Question

A nurse is reinforcing teaching with an older adult client about expected physiological changes associated with aging. Which of the following statements by the client indicates an understanding of the teaching?

Answer 1

Correct Answers:

"I should expect to experience dry skin."

Rationale :

💎 Aging leads to a decrease in sebaceous and sweat gland activity, causing the skin to become dry, thin, and less elastic.

💎 Reduced collagen and subcutaneous fat make older adults more susceptible to bruising and skin injury.

💎 Dehydration or reduced fluid intake can worsen dryness, so adequate hydration and mild moisturizers are recommended.

💎 Other normal changes include delayed wound healing and decreased temperature regulation.

💎 The nurse should educate the client about gentle skincare routines and avoiding harsh soaps.

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Answer 2

Correct Answers:

0.65

Rationale :

✅ Given: Enoxaparin 1 mg/kg, client weight 65 kg

✅ Available: 80 mg/0.8 mL

✅ Step 1: Required dose = 1 mg × 65 kg = 65 mg

✅ Step 2: (65 mg × 0.8 mL) ÷ 80 mg = 0.65 mL

✅ Answer: 0.65 mL

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Answer 3

Correct Answers:

Consume probiotic sources.

Rationale :

🔷 Chronic constipation can improve with dietary modification, including increased fiber, water, and probiotics.

🔷 Probiotics (e.g., yogurt with live cultures) help balance gut flora and improve stool consistency and frequency.

🔷 Daily laxative use is discouraged due to dependence and decreased bowel tone.

🔷 White flour and calcium supplements reduce bowel motility, worsening constipation.

🔷 Encouraging regular exercise and hydration also promotes healthy bowel function.

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Answer 4

Correct Answers:

Witness the client sign the consent form.

Rationale :

💎 The nurse’s legal responsibility is to verify and witness that the client voluntarily signs the consent form.

💎 Explaining the procedure, risks, and alternatives is the provider’s duty, not the nurse’s.

💎 The nurse ensures that the client is competent, informed, and not coerced before signing.

💎 If the client has questions, the nurse should refer back to the provider for clarification.

💎 This action upholds ethical and legal standards of informed consent.

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Answer 5

Correct Order:

Order : 1 : No answer text available
Order : 2 : No answer text available
Order : 3 : No answer text available
Order : 4 : No answer text available

Rationale :

✅ The gown protects the uniform and should go on first.

✅ The mask is next to prevent contamination of respiratory droplets while applying other items.

✅ Goggles or face shield protect the eyes from splashes.

✅ Gloves are worn last to prevent contamination of previously applied PPE.

✅ Following the correct sequence prevents cross-contamination and ensures maximum protection.

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Answer 6

Correct Answers:

A client receives burns from a heating pad.
A client's visitor becomes dizzy and faints in the client's room.
A client becomes disoriented and falls out of bed.

Rationale :

💎A client receives burns from a heating pad.

💎 Burns from a heating pad are considered a treatment-related injury, requiring an incident report because it reflects a safety failure.

💎 The report allows for evaluation of device use and reinforcement of safe temperature guidelines.

💎 Documentation ensures proper follow-up and prevention of recurrence.

💎 Incident reports are confidential and not part of the client’s medical record.

🔷 A client's visitor becomes dizzy and faints in the client’s room.

🔷 Any injury or medical emergency involving a visitor requires an incident report for facility risk management.

🔷 The report ensures timely evaluation, documentation, and safety follow-up.

🔷 It provides a record for potential liability issues or safety improvements.

🔷 The nurse should assist the visitor and notify the charge nurse or supervisor.

💠 A client becomes disoriented and falls out of bed.

💠 All falls—even if no injury occurs—require completion of an incident report.

💠 Falls are considered a sentinel safety event and must be documented to evaluate prevention measures.

💠 The nurse should assess for injuries and implement fall precautions immediately after.

💠 Reporting ensures compliance with patient safety and quality improvement standards.

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Answer 7

Correct Answers:

Collaborate with the RN to plan an interprofessional client care conference.

Rationale :

🔵 A care conference allows collaboration among nurses, physicians, social workers, chaplains, and hospice staff to support families coping with a terminal condition.

🔵 This approach ensures holistic care addressing emotional, physical, and spiritual needs.

🔵 It promotes clear communication and decision-making consistency for the family.

🔵 The nurse’s role includes advocacy, coordination, and family education.

🔵 Collaboration improves end-of-life quality and family satisfaction with care.

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Answer 8

Correct Answers:

Uses firm, circular motions to wash his hands

Rationale :

💠 Effective hand hygiene involves friction using firm circular motions for at least 20 seconds with soap and warm water.

💠 Friction removes transient microorganisms and organic matter from skin surfaces.

💠 Hot water is avoided as it can irritate and dry the skin, leading to cracks that harbor microbes.

💠 The hands are dried from fingers to forearms to prevent recontamination.

💠 Proper hand hygiene is the most effective infection control practice in healthcare.

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Answer 9

Correct Answers:

Assist the client to the bathroom to empty the appliance.

Rationale :

🔷 Emptying a colostomy bag in a private bathroom promotes client dignity and privacy, especially in front of visitors.

🔷 This encourages independence and self-care while maintaining infection control.

🔷 The nurse should provide assistance as needed, but in a discreet, comfortable environment.

🔷 This approach reinforces client education on colostomy care before discharge.

🔷 Maintaining privacy helps build the client’s confidence and acceptance of body changes.

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Answer 10

Correct Answers:

Transfer the specimen to a cup without it touching the outside of the container.

Rationale :

💎 Preventing contact between stool and the outside of the container reduces contamination and maintains specimen integrity.

💎 Using clean gloves and sterile equipment prevents transfer of pathogens to the sample or the nurse’s hands.

💎 The specimen should be collected from representative stool areas, including those with visible mucus or blood if ordered.

💎 The sample should be sent to the laboratory promptly (within 1 hour) to ensure accurate analysis.

💎 Proper labeling and handling maintain infection control and diagnostic accuracy.

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✅PN FUNDAMENTALS 2023

No.

1 :
A nurse is reinforcing teaching with an older adult client about expected physiological changes associated with aging. Which of the following statements by the client indicates an understanding of the teaching?

3 :
A nurse is caring for a client who has chronic constipation. Which of the following actions should the nurse recommend to the client?

4 :
A nurse is caring for a client who is scheduled for surgery the following day. Which of the following actions should the nurse take?

6 :
A nurse is caring for a group of clients. For which of the following situations should the nurse complete an incident report? (Select all that apply.)

7 :
A nurse is assisting with the care of a client who has a terminal condition, and their family is requesting more guidance and support. Which of the following actions should the nurse take?

8 :
A nurse is observing an assistive personnel (AP) who is performing hand hygiene. The nurse should recognize that the AP is using proper technique when he does which of the following?

9 :
A nurse is caring for a client who is scheduled to be discharged and has a new colostomy. The client has several visitors in the room with him when the appliance requires emptying. Which of the following actions should the nurse take?

10 :
A nurse is preparing to collect a stool specimen from a client for laboratory testing. Which of the following actions should the nurse take when collecting the specimen

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✅PN FUNDAMENTALS 2023

No.

1 : A nurse is reinforcing teaching with an older adult client about expected physiological changes associated with aging. Which of the following statements by the client indicates an understanding of the teaching?

3 : A nurse is caring for a client who has chronic constipation. Which of the following actions should the nurse recommend to the client?

4 : A nurse is caring for a client who is scheduled for surgery the following day. Which of the following actions should the nurse take?

6 : A nurse is caring for a group of clients. For which of the following situations should the nurse complete an incident report? (Select all that apply.)

7 : A nurse is assisting with the care of a client who has a terminal condition, and their family is requesting more guidance and support. Which of the following actions should the nurse take?

8 : A nurse is observing an assistive personnel (AP) who is performing hand hygiene. The nurse should recognize that the AP is using proper technique when he does which of the following?

9 : A nurse is caring for a client who is scheduled to be discharged and has a new colostomy. The client has several visitors in the room with him when the appliance requires emptying. Which of the following actions should the nurse take?

10 : A nurse is preparing to collect a stool specimen from a client for laboratory testing. Which of the following actions should the nurse take when collecting the specimen

1 :
A nurse is reinforcing teaching with an older adult client about expected physiological changes associated with aging. Which of the following statements by the client indicates an understanding of the teaching?

3 :
A nurse is caring for a client who has chronic constipation. Which of the following actions should the nurse recommend to the client?

4 :
A nurse is caring for a client who is scheduled for surgery the following day. Which of the following actions should the nurse take?

6 :
A nurse is caring for a group of clients. For which of the following situations should the nurse complete an incident report? (Select all that apply.)

7 :
A nurse is assisting with the care of a client who has a terminal condition, and their family is requesting more guidance and support. Which of the following actions should the nurse take?

8 :
A nurse is observing an assistive personnel (AP) who is performing hand hygiene. The nurse should recognize that the AP is using proper technique when he does which of the following?

9 :
A nurse is caring for a client who is scheduled to be discharged and has a new colostomy. The client has several visitors in the room with him when the appliance requires emptying. Which of the following actions should the nurse take?

10 :
A nurse is preparing to collect a stool specimen from a client for laboratory testing. Which of the following actions should the nurse take when collecting the specimen