Fundamentals of Nursing
Exam 2 2026 | Practice
Questions, Answers,
Rationales &
Comprehensive Nursing
Review | Complete Ethics
Study Guide
Updated 2026 Questions and Answers
100% Verified Exam Prep and Comprehensive
Rationales
Included
,1) The nurse is inserting a nasogastric tube in an adult d
client. During the procedure, the client begins to cough Rationale: During the insertion of the nasogastric tube, if the client experiences
and has difficulty breathing. What is the most appropriate difficulty breathing or any respiratory distress, withdraw the tube slightly, stop the
action? tube advancement, and wait until the distress subsides. It is not necessary to notify
a. Insert the tube quickly. the HCP immediately or remove the tube completely. Quick inserting the tube is not
b. Notify the health care provider immediately. an appropriate action because, in this situation, it is likely that the tube has entered
c. Remove the tube and reinsert it when the respiratory the bronchus.
distress subsides.
d. Pull back on the tube and wait until the respiratory
distress subsides.
2) The nurse receives a telephone call from the post a
anesthesia care unit stating that a client is being Rationale: The first action of the nurse is to assess the patency of the airway and
transferred to the surgical unit. The nurse plans to take respiratory function. If the airway is not patent, the nurse must take immediate
which action first on arrival of the client? measures for the survival of the client. The nurse then takes vital signs followed by
a. Assess the patency of the airway checking the dressing and the tubes or drains. The other nursing actions should be
b. Check tubes or drains for patency performed after a patent airway has been established.
c. Check the dressing to assess for bleeding
d. Assess the vital signs to compare with preoperative
measurements
3) The nurse is administering a cleansing enema to a client a
with a fecal impaction. Before administering the enema, Rationale: For administering an enema, the client is placed in a left Sims' position
the nurse should place the client in which position? so that the enema solution can flow by gravity in the natural direction of the colon.
a. Left Sims' position The head of the bed is not elevated in the Sims' position.
b. Right Sims' position
c. On the left side of the body, with the head of the bed
elevated 45 degrees
d. On the right side of the body, with the head of the bed
elevated 45 degrees.
4) The nurse is preparing to insert a nasogastric tube into c
a client. The nurse should place the client in which position Rationale: During insertion of a nasogastric tube, the client is placed in a sitting or
for insertion? high Fowler's position to facilitate insertions of the tube and reduce the risk of
a. Right side pulmonary aspiration if the client should vomit. The right side, and low Fowler's and
b. Low Fowler's supine positions place the client at risk for aspiration; in addition, these positions do
c. High fowler's not facilitate insertion of the tube.
d. Supine with the head flat
5) The nurse is preparing to administer medication using a a, b, c, e
client's nasogastric tube. What actions should the nurse Rationale: By aspirating stomach contents, the residual volume can be determined,
take before administering the medication? Select all that and the pH checked. A pH less than 3.5 verifies gastric placement. The suction
apply. should be turned off before the tubing is disconnected to check for residual volume;
a. Check the residual volume in addition, suction should remain off for 30 to 60 minutes following medication
b. Aspirate the stomach contents administration to allow for medication absorption. There is no need to remove the
c. Turn off the suction to the nasogastric tube tube and place it in the other nostril in order to administer a feeding; in fact, this is
d. Remove the tube and place it in the other nostril an invasive procedure and is unnecessary.
e. Test the stomach contents for a pH indicating acidity
6) The nurse is preparing to administer medication through c
a nasogastric tube that is connected to suction. To Rationale: If the client has a nasogastric tube connected to suction, the nurse
administer the medication, the nurse should take which should wait 30 to 60 minutes before reconnecting the tube to suction apparatus to
action? allow adequate time for medication absorption. The client should not be placed in
a. Position the client supine to assist in medication the supine position because of the risk for aspiration. Aspirating the nasogastric
absorption tube will remove the medication just administered. Low intermittent suction also will
b. Aspirate the nasogastric tube after medication remove the medication just administered.
administration to maintain patency.
c. Clamp the nasogastric tube for 30 to 60 minutes
following administration of the medication
d. Change the suction setting to low intermittent suction for
30 minutes after medication administration
, 7) The nurse is assessing for correct placement of a d
nasogastric tube. The nurse aspirates the stomach Rationale: If the nasogastric tube is in the stomach, the pH of the contents will be
contents, checks the gastric pH, and notes a pH of 7.35, acidic. Gastric aspirates have acidic pH values and should be 3.5 or lower. A pH of
Based on this information, which action should the nurse 7.35 indicates a neutral pH, which may indicate that the tube is no longer in the
take at this time? stomach. Based on this information, the nurse should call the HCP to request a
a. Retest the pH using another strip chest xray to determine if placement is accurate. Retesting the pH using another
b. Document that the nasogastric tube is in the correct test strip is unnecessary and checking for placement by auscultating for air injected
place into the tube is not a definitive method of checking for tube placement. The nurse
c. Check for placement by auscultating for air injected into should not document that the tube is in the correct place because the data indicates
the tube this may not be the case.
d. Call the health care provider to request a prescription for
a chest radiograph (xray)
8) The registered nurse is preparing to insert a nasogastric c
tube in an adult client. To determine the accurate Rationale: Measuring the length of a nasogastric tube needed is done by placing
measurement of the length of the tube to be inserted, the the tube at the tip of the client's nose and extending the tube to the earlobe and
nurse should take which action? then down to the xiphoid process. The average length for an adult is about 22 to 26
a. Mark the tube at 10 inches (25.5 cm) inches (56 to 66 cm). The remaining options identify incorrect procedures for
b. Mark the tube a 32 inches (81 cm) measuring the length of the tube.
c. Place the tube at the tip of the nose and measure by
extending the tube to the earlobe and then down to the
xiphoid process
d. Place the tube at the tip of the nose and measure by
extending the tube to the earlobe and then down to the top
of the sternum
9) The nurse inspects the color of the drainage from a a
nasogastric tube on a postoperative client approximately Rationale: For the first 12 hours after gastric surgery, the nasogastric tube drainage
24 hours after gastric surgery. Which finding indicates the may be dark brown to dark red. Later, the drainage should change to a light
need to notify the health care provider (HCP)? yellowish-brown color. The presence of bile may cause a green-tinge. The HCP
a. Dark red drainage should be notified if dark red drainage, a sign of hemorrhage, is noted 24 hours
b. Dark brown drainage postoperatively.
c. Green-tinged drainage
d. Light yellowish-brown drainage
10) A nurse is assessing a patient who has had diarrhea b, c, d
for 4 days. Which of the following findings should the nurse Rationale: Prolonged diarrhea leads to dehydration, expect the client to have an
expect? (Select all that apply) elevated temperature, a decrease in blood pressure, poor skin turgor, tachycardia,
a. Bradycardia and weakened peripheral pulses. Peripheral edema results from a fluid overload.
b. Hypotension
c. Elevated temperature
d. Poor skin turgor
e. Peripheral edema
11) While a nurse is performing a cleansing enema, the b
client reports abdominal cramping. Which of the following Rationale: Clamp the enema tubing for 30 seconds to reduce intestinal spasms.
actions should the nurse take? Telling the client that cramping is common is non therapeutic and implies that the
a. Have the client hold their breath briefly and bear down client must tolerate the discomfort and that the nurse cannot or will not do anything
b. Clamp the enema tubing to ease it.
c. Remind the client that cramping is common at this time
d. Raise the level of the enema fluid container
12) A nurse is preparing to administer a cleansing enema a, b, c
to an adult client in preparation for a diagnostic procedure. Rationale: Warm enema solution because cold fluid can cause abdominal cramping,
Which of the following steps should the nurse take? and hot fluid can damage the intestinal mucosa. Place the client on the left side with
(Select all that apply) the right leg flexed forward to promote a downward flow of solution by gravity along
a. Warm the enema solution prior to instillation the natural anatomical curve of the sigmoid colon. Lubricate the tubing to prevent
b. Position the client on the left side with the right leg trauma or irritation to the rectal mucosa. The correct length of insertion of an adult
flexed forward patient is 7.6 to 10.2 cm (3 to 4 in). The maximum recommended height to hang
c. Lubricate the rectal tube or nozzle enema container is 46 cm (18 in).
d. Slowly insert the rectal tube about 5 cm (2 in)
e. Hang the enema container 61 cm (24 in) above the
client's anus
Exam 2 2026 | Practice
Questions, Answers,
Rationales &
Comprehensive Nursing
Review | Complete Ethics
Study Guide
Updated 2026 Questions and Answers
100% Verified Exam Prep and Comprehensive
Rationales
Included
,1) The nurse is inserting a nasogastric tube in an adult d
client. During the procedure, the client begins to cough Rationale: During the insertion of the nasogastric tube, if the client experiences
and has difficulty breathing. What is the most appropriate difficulty breathing or any respiratory distress, withdraw the tube slightly, stop the
action? tube advancement, and wait until the distress subsides. It is not necessary to notify
a. Insert the tube quickly. the HCP immediately or remove the tube completely. Quick inserting the tube is not
b. Notify the health care provider immediately. an appropriate action because, in this situation, it is likely that the tube has entered
c. Remove the tube and reinsert it when the respiratory the bronchus.
distress subsides.
d. Pull back on the tube and wait until the respiratory
distress subsides.
2) The nurse receives a telephone call from the post a
anesthesia care unit stating that a client is being Rationale: The first action of the nurse is to assess the patency of the airway and
transferred to the surgical unit. The nurse plans to take respiratory function. If the airway is not patent, the nurse must take immediate
which action first on arrival of the client? measures for the survival of the client. The nurse then takes vital signs followed by
a. Assess the patency of the airway checking the dressing and the tubes or drains. The other nursing actions should be
b. Check tubes or drains for patency performed after a patent airway has been established.
c. Check the dressing to assess for bleeding
d. Assess the vital signs to compare with preoperative
measurements
3) The nurse is administering a cleansing enema to a client a
with a fecal impaction. Before administering the enema, Rationale: For administering an enema, the client is placed in a left Sims' position
the nurse should place the client in which position? so that the enema solution can flow by gravity in the natural direction of the colon.
a. Left Sims' position The head of the bed is not elevated in the Sims' position.
b. Right Sims' position
c. On the left side of the body, with the head of the bed
elevated 45 degrees
d. On the right side of the body, with the head of the bed
elevated 45 degrees.
4) The nurse is preparing to insert a nasogastric tube into c
a client. The nurse should place the client in which position Rationale: During insertion of a nasogastric tube, the client is placed in a sitting or
for insertion? high Fowler's position to facilitate insertions of the tube and reduce the risk of
a. Right side pulmonary aspiration if the client should vomit. The right side, and low Fowler's and
b. Low Fowler's supine positions place the client at risk for aspiration; in addition, these positions do
c. High fowler's not facilitate insertion of the tube.
d. Supine with the head flat
5) The nurse is preparing to administer medication using a a, b, c, e
client's nasogastric tube. What actions should the nurse Rationale: By aspirating stomach contents, the residual volume can be determined,
take before administering the medication? Select all that and the pH checked. A pH less than 3.5 verifies gastric placement. The suction
apply. should be turned off before the tubing is disconnected to check for residual volume;
a. Check the residual volume in addition, suction should remain off for 30 to 60 minutes following medication
b. Aspirate the stomach contents administration to allow for medication absorption. There is no need to remove the
c. Turn off the suction to the nasogastric tube tube and place it in the other nostril in order to administer a feeding; in fact, this is
d. Remove the tube and place it in the other nostril an invasive procedure and is unnecessary.
e. Test the stomach contents for a pH indicating acidity
6) The nurse is preparing to administer medication through c
a nasogastric tube that is connected to suction. To Rationale: If the client has a nasogastric tube connected to suction, the nurse
administer the medication, the nurse should take which should wait 30 to 60 minutes before reconnecting the tube to suction apparatus to
action? allow adequate time for medication absorption. The client should not be placed in
a. Position the client supine to assist in medication the supine position because of the risk for aspiration. Aspirating the nasogastric
absorption tube will remove the medication just administered. Low intermittent suction also will
b. Aspirate the nasogastric tube after medication remove the medication just administered.
administration to maintain patency.
c. Clamp the nasogastric tube for 30 to 60 minutes
following administration of the medication
d. Change the suction setting to low intermittent suction for
30 minutes after medication administration
, 7) The nurse is assessing for correct placement of a d
nasogastric tube. The nurse aspirates the stomach Rationale: If the nasogastric tube is in the stomach, the pH of the contents will be
contents, checks the gastric pH, and notes a pH of 7.35, acidic. Gastric aspirates have acidic pH values and should be 3.5 or lower. A pH of
Based on this information, which action should the nurse 7.35 indicates a neutral pH, which may indicate that the tube is no longer in the
take at this time? stomach. Based on this information, the nurse should call the HCP to request a
a. Retest the pH using another strip chest xray to determine if placement is accurate. Retesting the pH using another
b. Document that the nasogastric tube is in the correct test strip is unnecessary and checking for placement by auscultating for air injected
place into the tube is not a definitive method of checking for tube placement. The nurse
c. Check for placement by auscultating for air injected into should not document that the tube is in the correct place because the data indicates
the tube this may not be the case.
d. Call the health care provider to request a prescription for
a chest radiograph (xray)
8) The registered nurse is preparing to insert a nasogastric c
tube in an adult client. To determine the accurate Rationale: Measuring the length of a nasogastric tube needed is done by placing
measurement of the length of the tube to be inserted, the the tube at the tip of the client's nose and extending the tube to the earlobe and
nurse should take which action? then down to the xiphoid process. The average length for an adult is about 22 to 26
a. Mark the tube at 10 inches (25.5 cm) inches (56 to 66 cm). The remaining options identify incorrect procedures for
b. Mark the tube a 32 inches (81 cm) measuring the length of the tube.
c. Place the tube at the tip of the nose and measure by
extending the tube to the earlobe and then down to the
xiphoid process
d. Place the tube at the tip of the nose and measure by
extending the tube to the earlobe and then down to the top
of the sternum
9) The nurse inspects the color of the drainage from a a
nasogastric tube on a postoperative client approximately Rationale: For the first 12 hours after gastric surgery, the nasogastric tube drainage
24 hours after gastric surgery. Which finding indicates the may be dark brown to dark red. Later, the drainage should change to a light
need to notify the health care provider (HCP)? yellowish-brown color. The presence of bile may cause a green-tinge. The HCP
a. Dark red drainage should be notified if dark red drainage, a sign of hemorrhage, is noted 24 hours
b. Dark brown drainage postoperatively.
c. Green-tinged drainage
d. Light yellowish-brown drainage
10) A nurse is assessing a patient who has had diarrhea b, c, d
for 4 days. Which of the following findings should the nurse Rationale: Prolonged diarrhea leads to dehydration, expect the client to have an
expect? (Select all that apply) elevated temperature, a decrease in blood pressure, poor skin turgor, tachycardia,
a. Bradycardia and weakened peripheral pulses. Peripheral edema results from a fluid overload.
b. Hypotension
c. Elevated temperature
d. Poor skin turgor
e. Peripheral edema
11) While a nurse is performing a cleansing enema, the b
client reports abdominal cramping. Which of the following Rationale: Clamp the enema tubing for 30 seconds to reduce intestinal spasms.
actions should the nurse take? Telling the client that cramping is common is non therapeutic and implies that the
a. Have the client hold their breath briefly and bear down client must tolerate the discomfort and that the nurse cannot or will not do anything
b. Clamp the enema tubing to ease it.
c. Remind the client that cramping is common at this time
d. Raise the level of the enema fluid container
12) A nurse is preparing to administer a cleansing enema a, b, c
to an adult client in preparation for a diagnostic procedure. Rationale: Warm enema solution because cold fluid can cause abdominal cramping,
Which of the following steps should the nurse take? and hot fluid can damage the intestinal mucosa. Place the client on the left side with
(Select all that apply) the right leg flexed forward to promote a downward flow of solution by gravity along
a. Warm the enema solution prior to instillation the natural anatomical curve of the sigmoid colon. Lubricate the tubing to prevent
b. Position the client on the left side with the right leg trauma or irritation to the rectal mucosa. The correct length of insertion of an adult
flexed forward patient is 7.6 to 10.2 cm (3 to 4 in). The maximum recommended height to hang
c. Lubricate the rectal tube or nozzle enema container is 46 cm (18 in).
d. Slowly insert the rectal tube about 5 cm (2 in)
e. Hang the enema container 61 cm (24 in) above the
client's anus
