Question

A nurse is preparing to administer three liquid medications to a client who has an NG feeding tube with continuous enteral feedings. Which of the following actions should the nurse take?

Answer 1

Correct Answers:

Flush the NG feeding tube with 30 mL of water immediately following medication administration.

Rationale :

📌Flushing the NG tube with 30 mL of water after medication administration ensures that the entire dose of the medication is delivered and helps prevent clogging of the tube.

📌This is especially important when administering multiple medications.

📌Each medication should also be administered separately, with water flushes in between, to maintain tube patency and avoid interactions.

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Answer 2

Correct Answers:

Urinary tract infection

Rationale :

🔹Dark amber, cloudy urine with a foul odor are hallmark signs of a urinary tract infection (UTI).

🔹These findings are typically due to the presence of bacteria, white blood cells, and epithelial cells in the urine.

🔹The nurse should anticipate further testing, such as a urinalysis and culture, and notify the provider.

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Answer 3

Correct Answers:

"l may eat 2 cans of soup a day."

Rationale :

📌This statement demonstrates a need for further teaching because canned soups are typically high in sodium, which can worsen hypertension.

📌A heart-healthy diet emphasizes low-sodium, high-fiber, and potassium-rich foods, and clients should be educated to read nutrition labels to avoid hidden sources of sodium.

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Answer 4

Correct Answers:

Chicken

Rationale :

💎Among the listed options, chicken is the best source of high-quality, complete protein, containing all essential amino acids necessary for tissue repair and growth.

💎While peanuts and eggs also provide protein, chicken offers a higher protein density per serving and is generally low in saturated fat when skinless.

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Answer 5

Correct Answers:

Surgeon

Rationale :

♦The responsibility for obtaining informed consent lies with the surgeon, as they are the one performing the procedure and must ensure the client understands the nature of the surgery, potential risks, benefits, and available alternatives.

♦Only the provider performing or ordering the procedure has the authority and knowledge to discuss these in full.

♦The nurse’s role is to act as a witness to the client’s voluntary signature, confirm the form is signed before sedation, and to advocate for client understanding by notifying the provider if clarification is needed.

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Answer 6

Correct Answers:

Perform the Heimlich maneuver

Rationale :

💎A client exhibiting inability to speak, ineffective coughing, and clutching the throat is experiencing a complete airway obstruction—a medical emergency.

💎The appropriate immediate response is to perform the Heimlich maneuver (abdominal thrusts) to expel the foreign object blocking airflow.

💎This maneuver increases intrathoracic pressure to forcefully remove the obstruction and restore ventilation.

💎Delayed action can lead to hypoxia and loss of consciousness.

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Answer 7

Correct Answers:

Discard the tablet and obtain another dose of medication.

Rationale :

💥If a medication tablet falls on a non-sterile surface, such as a countertop, it is considered contaminated and must be safely discarded to prevent the risk of cross-contamination or infection.

💥The nurse must then retrieve a new, properly packaged dose from the medication system.

💥This action upholds medication administration safety, ensures the client receives the intended therapeutic effect, and demonstrates adherence to infection control and institutional protocols.

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Answer 8

Correct Answers:

Facility-assigned identification number
Client's full name

Rationale :

✅ Facility-assigned identification number:

This unique identifier ensures accurate linkage between the client and their medical records, orders, and treatments, especially in settings with many clients.

✅Client’s full name:

Verifying the full legal name is a primary step in confirming client identity and is used universally in clinical settings for safe medication and procedure verification.

✅Using two unique identifiers is a Joint Commission National Patient Safety Goal, designed to prevent treatment and medication errors and ensure all care is matched to the correct client.

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Answer 9

Correct Answers:

Performing hand hygiene before, during, and after direct contact with the client

Rationale :

💥Hand hygiene is the most critical action to prevent the transmission of infections in healthcare settings.

💥Performing it before, during, and after client contact ensures that the nurse does not transmit organisms between clients or self-contaminate.

💥Proper hand hygiene interrupts the chain of infection and is a cornerstone of standard precautions in all client care environments.

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Answer 10

Correct Answers:

Earlobe

Rationale :

💎When fingers and toes are unavailable or unreliable for pulse oximetry due to poor perfusion, nail polish, or injury, the earlobe is a valid alternative site.

💎It is highly vascular and provides a reliable reading of oxygen saturation levels (SpO₂).

💎Selecting an accurate site is critical for assessing oxygenation status, especially in critically ill or postoperative clients.

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RN Nsg131 Fundamentals Exam

No.

1 : A nurse is preparing to administer three liquid medications to a client who has an NG feeding tube with continuous enteral feedings. Which of the following actions should the nurse take?

2 : A nurse is caring for a client and observes that the client's urine is dark amber, cloudy, and has an unpleasant odor. The nurse should recognize that these findings are associated with which of the following?

3 : A nurse is providing teaching about a heart-healthy diet to a group of clients with hypertension. Which of the following statements by one of the clients indicates a need for further teaching?

4 : A nurse is caring for a client who needs to increase his protein intake. The client tells the nurse some of the food he enjoys. Which of the following foods should the nurse recommend as the best source of protein among these suggestions?

5 : A nurse is caring for a client who has a hip fracture that requires surgical repair. Which of the following health care professionals is responsible for obtaining informed consent from the client for the procedure?

6 : A nurse is attending a social event when another guest coughs weakly once, grasps his throat with his hands, and cannot talk. Which of the following actions should the nurse take?

7 : A nurse is preparing a client's evening dose of risperidone when the tablet falls on the countertop. Which of the following actions should the nurse take?

8 : A nurse is preparing to administer oral medications to a client. Which of the following should the nurse recognize as an acceptable client identifier? (Select All that Apply)

9 : A nurse is caring for a client who has an infection. The nurse should use which of the following strategies to prevent the transmission of the client's infection?

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

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