to bed with sleep. Therefore, the client should not get into bed until she is sleepy. D. Advise the client to take several naps during the day -incorrect: Napping in the daytime can prevent sound sleep at night 11. A nurse is conducting an admission interview with a client. Which of the following pieces of assessment information should the nurse collect during the introductory phase of the interview? A. Clients level of comfort and ability to participate in the interview -The nurse should assess the client’s level of comfort and establish a rapport during the introductory or orientation phase. The nurse should engage in active listening and present a relaxed attitude to place the client at ease and encourage client participation. This will assist the nurse in gaining the necessary data to formulate appropriate nursing diagnoses and outcomes. B. Previous illnesses and surgeries -incorrect: The nurse should assess the client’s health history, including previous illnesses and surgeries, during the working phase of the interview. C. Events surrounding the client’s recent illness -incorrect: The nurse should assess the client’s health history, including events surrounding the recent or current illness, during the working phase of the interview. D. Sociocultural history -incorrect: The nurse should assess the client’s sociocultural history during the working phase of the interview. 12. A nurse is performing an abdominal assessment of a client. Which of the following positions should the nurse tell the client to assume for this examination? A. Lithotomy -incorrect: The lithotomy position is useful for gynecological examinations. Downloaded by: franklinalvarez16 | franklinalvarez16@hotmail.com Distribution of this document is illegal Stuvia.com - The Marketplace to Buy and Sell your Study Material B. Lateral -incorrect: The lateral recumbent, or side-lying position, limits access to the abdomen. This position is useful when auscultating the heart to detect murmurs. C. Supine -The nurse should tell the client to assume the supine position to promote relaxation of the abdominal muscles. Having the client bend the knees enhances relaxation of the stomach muscles. D. Sims -incorrect: The Sims’ position limits access to the abdomen. This position is useful for rectal and vaginal examinations. 13. A nurse is caring for a client who is postoperative following an abdominal surgery. Which of the following actions should the nurse perform first after discovering the client’s wound has eviscerated? A. Cover the incision with [Show More]

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