Question

A nurse is preparing to measure a client's oxygen saturation and notes edema of the client's hands and thickened toenails. The nurse should apply the pulse oximeter probe to which of the following locations?

Answer 1

Correct Answers:

Earlobe

Rationale :

💎 The earlobe is ideal for measuring oxygen saturation when the fingers or toes are affected by edema, poor circulation, or nail thickening, as these conditions interfere with light transmission.

💎 The earlobe has good perfusion and is less affected by peripheral vasoconstriction, providing a more accurate SpO₂ reading.

💎 Other common sites like fingers or toes can give false low readings due to swelling or nail deformities.

💎 The probe should be applied securely but gently to ensure optimal sensor contact and stable waveforms.

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Answer 2

Correct Answers:

Place a surgical mask on the client prior to exiting the room.

Rationale :

🔷 Clients with active TB require airborne precautions, and wearing a surgical mask helps contain infectious droplets when leaving isolation for essential procedures.

🔷 Healthcare staff and transport personnel should wear N95 respirators, but the infected client uses a surgical mask (not N95) to prevent droplet spread.

🔷 This measure protects others from exposure while allowing necessary diagnostic procedures.

🔷 The client should be escorted through less crowded routes to minimize transmission risk.

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Answer 3

Correct Answers:

Maintain the drainage container below the level of the client's chest

Rationale :

🟩 Keeping the drainage system below chest level ensures gravity drainage and prevents backflow of fluid or air into the pleural cavity, which could cause tension pneumothorax.

🟩 The chest tube should never be clamped unless directed by a provider, as this can trap air and raise intrapleural pressure.

🟩 The collection chamber should be monitored for fluid accumulation, bubbling, and fluctuation to assess tube patency and lung re-expansion.

🟩 Always maintain the water seal chamber at the proper level with sterile water, not tap water, to preserve system function.

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Answer 4

Correct Answers:

A deep crater without visible bone, tendon, or muscle

Rationale :

🟧 A stage 3 pressure ulcer involves full-thickness skin loss, extending into the subcutaneous tissue but not exposing bone, tendon, or muscle.

🟧 The ulcer appears as a deep crater with possible slough or undermining, indicating damage through the dermis.

🟧 This stage requires wound care, debridement, and infection prevention, as the tissue is at risk for further breakdown.

🟧 Accurate staging guides treatment planning and helps evaluate healing progress.

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Answer 5

Correct Answers:

Place the client's arm above the level of the heart.

Rationale :

🟦 The arm should be positioned at heart level to obtain an accurate blood pressure reading.

🟦 If the arm is above heart level, the reading will be falsely low; if below, it will be falsely high.

🟦 The cuff should fit snugly, with the bladder centered over the brachial artery, and the gauge must start at zero before inflation.

🟦 Proper technique ensures reliable readings and supports accurate blood pressure monitoring at home.

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Answer 6

Correct Answers:

Assess the patient for any adverse reactions or changes in condition.

Rationale :

🔴 The first nursing priority after identifying a medication error is to assess the client’s condition for any adverse effects or physiological changes.

🔴 Immediate assessment ensures early detection of potential harm, allowing prompt intervention and stabilization if necessary.

🔴 After ensuring patient safety, the nurse should notify the provider, document objectively, and complete an incident report according to facility policy.

🔴 The focus must always remain on patient safety first, not administrative documentation.

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Answer 7

Correct Answers:

Sterile gloves
Suction machine
Slit gauze pads

Rationale :

1️⃣ Sterile Gloves

💎 Sterile gloves are essential for performing tracheostomy care and suctioning to maintain a sterile field and prevent infection of the airway.

💎 The tracheostomy site is a direct portal to the lower respiratory tract, so contamination can quickly lead to tracheitis, bronchitis, or pneumonia.

💎 Gloves must be sterile when cleaning the inner cannula, changing the trach dressing, or performing deep suctioning.

💎 Teaching the client and caregivers about proper hand hygiene and sterile technique is a key component of safe tracheostomy management at home.

2️⃣ Suction Machine

🔷 A portable suction machine is vital for clearing secretions that the client cannot expel effectively through coughing.

🔷 Regular suctioning prevents airway obstruction, hypoxia, and respiratory distress, especially if mucus becomes thick or excessive.

🔷 The machine allows caregivers to perform as-needed suctioning using sterile catheters, maintaining a clear airway and promoting adequate ventilation.

🔷 Having backup power sources or batteries ensures continuous function during outings or power outages, enhancing safety and independence.

3️⃣ Slit Gauze Pads

🟢 Slit gauze (tracheostomy dressing) fits neatly around the trach tube without fraying or blocking airflow, absorbing moisture and secretions at the insertion site.

🟢 These dressings help prevent skin breakdown and infection by keeping the stoma area clean and dry.

🟢 Using pre-cut slit gauze is safer than cutting standard gauze, which can shed fibers that risk aspiration.

🟢 The dressing should be changed as often as needed—whenever it becomes wet or soiled—to maintain hygiene and comfort.

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Answer 8

Correct Answers:

Incomplete patient medication history

Rationale :

💎 Medication reconciliation is the process of verifying and documenting all medications a patient is currently taking to prevent errors, omissions, and duplications.

💎 One of the most common challenges is obtaining a complete and accurate medication history, as patients may forget drug names, doses, or frequency, especially when using multiple providers or pharmacies.

💎 Factors like language barriers, poor documentation, and unavailable pharmacy records can further complicate data accuracy.

💎 To address this, nurses must use multiple information sources—including family input, pill bottles, and prior records—to ensure medication safety and continuity of care.

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Answer 9

Correct Answers:

Aspiration pneumonia

Rationale :

🔷 Aspiration pneumonia occurs when gastric contents or secretions enter the lungs, often due to improper NG tube placement or dislodgement.

🔷 If the tube is mistakenly inserted into the trachea or bronchus, feeding or medication administration can lead to severe respiratory compromise.

🔷 Verification of correct placement by checking pH of aspirate and radiographic confirmation (for initial insertion) is essential before use.

🔷 Elevating the head of the bed 30–45° during feedings and suctioning after vomiting helps prevent aspiration and respiratory infections.

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Answer 10

Correct Answers:

To restore circulating blood volume through fluid resuscitation

Rationale :

💎 Hypovolemic shock results from severe fluid or blood loss, causing decreased preload, cardiac output, and tissue perfusion.

💎 The priority is to restore intravascular volume using isotonic fluids (0.9% NS or LR) and blood products if hemorrhage is the cause.

💎 Restoring volume improves oxygen delivery to tissues, prevents organ failure, and stabilizes vital signs.

💎 Vasopressors are not the first-line treatment because they can worsen perfusion if volume is not yet restored.

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Custom Fundamentals Midterm Exam Fall 2025

No.

1 :
A nurse is preparing to measure a client's oxygen saturation and notes edema of the client's hands and thickened toenails. The nurse should apply the pulse oximeter probe to which of the following locations?

2 :
A nurse is caring for a client who has active pulmonary tuberculosis (TB) and a prescription for a chest x-ray. Which of the following actions should the nurse plan to take?

3 :
The nurse is caring for a client who has a pneumothorax and a water-seal chest tube drainage system to suction. Which of the following actions should the nurse take?

4 :
A nurse is discussing pressure ulcer staging with a newly licensed nurse. Which of the following statements should the nurse use to describe a stage 3 pressure ulcer?

5 :
A nurse is reinforcing teaching with the spouse of a client about how to take a blood pressure. Which of the following actions by the spouse indicates a need for further instruction?

6 :
Which of the following actions should be taken immediately after recognizing a medication error to ensure patient safety?

7 :
A nurse is assisting with the discharge plan of a client who has a permanent tracheostomy and breathes on his own. Which of the following equipment should the nurse ensure is available for home care of the tracheostomy? (Select all that apply.)

8 :
Which of the following is a common challenge in medication reconciliation?

9 :
Which of the following is a common complication associated with nasogastric (NG) tube insertion?

10 :
What is the primary goal of nursing care for a patient experiencing hypovolemic shock?

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Custom Fundamentals Midterm Exam Fall 2025

No.

1 : A nurse is preparing to measure a client's oxygen saturation and notes edema of the client's hands and thickened toenails. The nurse should apply the pulse oximeter probe to which of the following locations?

2 : A nurse is caring for a client who has active pulmonary tuberculosis (TB) and a prescription for a chest x-ray. Which of the following actions should the nurse plan to take?

3 : The nurse is caring for a client who has a pneumothorax and a water-seal chest tube drainage system to suction. Which of the following actions should the nurse take?

4 : A nurse is discussing pressure ulcer staging with a newly licensed nurse. Which of the following statements should the nurse use to describe a stage 3 pressure ulcer?

5 : A nurse is reinforcing teaching with the spouse of a client about how to take a blood pressure. Which of the following actions by the spouse indicates a need for further instruction?

6 : Which of the following actions should be taken immediately after recognizing a medication error to ensure patient safety?

7 : A nurse is assisting with the discharge plan of a client who has a permanent tracheostomy and breathes on his own. Which of the following equipment should the nurse ensure is available for home care of the tracheostomy? (Select all that apply.)

8 : Which of the following is a common challenge in medication reconciliation?

9 : Which of the following is a common complication associated with nasogastric (NG) tube insertion?

10 : What is the primary goal of nursing care for a patient experiencing hypovolemic shock?

1 :
A nurse is preparing to measure a client's oxygen saturation and notes edema of the client's hands and thickened toenails. The nurse should apply the pulse oximeter probe to which of the following locations?

2 :
A nurse is caring for a client who has active pulmonary tuberculosis (TB) and a prescription for a chest x-ray. Which of the following actions should the nurse plan to take?

3 :
The nurse is caring for a client who has a pneumothorax and a water-seal chest tube drainage system to suction. Which of the following actions should the nurse take?

4 :
A nurse is discussing pressure ulcer staging with a newly licensed nurse. Which of the following statements should the nurse use to describe a stage 3 pressure ulcer?

5 :
A nurse is reinforcing teaching with the spouse of a client about how to take a blood pressure. Which of the following actions by the spouse indicates a need for further instruction?

6 :
Which of the following actions should be taken immediately after recognizing a medication error to ensure patient safety?

7 :
A nurse is assisting with the discharge plan of a client who has a permanent tracheostomy and breathes on his own. Which of the following equipment should the nurse ensure is available for home care of the tracheostomy? (Select all that apply.)

8 :
Which of the following is a common challenge in medication reconciliation?

9 :
Which of the following is a common complication associated with nasogastric (NG) tube insertion?

10 :
What is the primary goal of nursing care for a patient experiencing hypovolemic shock?