NR226/NR 226 Exam 2 V1 | Fundamentals of Patient Care Q&A with Rationale | Chamberlain
University
1. A nurse is preparing to administer an enteral feeding to a client through a nasogastric (NG)
tube. What is the priority nursing action before starting the infusion?
A. Auscultate for bowel sounds in all four quadrants.
B. Flush the tube with 30 mL of tap water.
C. Warm the formula to room temperature to prevent cramping.
D. Verify the placement of the tube via radiographic imaging or pH testing.
Correct Answer: D
Explanation: Verifying tube placement is the most critical step to prevent pulmonary
aspiration of the feeding. While auscultation and flushing are important, they do not
definitively confirm that the tube is in the stomach rather than the lungs. Radiographic
imaging remains the gold standard for confirmation, followed by pH testing of aspirate in
some clinical guidelines.
2. A client is diagnosed with a Stage 2 pressure injury. How should the nurse describe this
wound in the medical record?
A. Intact skin with non-blanchable redness over a bony prominence.
B. Partial-thickness skin loss involving the epidermis and dermis, presenting as a shallow
open ulcer.
C. Full-thickness tissue loss where subcutaneous fat may be visible.
,D. Full-thickness tissue loss with exposed bone, tendon, or muscle.
Correct Answer: B
Explanation: Stage 2 pressure injuries involve partial-thickness loss of skin with a pink or
red wound bed. It often presents as an intact or ruptured serum-filled blister or a shallow
ulcer without slough. The nurse must differentiate this from Stage 1 (non-blanchable
redness) and Stage 3 (subcutaneous fat involvement) to ensure appropriate wound care
interventions.
3. During the preoperative assessment, a client tells the nurse they are allergic to bananas
and avocados. Which allergy should the nurse also suspect?
A. Penicillin
B. Iodine
C. Latex
D. Adhesive tape
Correct Answer: C
Explanation: There is a known cross-reactivity between certain fruits, such as bananas,
avocados, and kiwi, and latex sensitivity. Identifying this risk factor is essential for
maintaining a safe intraoperative environment for the client. The nurse should document
this clearly and ensure the surgical team uses latex-free supplies to prevent anaphylaxis.
, 4. A nurse is caring for a client who is 24 hours postoperative. The nurse notes the client has
not voided since the indwelling catheter was removed 8 hours ago. What is the nurse’s first
action?
A. Encourage the client to increase oral fluid intake.
B. Notify the provider and request an order for re-catheterization.
C. Perform a bladder scan to assess for urinary retention.
D. Apply fundal pressure to the bladder area.
Correct Answer: C
Explanation: A bladder scan is a non-invasive method to determine the volume of urine in
the bladder and confirm urinary retention. This assessment data is necessary before calling
the provider or performing invasive procedures. Providing objective data regarding
bladder volume helps guide further interventions like intermittent catheterization.
5. When assessing a client with hypokalemia (potassium level 3.2 mEq/L), which finding
should the nurse prioritize?
A. Cardiac dysrhythmias and ECG changes.
B. Muscle weakness and leg cramps.
C. Abdominal distention and decreased bowel sounds.
D. Hyporeflexia and lethargy.
Correct Answer: A
University
1. A nurse is preparing to administer an enteral feeding to a client through a nasogastric (NG)
tube. What is the priority nursing action before starting the infusion?
A. Auscultate for bowel sounds in all four quadrants.
B. Flush the tube with 30 mL of tap water.
C. Warm the formula to room temperature to prevent cramping.
D. Verify the placement of the tube via radiographic imaging or pH testing.
Correct Answer: D
Explanation: Verifying tube placement is the most critical step to prevent pulmonary
aspiration of the feeding. While auscultation and flushing are important, they do not
definitively confirm that the tube is in the stomach rather than the lungs. Radiographic
imaging remains the gold standard for confirmation, followed by pH testing of aspirate in
some clinical guidelines.
2. A client is diagnosed with a Stage 2 pressure injury. How should the nurse describe this
wound in the medical record?
A. Intact skin with non-blanchable redness over a bony prominence.
B. Partial-thickness skin loss involving the epidermis and dermis, presenting as a shallow
open ulcer.
C. Full-thickness tissue loss where subcutaneous fat may be visible.
,D. Full-thickness tissue loss with exposed bone, tendon, or muscle.
Correct Answer: B
Explanation: Stage 2 pressure injuries involve partial-thickness loss of skin with a pink or
red wound bed. It often presents as an intact or ruptured serum-filled blister or a shallow
ulcer without slough. The nurse must differentiate this from Stage 1 (non-blanchable
redness) and Stage 3 (subcutaneous fat involvement) to ensure appropriate wound care
interventions.
3. During the preoperative assessment, a client tells the nurse they are allergic to bananas
and avocados. Which allergy should the nurse also suspect?
A. Penicillin
B. Iodine
C. Latex
D. Adhesive tape
Correct Answer: C
Explanation: There is a known cross-reactivity between certain fruits, such as bananas,
avocados, and kiwi, and latex sensitivity. Identifying this risk factor is essential for
maintaining a safe intraoperative environment for the client. The nurse should document
this clearly and ensure the surgical team uses latex-free supplies to prevent anaphylaxis.
, 4. A nurse is caring for a client who is 24 hours postoperative. The nurse notes the client has
not voided since the indwelling catheter was removed 8 hours ago. What is the nurse’s first
action?
A. Encourage the client to increase oral fluid intake.
B. Notify the provider and request an order for re-catheterization.
C. Perform a bladder scan to assess for urinary retention.
D. Apply fundal pressure to the bladder area.
Correct Answer: C
Explanation: A bladder scan is a non-invasive method to determine the volume of urine in
the bladder and confirm urinary retention. This assessment data is necessary before calling
the provider or performing invasive procedures. Providing objective data regarding
bladder volume helps guide further interventions like intermittent catheterization.
5. When assessing a client with hypokalemia (potassium level 3.2 mEq/L), which finding
should the nurse prioritize?
A. Cardiac dysrhythmias and ECG changes.
B. Muscle weakness and leg cramps.
C. Abdominal distention and decreased bowel sounds.
D. Hyporeflexia and lethargy.
Correct Answer: A
