NR226/NR 226 Exam 2 V2 | Fundamentals of
Patient Care Q&A with Rationale | Chamberlain
University
1. A nurse is caring for a client receiving continuous enteral feedings via a nasogastric tube.
Which action should the nurse include in the plan of care to prevent aspiration?
A. Check gastric residual volume once every 24 hours.
B. Administer the feeding at room temperature.
C. Flush the tube with 100 mL of water every 4 hours.
D. Keep the head of the bed elevated at least 30 to 45 degrees.
Correct Answer: D
Explanation: Maintaining the head of the bed at 30 to 45 degrees is a critical intervention
to minimize the risk of gastric reflux and aspiration. The nurse should also monitor gastric
residuals more frequently than every 24 hours to assess tolerance. Ensuring the tube is
properly placed before feeding is another vital safety step in enteral nutrition management.
2. A nurse is preparing to insert an indwelling urinary catheter for a female client. Which
action is the priority for preventing a catheter-associated urinary tract infection (CAUTI)?
A. Cleanse the perineal area from back to front.
B. Maintain strict sterile technique during the procedure.
C. Inflate the balloon with 15 mL of sterile water.
,D. Secure the catheter to the client’s inner thigh.
Correct Answer: B
Explanation: Using strict sterile technique during insertion is the primary way to prevent
introducing pathogens into the urinary tract. The drainage bag should always be kept
below the level of the bladder to prevent backflow of urine. Routine perineal hygiene with
soap and water is recommended over the use of harsh antiseptic solutions to maintain skin
integrity.
3. A nurse is teaching a client about a fecal occult blood test (guaiac test). Which instruction
should the nurse include?
A. Take a dose of vitamin C before collecting the sample.
B. Use a sterile container for the stool collection.
C. Eat plenty of red meat for 3 days before the test.
D. Collect samples from three different bowel movements.
Correct Answer: D
Explanation: Collecting samples from three different bowel movements increases the
accuracy of detecting occult blood. Clients should avoid red meat, poultry, and fish for three
days prior to testing as these can cause false-positive results. Vitamin C and certain
medications should also be avoided because they can interfere with the chemical reaction
of the guaiac test.
, 4. A client is diagnosed with hyperkalemia. Which clinical manifestation should the nurse
monitor for most closely?
A. Increased muscle strength
B. Polyuria and polydipsia
C. Hypotension and bradycardia
D. Cardiac dysrhythmias and ECG changes
Correct Answer: D
Explanation: Hyperkalemia significantly affects cardiac electrical conduction, making
dysrhythmias the most dangerous manifestation. The nurse must prioritize monitoring the
heart rate and rhythm via ECG for signs like peaked T-waves. Prompt intervention is
required to lower potassium levels and prevent cardiac arrest.
5. When administering medications, the nurse must follow the ‘six rights’ of medication
administration. Which of the following is included in these rights?
A. Right room number
B. Right documentation
C. Right diagnosis
D. Right family member
Correct Answer: B
Patient Care Q&A with Rationale | Chamberlain
University
1. A nurse is caring for a client receiving continuous enteral feedings via a nasogastric tube.
Which action should the nurse include in the plan of care to prevent aspiration?
A. Check gastric residual volume once every 24 hours.
B. Administer the feeding at room temperature.
C. Flush the tube with 100 mL of water every 4 hours.
D. Keep the head of the bed elevated at least 30 to 45 degrees.
Correct Answer: D
Explanation: Maintaining the head of the bed at 30 to 45 degrees is a critical intervention
to minimize the risk of gastric reflux and aspiration. The nurse should also monitor gastric
residuals more frequently than every 24 hours to assess tolerance. Ensuring the tube is
properly placed before feeding is another vital safety step in enteral nutrition management.
2. A nurse is preparing to insert an indwelling urinary catheter for a female client. Which
action is the priority for preventing a catheter-associated urinary tract infection (CAUTI)?
A. Cleanse the perineal area from back to front.
B. Maintain strict sterile technique during the procedure.
C. Inflate the balloon with 15 mL of sterile water.
,D. Secure the catheter to the client’s inner thigh.
Correct Answer: B
Explanation: Using strict sterile technique during insertion is the primary way to prevent
introducing pathogens into the urinary tract. The drainage bag should always be kept
below the level of the bladder to prevent backflow of urine. Routine perineal hygiene with
soap and water is recommended over the use of harsh antiseptic solutions to maintain skin
integrity.
3. A nurse is teaching a client about a fecal occult blood test (guaiac test). Which instruction
should the nurse include?
A. Take a dose of vitamin C before collecting the sample.
B. Use a sterile container for the stool collection.
C. Eat plenty of red meat for 3 days before the test.
D. Collect samples from three different bowel movements.
Correct Answer: D
Explanation: Collecting samples from three different bowel movements increases the
accuracy of detecting occult blood. Clients should avoid red meat, poultry, and fish for three
days prior to testing as these can cause false-positive results. Vitamin C and certain
medications should also be avoided because they can interfere with the chemical reaction
of the guaiac test.
, 4. A client is diagnosed with hyperkalemia. Which clinical manifestation should the nurse
monitor for most closely?
A. Increased muscle strength
B. Polyuria and polydipsia
C. Hypotension and bradycardia
D. Cardiac dysrhythmias and ECG changes
Correct Answer: D
Explanation: Hyperkalemia significantly affects cardiac electrical conduction, making
dysrhythmias the most dangerous manifestation. The nurse must prioritize monitoring the
heart rate and rhythm via ECG for signs like peaked T-waves. Prompt intervention is
required to lower potassium levels and prevent cardiac arrest.
5. When administering medications, the nurse must follow the ‘six rights’ of medication
administration. Which of the following is included in these rights?
A. Right room number
B. Right documentation
C. Right diagnosis
D. Right family member
Correct Answer: B
