Fundamentals: Exam 3 Practice Questions Exam Question & Answers 2024, Exams of Nursing

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Exam Question & Answers 2024

A nurse is caring for a client who is at high risk for aspiration. Which of the following actions should the nurse take? A. Give the client thin liquids B. Instruct the client to tuck her chin while swallowing C. Have the client use a straw. D. Encourage the client to lie down and rest after meals - Correct Answers ✅✅B exp.) tucking the chin when swallowing allows food to pass down the esophagus more easily A nurse is preparing a presentation about basic nutrients for a group of high school athletes. She should explain that which of the following nutrients provide the most energy? A. Fat B. Protein C. Glycogen D. Carbohydrates - Correct Answers ✅✅D exp.) carbohydrates are the body's greatest energy source; providing energy for cells is their primary function. They provide glucose, which burns completely and efficiently without end products to excrete. They are also a ready source of energy, and they spare proteins for depletion.

Exam Question & Answers 2024

A nurse is caring for a client who requires a low-residue diet. The nurse should expect to see which of the following foods on the clients meal tray? A. Cooked barley B. Pureed broccoli C. Vanilla custard D. Lentil soup - Correct Answers ✅✅C exp.) A low residue diet consists of foods that are low in fiber and easy to digest. Dairy products and eggs such as custard and yogurt, are appropriate. A nurse is caring for a client who weighs 80 kg (176 lbs) and 1.6 m (5 ft, 3 in tall) Calculate her body mass index (BMI) and determine whether this clients BMI indicates she is of a healthy weight, overweight, or obese. - Correct Answers ✅✅BMI = weight (kg) / height (m2) Step 1: Clients weight (kg) and height (m) = 80 kg and 1.6 m Step 2: 1.6 X 1.6 = 2.56 m Step 3: 80/2.56 = 31. So this client is considered obese (BMI over 30 indicates obesity)

Exam Question & Answers 2024

A nurse in a senior center is counseling a group of older adults about their nutritional needs and considerations. Which of the following information should the nurse include? (Select all that apply). A. Older adults are more prone to dehydration than younger adults are B. Older adults need the same amount of most vitamins and minerals as younger adults do C. Many older men and women need calcium supplementation D. Older adults need more calories than they did when they were younger E. Older adults should consume a diet low in carbohydrates. - Correct Answers ✅✅A exp.) sensations of thirst diminish with age, leaving older adults more prone to dehydration B exp.) requirements for vitamins and minerals do not change from middle to older adulthood C exp.) if older adults ingest insufficient calcium in the diet, the need supplements to help prevent bone demineralization (osteoporosis) A nurse is calculating the body mass index of a 35 year old male patient who is extremely obese. The patients height is 5'6 and his current weight is 325 lbs. What would the nurse document as his BMI?

Exam Question & Answers 2024

A. 50.

B. 52.

C. 54.

D. 55.2` - Correct Answers ✅✅BMI = weight in pounds (325) / height in inches (66) X height in inches (66) X 703 BMI = 52. A nurse is helping an overweight female patient to devise a meal plan to lose 2 pounds per week. How many calories would the patient need to deplete per day in order to accomplish this goal? A. 250 calories B. 500 calories C. 750 calories D. 1000 calories - Correct Answers ✅✅D exp.) 1 lb (0.45 kg) of body fat equals about 3.500 calories. Therefore, to gain or lose 1 lb (0.45 kg) in a week, daily calorie intake should be increase or decreased by 500 cals a day so to lose or gain 2 lbs per week, the calorie intake should increase or decrease by 1000 cals a day A nurse is feeding an elderly patient who has dementia. Which intervention should the nurse perform to facilitate this process? A. Stroke the underside of the patients chin to promote swallowing

Exam Question & Answers 2024

B. Serve meals in different places at different times C. Offer a whole tray of various foods to choose from D. Avoid between-meal snacks to ensure hunger at mealtime - Correct Answers ✅✅A exp.) to feed a patient with dementia, the nurse should stroke the underside of the patients chin to promote swallowing, serve meals in the same place and at the same time, provide one food item at a time since a whole tray may overwhelming and provide between-meal snacks that are easy to consume using the hands A 56 year old male patient who has COPD is refusing to eat. Which intervention would be most helpful in simulating his appetite? A. Administering pain meds after meals B. Encouraging food from home when possible C. Scheduling his respiratory therapy before each meal D. Reinforcing the importance of his eating exactly what is delivered to him - Correct Answers ✅✅B. exp.) Food from home that the patient enjoys may stimulate him to eat. Pain medication should be given before meals, respiratory therapy should be scheduled after meals, and tells the patient what he must eat is no guarantee that he will comply A nurse is feeding a patient who is experiencing dysphagia. Which nursing intervention would the nurse initiate for this patient?

Exam Question & Answers 2024

A. Feed the patient solids first then liquids last B. Place the head of the bed at a 30 degree angle during feeding C. Puree all foods to a liquid consistency D. Provide a 30 minute rest period prior to mealtime - Correct Answers ✅✅D. exp.) when feeding a patient who has dysphagia, the nurse should provide a 30 minute rest period prior to mealtime to promote swallowing; alternate solids and liquids when feeding the patient; sit the patient upright or, if on bedrest, elevate the head of the bed at a 90 degree angle; and initiate a nutrition consultant for diet modification and food size and/or consistency A nurse is evaluating patients to determine their need for total parenteral nutrition. (TPN) Which patients would be the best candidates for this type of nutritional support? Select all that apply A. A patient with irritable bowel syndrome who has intractable diarrhea. B. A patient with celiac disease not absorbing nutrients from the GI tract. C. A patient who is underweight and needs short term nutritional support D. A patient who is comatose and needs long term nutritional support E. A patient who has anorexia and refuses to take foods via the oral route

Exam Question & Answers 2024

F. A patient with burns who has not been able to eat adequately for 5 days - Correct Answers ✅✅A, B, F A nurse is feeding a patient who states that she is feeling is nauseated and can't eat what is being offered. What would be the most appropriate initial action of the nurse in this situation? A. Remove the tray from the room B. Administer an antiemtetic and encourage the patient to take small amounts C. Explore with the patient why she does not want to eat her food D. Offer high-calorie snacks such as pudding and icecream - Correct Answers ✅✅A exp.) the first action of the nurse when a patient ha nausea is to remove the tray from the room. The nurse may then offer small amounts of foods and liquids such as crackers or ginger ale. The nurse may also administer a prescribed antiemetic and try small amounts of food when it takes effect A 62 year old male patient has been admitted to the alcoholic referral unit in the local hospital. Based on an understanding of the effects of alcohol on the GI tract, which is a priority concern related to nutrition? A. Vitamin B malnutrition B. Obesity C. Dehydration

Exam Question & Answers 2024

D. Vitamin C deficiency - Correct Answers ✅✅A exp.) the need for vitamin B is increased in alcoholics because these nutrients are used to metabolize alcohol, thus depleting their supply. A nurse is caring for a newly placed gastrostomy tube of a post op patient. Which nursing action is performed correctly? A. The nurse dips a cotton-tipped applicator into sterile saline solution and gently cleans around the insertion site B. The nurse wets a washcloth and washes the area around the tube with soap and water C. The nurse adjusts the external disk every 3 hours to avoid crusting around the tube D. The nurse tapes a gauze dressing over the site after cleaning it - Correct Answers ✅✅A exp.) when caring for a new gastrostomy tube, the nurse would use a cotton tipped applicator dipped in sterile saline to gently cleanse the area, removing any crust or drainage. A nurse is assessing a patient who has been NPO prior to abdominal surgery. The patient is ordered a clear liquid diet for breakfast to advance to a house diet as tolerated. Which assessments would indicate to the nurse that the patient's diet should not be advanced? A. The patient consumed 75% of the liquids on her breakfast tray B. The patient tells you she is hungry

Exam Question & Answers 2024

C. The patients abdomen is soft, nondistended, with bowel sounds D. The patient reports fullness and diarrhea after breakfast. - Correct Answers ✅✅D exp.) tolerance of diet can be assessed by the following: absence of nausea, vomiting and diarrhea; absence of feelings of fullness; absence of abdominal pain and distention; feelings of hunger; and the ability to consume at least 50-75% of the food on the meal tray A patient who is moved to a hospital bed following throat surgery is ordered to receive continuous tube feedings through a small-bore nasogastic tube. Following placement of the tube, which nursing action would the nurse initiate to ensure correct placement of the tube? A. Auscultate the bowel sounds B. Measure the gastric aspirate ph C. Measure the amount of residual in the tube D. order radiographic examination of the tube - Correct Answers ✅✅D Which of the following nursing diagnoses would be most appropriate for a patient with a body mass index of 18? A. Risk for Imbalanced Nutrition: More Than Body Requirements B. Imbalanced Nutrition: More than Body Requirements C. Readiness for Enhanced Nutrition

Exam Question & Answers 2024

D. Imbalanced Nutrition: Less than Body Requirements - Correct Answers ✅✅D exp.) BMI of 18 is considered underweight A nurse is inserting a nasogastric tube ordered for a patient to monitor bleeding in his GI tract. When the tube is being passed through the pharynx, the patient begins to cough and shows signs of respiratory distress. What would be the priority action of the nurse upon this assessment? A. Keep the tube in place and notify the primary HCP immediately B. Stop advancing the tube and pull it back into the nasal area C. Ask the patient if he wants the nurse to stop the procedure D. Call for help for perform CPR - Correct Answers ✅✅B A nurse is administering a tube feeding for a patient who is post bowel surgery. When attempting to aspirate the contents, the nurse notes that the tube is clogged. What would be the nurses next action following this assessment? A. Use warm water and gentle pressure to remove the clog B. Use a stylet to unclog the tube C. Administer cola to unclog the tube D. Replace the tube with a new one - Correct Answers ✅✅A

Exam Question & Answers 2024

A nurse performs surgical assessments of patients in an ambulatory care center. Which patient would the nurse report to the surgeon as possibly needing surgery to be postponed? A. A 19 year old patient who is vegan B. An elderly patient who takes daily nutritional drinks C. A 43 year old patient who takes gingko bilboa and an aspirin daily D. An infant who is breast feeding - Correct Answers ✅✅C exp.) A patient taking gingko biloba (an herbal) aspirin and vitamin E may have to have surgery postponed due to an increase risk for excessive bleeding, because each of those substances have anticoagulant properties. A nurse is a providers office is evaluating a client who reports losing control of urine whenever she coughs, laughs, or sneezes. The client relates a history of three vaginal births, but no serious accidents or illnesses. Which of the following interventions should the nurse suggest for helping to control or eliminate the client's incontinence? (Select all that apply). A. Limit total daily fluid intake B. Decrease or avoid caffeine C. Take calcium supplements D. Avoid drinking alcohol E. Use the crede maneuver - Correct Answers ✅✅B, D

Exam Question & Answers 2024

A client who has an indwelling catheter reports a need to urinate. Which of the following actions should the nurse take? A. Check to see whether the catheter is patent B. Reassure the client that it is not possible for her to urinate C. Recatheterize the bladder with a larger-gauge catheter D. Collect a urine specimen for analysis - Correct Answers ✅✅A exp.) a clogging or kinked catheter causes the bladder to fill and stimulates the need to urinate A nurse is caring for a client who has a prescription for a 24 hr urine collection. Which of the following actions should the nurse take? A. Discard the first voiding B. Keep the urine in a single container at room temperature C. Ask the client to urinate and pour the urine into a specimen container D. Ask the client to urinate into the toilet, stop midstream, and finish urinating into the specimen container - Correct Answers ✅✅A exp.) the nurse should discard the first voiding of the 24 hr urine specimen and note the time

Exam Question & Answers 2024

A nurse is reviewing factors that increase the risk of urinary tract infections with a client who has recurrent UTI's. Which of the following factors should the nurse include? (Select all that apply) A. Frequent sexual intercourse B. Lowering of testosterone levels C. Wiping from front to back D. Location of the urethra in relation to the anus E. Frequent catheterization - Correct Answers ✅✅A, D, E A nurse is preparing to initiate a bladder-retraining program for a client who has incontinence. Which of the following actions should the nurse take? (Select all that apply) A. Establish a schedule of urinating prior to meal times B. Have the client record urination times C. Gradually increase urination intervals D. Remind the client to hold urine until the next scheduled urination time E. Provide a sterile container for urine - Correct Answers ✅✅B, C, D A nurse caring for patients in a long-term care facility is often required to collect urine specimens from patients for lab testing. Which techniques for urine collection are performed correctly? (Select all that apply)

Exam Question & Answers 2024

A. The nurse catheterizes a patient to collect a sterile urine sample for routine urinalysis. B. The nurse collects a clean-catch urine specimen in the morning from a patient and stores it at room temperature until an afternoon pick up. C. The nurse collects a sterile urine specimen from the collection receptacle of a patient's indwelling catheter. D. The nurse collects about 3 mL of urine from a patient's indwelling catheter to send for a urine culture E. The nurse collects a urine specimen from a patient with urinary diversion by catheterizing the stoma. F. The nurse discards the first urine of the day when performing a 24 hr urine specimen collection on a patient. - Correct Answers ✅✅D, E, F A nurse caring for patients in an extended-care facility performs regular assessments of the patients' urinary functioning. Which patients would the nurse screen for urinary retention. (Select all that apply). A. A 78 year old patient diagnosed with an enlarged prostate. B. An 83 year old female patient who is on bed rest. C. A 75 year old female patient who is diagnosed with vaginal prolapse. D. An 89 year old male patient who has dementia. E. A 73 year old female patient who is taking antihistamines to treat allergies

Exam Question & Answers 2024

F. A 90 year old male patient who has difficulty walking to the bathroom. - Correct Answers ✅✅A, C, E exp.) urinary retention occurs when urine is produced normally but not excreted completely from the bladder. Factors associated with urinary retention include medications such as antihistamines, an enlarged prostate, or vaginal prolapse A nurse is preparing a brochure to teach patients how to prevent urinary tract infections. Which teaching points would the nurse include? (Select all that apply) A. Wear underwear with a synthetic crotch B. Take baths rather than showers C. Drink 8-10 oz glasses of water per day D. Drink a glass of water before and after intercourse and void afterwards E. Limit caffeine containing beverages F. Drink 10 oz of cranberry of blueberry juice daily - Correct Answers ✅✅C, E, F A patient who has pneumonia has had a fever for 3 days. What characteristics would the nurse anticipate related to the patients urine output? A. Decreased and highly concentrated

Exam Question & Answers 2024

B. Decreased and highly dilute C. Increased and concentrated D. Increased and dilute - Correct Answers ✅✅A exp.) fever and diaphoresis cause the kidneys to conserve body fluids. Thus, the urine is concentrated and decreased in amount The physician has ordered an indwelling catheter inserted in a hospitalized male patient. What consideration would the nurse keep in mind when performing this procedure? A. The male urethra is more vulnerable to injury during insertion B. In the hospital, a clean technique is used for catheter insertion C. The catheter is inserted 2' to 3' in into the meatus D. Since it uses a closed system, the risk for UTI is absent - Correct Answers ✅✅A exp.) b/c of its length, the male urethra is more prone to injury and requires that the catheter be inserted 6' to 8' inches. This procedure requires surgical asepsis to prevent introducing bacteria into the urinary tract. A nurse is performing intermittent closed-catheter irrigation for a patient with an indwelling catheter. After attaching the syringe to the access port on the catheter, the nurse finds that the irrigant will not enter the catheter. What intervention would the nurse appropriately perform next?

Exam Question & Answers 2024

A. Apply pressure to the catheter to force the solution into the catheter. B. Disconnect and reconnect the drainage system quickly C. Notify the primary HCP D. Change the catheter - Correct Answers ✅✅C A nurse is caring for a 56 year old male patient diagnosed with bladder cancer who has a urinary diversion. Which actions would the nurse take when caring for this patient? (Select all that apply) A. Measure the patients intake and output. B. Keep the skin around the stoma moist C. Empty the appliance frequently D. Report any mucous in the urine to the primary care provider E. Encourage the patient to look away when changing the appliance F. Monitor the return of intestinal function and peristalsis - Correct Answers ✅✅A, C, F exp.) when caring for a patient with a urinary diversion, the skin around the stoma should be kept dry and watch for mucous in the urine as a normal finding and encourage the patient to participate in care and look at the stoma.

Exam Question & Answers 2024

A nurse is changing a stoma appliance on a patients ileal conduit. Which characteristic of the stoma would alert the nurse that the patient is experiencing ischemia? A. The stoma is hard and dry B. The stoma is a pale pink color C. The stoma is swollen D. The stoma is a purple-blue color - Correct Answers ✅✅D After surgery, a patient is having difficulty voiding. Which nursing action would most likely lead to an increased difficulty with voiding? A. Pouring warm water over the patients fingers B. Having the patient ignore the urge to void until her bladder is full C. Using a warm bedpan when the patient feels the urge to void D. Stroking the patients leg or thigh - Correct Answers ✅✅B A nurse is caring for a patients hemodialysis access documents the following: "5/10/15 0930 Arteriovenous fistula patent in right upper arm. Area is warm to touch and edematous. Patient denies pain and tenderness. Positive bruit and thrill noted." Which documented finding would the nurse report to the HCP? A. Positive bruit noted B. Area is warm to touch and edematous C. Patient denies pain and tenderness

Exam Question & Answers 2024

D. Insert an indwelling catheter to prevent skin breakdown - Correct Answers ✅✅B exp.) the nurse would report a site that is warma nd edematous as this could be a sign of infection. The thrill and bruit are normal findings caused by arterial blood flowing into the vein A nurse is caring for an alert, ambulatory, older resident in a long term care facility who voids frequently and has difficulty making it to the bathroom in time. Which nursing intervention would be the most helpful for this patient? A. Teach the patient that incontinence is a normal occurrence of aging B. Ask the patients family to purchase incontinence pads for the patient C. Teach the patient to perform Kegel exercises at regular intervals daily D. Insert an indwelling catheter to prevent skin breakdown - Correct Answers ✅✅C A nurse is caring for a patient who is taking phenazopyridine. The patient questions the nurse: "My urine was bright orangish-red today; is there something wrong with me?" What would be the nurses best response? A. This is a normal finding when taking phenazopyridine B. This may be a sign of blood in the urine C. This may be a result of an injury to your bladder

Exam Question & Answers 2024

D. This is a sign that you are allergic to the medication and must stop it

• Correct Answers ✅✅A A nurse is caring for a male patient who had a condom catheter applied following his surgery. What action would be a priority when caring for this patient? A. Preventing the tubing from kinking to maintain free urinary drainage B. Not removing the catheter for any reason C. Fastening the condom tightly to prevent the possibility of leakage D. Maintaining bedrest at all times to prevent the catheter from slipping off - Correct Answers ✅✅A A nurse forms the following nursing diagnosis for a patient: Impaired Urinary Elimination r/t maturational enuresis. Based on this diagnosis, for which patient is the nurse caring? A. An older older than 65 who is incontinent B. A child older than 4 who has voluntary urination C. A 12 month old child who has involuntary urination D. A patient with neurologic damage resulting in bladder dysfunction - Correct Answers ✅✅B exp.) maturational enuresis is involuntary urination after an age when continence should be present.

Exam Question & Answers 2024

Data must be collected to evaluate the effectiveness of a plan to reduce urinary incontinence in an older adult patient. Which information is least important for the evaluation process? A. The incontinence pattern B. State of physical mobility C. Medications being taken D. Age of the patient - Correct Answers ✅✅D exp.) incontinence is not a natural consequence of the aging process. A nurse is caring for a client who will perform fecal occult blood testing at home. Which of the following information should the nurse include when explaining the procedure to the client? A. Eating more protein is optimal prior to testing B. One stool specimen is sufficient for testing C. A red color change indicates a positive test D. The specimen cannot be contaminated with urine - Correct Answers ✅✅D A nurse is talking with a client who reports constipation. When the nurse discusses dietary changes that can help prevent constipation, which of the following foods should the nurse recommend? A. Mac and cheese B. Fresh fruit and whole wheat toast

Exam Question & Answers 2024

C. Bread pudding and yogurt D. Roast chicken and white rice - Correct Answers ✅✅B A nurse is caring for a client who has had diarrhea for 4 days. When assessing the client, the nurse should expect which of the following findings? (Select all that apply) A. Bradycardia B. Hypotension C. Elevated temperature D. Poor skin turgor E. Peripheral edema - Correct Answers ✅✅B, C, D While a nurse is administering a cleansing enema, the client reports abdominal cramping. Which of the following actions should the nurse take? A. Have the client hold his breath briefly and bear down B. Discontinue the fluid instillation C. Remind the client that cramping is common at this time D. Lower the enema fluid container - Correct Answers ✅✅D

Exam Question & Answers 2024

A nurse is preparing to administer a cleansing enema to an adult client in preparation for a diagnostic procedure. Which of the following steps should the nurse take? (Select all that apply) A. Warm the enema solution prior to instillation B. Position the client on the left side with the right legs flexed forward C. Lubricate the rectal tube or nozzle D. Slowly insert the rectal tube about 5 cm (2 in) E. Hang the enema container 61 cm (24 in) above the clients anus. - Correct Answers ✅✅A, B, C exp.) the correct length or insertion for a child is 5 cm (2 in) and for an adult, the nurse should insert the tube 7.6 to 10.2 cm (3-4in) and the maximum recommended height is 46 cm (18 in) A nurse is assessing the abdomen of a patient who is experiencing frequent bouts of diarrhea. The nurse first observes the contour of the abdomen, noting any masses, scars, or areas of distention. What action should the nurse perform next? A. Auscultate the abdomen using an orderly clockwise approach in all abdominal quadrants B. Percuss all quadrants of the abdomen in a systemic clockwise manner to identify masses, fluid, or air in the abdomen C. Lightly palpate over the abdominal quadrants; first checking for any areas of pain or discomfort

Exam Question & Answers 2024

D. Deeply palpate over the abdominal quadrants, noting muscular resistance, tenderness, organ enlargement, or masses. - Correct Answers ✅✅A A nurse is administering a large volume cleansing enema to a patient prior to surgery. Once the enema solution is introduced, the patient complains of severe cramping. What would be the appropriate nursing intervention in this situation? A. Elevate the HOB 30 degrees and reposition the rectal tube B. Place the patient in a supine position and modify the amount of solution. C. Lower the solution container and check the temperature and flow rate D. Remove the rectal tube and notify the HCP - Correct Answers ✅✅C A nurse working in a hospital includes abdominal assessment as part of patient assessment. In which patients would a nurse expect to find decreased or absent bowel sounds after listening for 5 minutes? (Select all that apply) A. A patient diagnosed with peritonitis B. A patient who is on prolonged bedrest C. A patient who has diarrhea D. A patient who has gastroenteritis

Exam Question & Answers 2024

E. A patient who has an early bowel obstruction F. A patient who has paralytic ileus caused by surgery - Correct Answers ✅✅A, B, F A nurse assesses the stool of patients who are experiencing gastrointestinal problems. In which patients would diarrhea be a possible finding? (Select all that apply) A. A patient who is taking narcotics for pain B. A patient who is taking laxatives C. A patient who is taking diuretics D. A patient who is dehydrated E. A patient who is taking amoxicillin for an infection F. A patient who is taking OTC antacids - Correct Answers ✅✅D, E, F A patient has a fecal impaction. The nurse correctly administers an oil- retention enema by: A. Administering a large volume of solution (500-1000 mL) B. Mixing milk and molasses in equal parts for an enema C. Instructing the patient to retain the enema for at least 30 min D. Administering the enema while the patient is sitting on the toilet - Correct Answers ✅✅C