NR226/NR 226 Exam 3 V2 | Fundamentals of
Patient Care Q&A with Rationale | Chamberlain
University
1. A nurse is preparing to administer an enteral feeding via a nasogastric (NG) tube. What is
the gold standard for confirming the placement of the tube before starting the feeding?
A. Aspiration of gastric contents to check pH levels.
B. Auscultating for a ‘whoosh’ sound after injecting air.
C. Checking the measurement markings on the external portion of the tube.
D. Radiographic verification via X-ray.
Correct Answer: D
Explanation: Radiographic confirmation is the only definitive method to ensure the tube is
in the stomach and not the lungs. While pH testing and measuring external length are
useful ongoing checks, they do not replace the initial X-ray. Auscultation is no longer
considered a reliable method for placement verification due to the risk of error.
2. Which clinical manifestation would the nurse expect to find in a patient experiencing fluid
volume deficit?
A. Decreased skin turgor and dry mucous membranes.
B. Increased blood pressure and bounding pulse.
C. Distended neck veins while sitting upright.
,D. Presence of crackles in the lower lung lobes.
Correct Answer: A
Explanation: Fluid volume deficit, or dehydration, leads to reduced interstitial fluid,
resulting in poor skin turgor (tenting). Dry mucous membranes and concentrated urine are
also common signs of inadequate hydration. The other options describe symptoms of fluid
volume excess, such as edema and hypertension.
3. A patient with a history of heart failure is prescribed a 2g sodium diet. Which food choice
indicates that the patient understands the dietary restriction?
A. Canned vegetable soup with crackers.
B. Fresh roasted chicken with steamed broccoli.
C. A deli ham sandwich with pickles.
D. Frozen pepperoni pizza.
Correct Answer: B
Explanation: Fresh meats and vegetables are naturally lower in sodium compared to
processed or canned alternatives. Canned soups, deli meats, and frozen pizzas are typically
very high in sodium to preserve shelf life. Following a low-sodium diet is essential for heart
failure patients to prevent fluid retention and exacerbation of symptoms.
4. When performing indwelling urinary catheter care, which action by the nurse is essential
for reducing the risk of a Catheter-Associated Urinary Tract Infection (CAUTI)?
A. Cleaning the length of the catheter from the meatus downward.
, B. Applying antiseptic ointment to the urinary meatus daily.
C. Cleaning the catheter from the drainage bag upward toward the meatus.
D. Changing the catheter every 72 hours regardless of condition.
Correct Answer: A
Explanation: Cleaning from the meatus downward prevents the migration of bacteria from
the contaminated tubing into the urinary tract. Antiseptic ointments are not recommended
as they can promote antibiotic resistance and skin irritation. Maintaining a closed drainage
system and performing routine hygiene are the most effective ways to prevent CAUTIs.
5. The nurse identifies a stage 2 pressure injury on a patient’s sacrum. How should the nurse
document the appearance of this wound?
A. Partial-thickness loss of dermis presenting as a shallow open ulcer.
B. Non-blanchable erythema of intact skin.
C. Full-thickness tissue loss with visible subcutaneous fat.
D. Full-thickness loss with exposed bone, tendon, or muscle.
Correct Answer: A
Explanation: A stage 2 pressure injury involves the epidermis and dermis, appearing as a
shallow ulcer or a serum-filled blister. Stage 1 is characterized by non-blanchable redness,
while Stage 3 involves subcutaneous fat. It is critical for the nurse to stage wounds
correctly to ensure appropriate treatment protocols are implemented.
Patient Care Q&A with Rationale | Chamberlain
University
1. A nurse is preparing to administer an enteral feeding via a nasogastric (NG) tube. What is
the gold standard for confirming the placement of the tube before starting the feeding?
A. Aspiration of gastric contents to check pH levels.
B. Auscultating for a ‘whoosh’ sound after injecting air.
C. Checking the measurement markings on the external portion of the tube.
D. Radiographic verification via X-ray.
Correct Answer: D
Explanation: Radiographic confirmation is the only definitive method to ensure the tube is
in the stomach and not the lungs. While pH testing and measuring external length are
useful ongoing checks, they do not replace the initial X-ray. Auscultation is no longer
considered a reliable method for placement verification due to the risk of error.
2. Which clinical manifestation would the nurse expect to find in a patient experiencing fluid
volume deficit?
A. Decreased skin turgor and dry mucous membranes.
B. Increased blood pressure and bounding pulse.
C. Distended neck veins while sitting upright.
,D. Presence of crackles in the lower lung lobes.
Correct Answer: A
Explanation: Fluid volume deficit, or dehydration, leads to reduced interstitial fluid,
resulting in poor skin turgor (tenting). Dry mucous membranes and concentrated urine are
also common signs of inadequate hydration. The other options describe symptoms of fluid
volume excess, such as edema and hypertension.
3. A patient with a history of heart failure is prescribed a 2g sodium diet. Which food choice
indicates that the patient understands the dietary restriction?
A. Canned vegetable soup with crackers.
B. Fresh roasted chicken with steamed broccoli.
C. A deli ham sandwich with pickles.
D. Frozen pepperoni pizza.
Correct Answer: B
Explanation: Fresh meats and vegetables are naturally lower in sodium compared to
processed or canned alternatives. Canned soups, deli meats, and frozen pizzas are typically
very high in sodium to preserve shelf life. Following a low-sodium diet is essential for heart
failure patients to prevent fluid retention and exacerbation of symptoms.
4. When performing indwelling urinary catheter care, which action by the nurse is essential
for reducing the risk of a Catheter-Associated Urinary Tract Infection (CAUTI)?
A. Cleaning the length of the catheter from the meatus downward.
, B. Applying antiseptic ointment to the urinary meatus daily.
C. Cleaning the catheter from the drainage bag upward toward the meatus.
D. Changing the catheter every 72 hours regardless of condition.
Correct Answer: A
Explanation: Cleaning from the meatus downward prevents the migration of bacteria from
the contaminated tubing into the urinary tract. Antiseptic ointments are not recommended
as they can promote antibiotic resistance and skin irritation. Maintaining a closed drainage
system and performing routine hygiene are the most effective ways to prevent CAUTIs.
5. The nurse identifies a stage 2 pressure injury on a patient’s sacrum. How should the nurse
document the appearance of this wound?
A. Partial-thickness loss of dermis presenting as a shallow open ulcer.
B. Non-blanchable erythema of intact skin.
C. Full-thickness tissue loss with visible subcutaneous fat.
D. Full-thickness loss with exposed bone, tendon, or muscle.
Correct Answer: A
Explanation: A stage 2 pressure injury involves the epidermis and dermis, appearing as a
shallow ulcer or a serum-filled blister. Stage 1 is characterized by non-blanchable redness,
while Stage 3 involves subcutaneous fat. It is critical for the nurse to stage wounds
correctly to ensure appropriate treatment protocols are implemented.
