Question

A nurse is delegating client care tasks to an assistive personnel. Which of the following tasks should the nurse delegate?

Answer 1

Correct Answers:

Inserting an NG tube

Rationale :

🔹Simple, routine tasks such as basic dressing changes can be delegated to trained assistive personnel (AP) if they are within the institution’s policy and the AP has been deemed competent. 🔹These tasks do not require clinical judgment or assessment. 🔹Tasks involving sterile technique, evaluation, or medication administration should always be performed by licensed personnel.

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Answer 2

Correct Answers:

I should limit the time that I spend sitting in a chair

Rationale :

🔹Prolonged immobility increases the risk of venous stasis and thrombus formation. 🔹Clients at risk for DVT should avoid long periods of sitting and be encouraged to ambulate, perform leg exercises, and elevate the legs periodically. 🔹Teaching clients to limit sedentary behaviors is key in preventing clot development.

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Answer 3

Correct Answers:

BRP for bathroom privileges

Rationale :

🔹BRP (bathroom privileges) is a commonly accepted abbreviation and is part of The Joint Commission’s approved abbreviation list. 🔹In contrast, abbreviations like “SS,” “OJ,” and “SQ” are discouraged or potentially unsafe due to the possibility of misinterpretation and medication errors.

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Answer 4

Correct Answers:

Present information about the benefits of quitting smoking.

Rationale :

🔹The contemplation stage is the second phase of the Transtheoretical Model of Change, where the individual is aware of a problem and seriously considering change but has not yet committed to taking action. 🔹During this stage, clients benefit from nonjudgmental support, education, and motivation. 🔹Presenting evidence-based information about the risks of smoking and the benefits of cessation can increase the client’s motivation and help move them toward the preparation or action stage. 🔹The nurse should avoid pushing for immediate change but instead focus on building awareness and confidence in the client’s ability to change.

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Answer 5

Correct Answers:

A gastric residual of 300 mL at the end of the shift

Rationale :

🔹A gastric residual volume (GRV) of 300 mL is higher than the generally accepted threshold of 250 mL, and may signal delayed gastric emptying or poor feeding tolerance. 🔹Retaining excessive formula in the stomach increases the risk of aspiration, regurgitation, and feeding intolerance. 🔹Per evidence-based practice, GRV should be assessed every 4–6 hours, and persistent elevations should prompt holding the feeding and notifying the provider. 🔹This helps prevent complications such as aspiration pneumonia.

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Answer 6

Correct Answers:

Aspirate residual volume every 4 hr.

Rationale :

🔹Regularly aspirating and checking the gastric residual volume (GRV) every 4 hours during continuous enteral feeding is essential to assess tolerance and gastric motility. 🔹 It helps identify delayed emptying and reduces the risk of aspiration. 🔹This intervention aligns with national enteral feeding protocols. Monitoring GRV ensures safe digestion, prevents complications, and helps determine whether to continue, hold, or adjust the feeding rate.

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Answer 7

Correct Answers:

Schedule the client as the first surgical procedure of the day

Rationale :

🔹Clients with a latex allergy are at risk for anaphylactic reactions during surgery due to latex exposure from gloves, tubing, or equipment. 🔹Scheduling the client first in the operating room minimizes airborne and surface latex particle exposure because the environment is cleanest at the beginning of the day. 🔹This is a well-established standard in preoperative nursing care for latex-sensitive patients.

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Answer 8

Correct Answers:

Keep the drainage bag below the level of the bladder.

Rationale :

🔹Maintaining the urine drainage bag below the level of the bladder ensures gravity-dependent drainage and prevents backflow of urine into the bladder, which could lead to urinary tract infections (UTIs) or catheter-associated urinary tract infections (CAUTIs). 🔹This positioning minimizes the risk of ascending infections and is a critical aspect of evidence-based catheter care. 🔹The bag should also never be attached to movable parts such as bed rails.

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Answer 9

Correct Answers:

'New dressing applied as prescribed: no drainage on old dressing.'

Rationale :

🔹This entry demonstrates objective, factual, and complete documentation. 🔹It states the intervention performed (“new dressing applied”) and includes a specific assessment of the wound dressing ("no drainage on old dressing") without using subjective or vague terms. 🔹Accurate documentation promotes continuity of care, legal protection, and effective communication between providers. 🔹Avoiding assumptions (e.g., “seems” or “appears”) upholds professional standards.

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Answer 10

Correct Answers:

Cover the area of percussion with a towel-

Rationale :

🔹Placing a thin towel or cloth over the chest area during percussion protects the skin from irritation and bruising while still allowing for effective mechanical mobilization of secretions. 🔹This technique is a standard part of chest physiotherapy used in conditions such as cystic fibrosis, where airway clearance is essential to prevent infection and maintain pulmonary function.

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RN Fundamentals 2019 Updated~2023 EXAM

No.

1 : A nurse is delegating client care tasks to an assistive personnel. Which of the following tasks should the nurse delegate?

2 : A nurse is providing teaching to a client who is at risk for thrombus formation. Which of the following statements made by the client indicates an understanding of the teaching?

3 : A nurse is documenting client care. Which of the following abbreviations should the nurse use?

4 : A nurse is planning care for a client who is concerned about her tobacco smoking habits and is in the contemplation stage of health behavior change. Which of the following actions should the nurse plan to take during this stage?

5 : A nurse is caring for a client who is receiving continuous enteral feeding via NG tube. Which of the following is an unexpected finding?

6 : A nurse is caring for a client who is receiving continuous enteral feedings through a gastrostomy tube. Which of the following actions should the nurse take?

7 : A nurse is planning care for a client who has a latex allergy and is scheduled for surgery. Which of the following actions is appropriate to include in the client's plan of care?

8 : A nurse is planning care for a female client who has an indwelling urinary catheter. Which of the following actions should the nurse include in the plan?

9 : A nurse is documenting a dressing change for a client who has a pressure injury. Which of the following entries by the nurse demonstrates correct documentation?

10 : A nurse is performing postural drainage with percussion and vibration for a client who has cystic fibrosis. Which of the following actions should the nurse take?

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