Nursing Fundamentals Exam 2 Questions & Answers
Latest 2025 Updated Version A+Scored
1. The nurse is assessing a 55 year-old patient who is in the clinic for a routine physical. When would
the nurse instruct the patient about the need to obtain a stool specimen for guaiac fecal occult blood
testing (gFOBT)?
a. If there is a family history of polyps
b. As part of a routine examination for colon cancer
c. If patient reports rectal bleeding
d. If a palpable mass is detected on digital examination - ✔✔✔ - b
Rationale: Guaiac fecal occult blood testing (gFOBT) is used as a diagnostic screening tool for colon
cancer as recommended by the American Cancer Society. More advanced screenings, such as a
colonoscopy, would be indicated for rectal bleeding, a palpable mass detected upon digital
examination, and/or a family history of polyps.
2. Which patients benefits the most from an enema prepared with a hypertonic solution?
a. A patient who is a young infant
b. A patient who is dehydrated
c. A patient who is suffering from acute inflammation in the lower colon
d. A patient who is unable to tolerate large volumes of fluid - ✔✔✔ - d
Rationale: An enema prepared with a hypertonic solution is designed to be low volume. Patients
unable to tolerate large volumes of fluid benefit most from this enema type. This type of enema is
contraindicated for infants and dehydrated patients. A patient with acute inflammation in the lower
colon will receive an enema containing steroid medication.
3. The nurse is developing a care plan for a client experiencing urge urinary incontinence. Which
interventions would be helpful for this type of incontinence? (Select all that apply)
1. Surgery
2. Bladder training
3. Scheduled toileting
4. Dietary modifications
,5. Pelvic muscle exercises
6. Intermittent Catheterization - ✔✔✔ - 2, 3, 4, 5
Rationale: Urge continence is the involuntary passage of urine after a strong sense of the urgency to
void. It's characterized by urinary urgency, often with frequency (more often than every 2 hours);
bladder spasm or contractions; and voiding in either small amounts (<100 mL)or large amounts
(>500 mL). It can be caused by decreased bladder capacity, irritation of the bladder stretch receptors,
infection, and alcohol or caffeine ingestion. Interventions to assist the client with urge incontinence
include bladder retraining, scheduled toileting, dietary modifications such as eliminating alcohol and
caffeine intake, and pelvic muscle exercises to strengthen the muscles. Surgery and urinary
catheterization are invasive measures and will not assist in the treatment or urge incontinence.
4. The nurse has administered approximately half of a high-cleansing enema when the client reports
pain and cramping. Which nursing action is appropriate?
1. Reassuring the client that those sensations will subside
2. Raising the enema bag so that the solution can be introduced quickly
3. Discontinuing the enema and notifying the primary health care provider
4. Clamping the tubing for 30 seconds and restarting the flow at a slower rate - ✔✔✔ - 4
Rationale: The enema fluid should be administered slowly. If the client complains of pain or
cramping, the flow is stopped for 30 seconds and restarted at a slower rate. Slow enema
administration and stopping the flow temporarily, if necessary, will decrease the likelihood of
intestinal spasm and premature ejection of the solution. The client's report of pain and cramping
should not be ignored. The higher the solution container is held above the rectum, the faster the flow
and the greater the force in the rectum. There is no need to discontinue the enema and notify the
primary health care provider at this time.
5. The nurse prepares the client for the removal of a nasogastric tube that was inserted to treat a
bowel obstruction. During the tube removal, the nurse instructs the client to take which action?
1. Inhale deeply
2. Exhale slowly
3. Hold in a deep breath
4. Pause between breaths - ✔✔✔ - 3
Rationale: Just before removing the tube, the client is asked to take a deep breath and hold it because
breath-holding minimizes the risk of aspirating gastric contents spilled from the tube during removal.
The maneuver partially occludes the airway during tube removal; afterward, the client exhales as
soon as the tube is out and thus avoids drawing the gastric contents into the trachea. The nurse pulls
the tube out steadily and smoothly while the client holds the breath. The remaining options are
incorrect because options 1 and 2 increase the risk of aspiration, and option 4 is ineffective.
,6) The nurse is preparing to administer medication through a nasogastric tube that is connected to
suction. To administer the medication, the nurse should take which action?
a. Position the client supine to assist in medication absorption
b. Aspirate the nasogastric tube after medication 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 - ✔✔✔ - c
Rationale: If the client has a nasogastric tube connected to suction, the nurse should wait 30 to 60
minutes before reconnecting the tube to suction apparatus to allow adequate time for medication
absorption. The client should not be placed in the supine position because of the risk for aspiration.
Aspirating the nasogastric tube will remove the medication just administered. Low intermittent
suction also will remove the medication just administered.
7) The nurse is assessing for correct placement of a nasogastric tube. The nurse aspirates the stomach
contents, checks the gastric pH, and notes a pH of 7.35, Based on this information, which action
should the nurse take at this time?
a. Retest the pH using another strip
b. Document that the nasogastric tube is in the correct place
c. Check for placement by auscultating for air injected into the tube
d. Call the health care provider to request a prescription for a chest radiograph (xray) - ✔✔✔ - d
Rationale: If the nasogastric tube is in the stomach, the pH of the contents will be acidic. Gastric
aspirates have acidic pH values and should be 3.5 or lower. A pH of 7.35 indicates a neutral pH, which
may indicate that the tube is no longer in the stomach. Based on this information, the nurse should
call the HCP to request a chest xray to determine if placement is accurate. Retesting the pH using
another test strip is unnecessary and checking for placement by auscultating for air injected into the
tube is not a definitive method of checking for tube placement. The nurse should not document that
the tube is in the correct place because the data indicates this may not be the case.
8) The registered nurse is preparing to insert a nasogastric tube in an adult client. To determine the
accurate measurement of the length of the tube to be inserted, the nurse should take which action?
a. Mark the tube at 10 inches (25.5 cm)
b. Mark the tube a 32 inches (81 cm)
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 - ✔✔✔ - c
Rationale: Measuring the length of a nasogastric tube needed is done by placing the tube at the tip of
the client's nose and extending the tube to the earlobe and then down to the xiphoid process. The
average length for an adult is about 22 to 26 inches (56 to 66 cm). The remaining options identify
incorrect procedures for measuring the length of the tube.
9) The nurse inspects the color of the drainage from a nasogastric tube on a postoperative client
approximately 24 hours after gastric surgery. Which finding indicates the need to notify the health
care provider (HCP)?
a. Dark red drainage
b. Dark brown drainage
c. Green-tinged drainage
d. Light yellowish-brown drainage - ✔✔✔ - a
Rationale: For the first 12 hours after gastric surgery, the nasogastric tube drainage may be dark
brown to dark red. Later, the drainage should change to a light yellowish-brown color. The presence
of bile may cause a green-tinge. The HCP should be notified if dark red drainage, a sign of hemorrhage,
is noted 24 hours postoperatively.
10) A nurse is assessing a patient who has had diarrhea for 4 days. Which of the following findings
should the nurse expect? (Select all that apply)
a. Bradycardia
b. Hypotension
c. Elevated temperature
d. Poor skin turgor
e. Peripheral edema - ✔✔✔ - b, c, d
Rationale: Prolonged diarrhea leads to dehydration, expect the client to have an elevated
temperature, a decrease in blood pressure, poor skin turgor, tachycardia, and weakened peripheral
pulses. Peripheral edema results from a fluid overload.
11) While a nurse is performing a cleansing enema, the client reports abdominal cramping. Which of
the following actions should the nurse take?
a. Have the client hold their breath briefly and bear down
b. Clamp the enema tubing
Latest 2025 Updated Version A+Scored
1. The nurse is assessing a 55 year-old patient who is in the clinic for a routine physical. When would
the nurse instruct the patient about the need to obtain a stool specimen for guaiac fecal occult blood
testing (gFOBT)?
a. If there is a family history of polyps
b. As part of a routine examination for colon cancer
c. If patient reports rectal bleeding
d. If a palpable mass is detected on digital examination - ✔✔✔ - b
Rationale: Guaiac fecal occult blood testing (gFOBT) is used as a diagnostic screening tool for colon
cancer as recommended by the American Cancer Society. More advanced screenings, such as a
colonoscopy, would be indicated for rectal bleeding, a palpable mass detected upon digital
examination, and/or a family history of polyps.
2. Which patients benefits the most from an enema prepared with a hypertonic solution?
a. A patient who is a young infant
b. A patient who is dehydrated
c. A patient who is suffering from acute inflammation in the lower colon
d. A patient who is unable to tolerate large volumes of fluid - ✔✔✔ - d
Rationale: An enema prepared with a hypertonic solution is designed to be low volume. Patients
unable to tolerate large volumes of fluid benefit most from this enema type. This type of enema is
contraindicated for infants and dehydrated patients. A patient with acute inflammation in the lower
colon will receive an enema containing steroid medication.
3. The nurse is developing a care plan for a client experiencing urge urinary incontinence. Which
interventions would be helpful for this type of incontinence? (Select all that apply)
1. Surgery
2. Bladder training
3. Scheduled toileting
4. Dietary modifications
,5. Pelvic muscle exercises
6. Intermittent Catheterization - ✔✔✔ - 2, 3, 4, 5
Rationale: Urge continence is the involuntary passage of urine after a strong sense of the urgency to
void. It's characterized by urinary urgency, often with frequency (more often than every 2 hours);
bladder spasm or contractions; and voiding in either small amounts (<100 mL)or large amounts
(>500 mL). It can be caused by decreased bladder capacity, irritation of the bladder stretch receptors,
infection, and alcohol or caffeine ingestion. Interventions to assist the client with urge incontinence
include bladder retraining, scheduled toileting, dietary modifications such as eliminating alcohol and
caffeine intake, and pelvic muscle exercises to strengthen the muscles. Surgery and urinary
catheterization are invasive measures and will not assist in the treatment or urge incontinence.
4. The nurse has administered approximately half of a high-cleansing enema when the client reports
pain and cramping. Which nursing action is appropriate?
1. Reassuring the client that those sensations will subside
2. Raising the enema bag so that the solution can be introduced quickly
3. Discontinuing the enema and notifying the primary health care provider
4. Clamping the tubing for 30 seconds and restarting the flow at a slower rate - ✔✔✔ - 4
Rationale: The enema fluid should be administered slowly. If the client complains of pain or
cramping, the flow is stopped for 30 seconds and restarted at a slower rate. Slow enema
administration and stopping the flow temporarily, if necessary, will decrease the likelihood of
intestinal spasm and premature ejection of the solution. The client's report of pain and cramping
should not be ignored. The higher the solution container is held above the rectum, the faster the flow
and the greater the force in the rectum. There is no need to discontinue the enema and notify the
primary health care provider at this time.
5. The nurse prepares the client for the removal of a nasogastric tube that was inserted to treat a
bowel obstruction. During the tube removal, the nurse instructs the client to take which action?
1. Inhale deeply
2. Exhale slowly
3. Hold in a deep breath
4. Pause between breaths - ✔✔✔ - 3
Rationale: Just before removing the tube, the client is asked to take a deep breath and hold it because
breath-holding minimizes the risk of aspirating gastric contents spilled from the tube during removal.
The maneuver partially occludes the airway during tube removal; afterward, the client exhales as
soon as the tube is out and thus avoids drawing the gastric contents into the trachea. The nurse pulls
the tube out steadily and smoothly while the client holds the breath. The remaining options are
incorrect because options 1 and 2 increase the risk of aspiration, and option 4 is ineffective.
,6) The nurse is preparing to administer medication through a nasogastric tube that is connected to
suction. To administer the medication, the nurse should take which action?
a. Position the client supine to assist in medication absorption
b. Aspirate the nasogastric tube after medication 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 - ✔✔✔ - c
Rationale: If the client has a nasogastric tube connected to suction, the nurse should wait 30 to 60
minutes before reconnecting the tube to suction apparatus to allow adequate time for medication
absorption. The client should not be placed in the supine position because of the risk for aspiration.
Aspirating the nasogastric tube will remove the medication just administered. Low intermittent
suction also will remove the medication just administered.
7) The nurse is assessing for correct placement of a nasogastric tube. The nurse aspirates the stomach
contents, checks the gastric pH, and notes a pH of 7.35, Based on this information, which action
should the nurse take at this time?
a. Retest the pH using another strip
b. Document that the nasogastric tube is in the correct place
c. Check for placement by auscultating for air injected into the tube
d. Call the health care provider to request a prescription for a chest radiograph (xray) - ✔✔✔ - d
Rationale: If the nasogastric tube is in the stomach, the pH of the contents will be acidic. Gastric
aspirates have acidic pH values and should be 3.5 or lower. A pH of 7.35 indicates a neutral pH, which
may indicate that the tube is no longer in the stomach. Based on this information, the nurse should
call the HCP to request a chest xray to determine if placement is accurate. Retesting the pH using
another test strip is unnecessary and checking for placement by auscultating for air injected into the
tube is not a definitive method of checking for tube placement. The nurse should not document that
the tube is in the correct place because the data indicates this may not be the case.
8) The registered nurse is preparing to insert a nasogastric tube in an adult client. To determine the
accurate measurement of the length of the tube to be inserted, the nurse should take which action?
a. Mark the tube at 10 inches (25.5 cm)
b. Mark the tube a 32 inches (81 cm)
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 - ✔✔✔ - c
Rationale: Measuring the length of a nasogastric tube needed is done by placing the tube at the tip of
the client's nose and extending the tube to the earlobe and then down to the xiphoid process. The
average length for an adult is about 22 to 26 inches (56 to 66 cm). The remaining options identify
incorrect procedures for measuring the length of the tube.
9) The nurse inspects the color of the drainage from a nasogastric tube on a postoperative client
approximately 24 hours after gastric surgery. Which finding indicates the need to notify the health
care provider (HCP)?
a. Dark red drainage
b. Dark brown drainage
c. Green-tinged drainage
d. Light yellowish-brown drainage - ✔✔✔ - a
Rationale: For the first 12 hours after gastric surgery, the nasogastric tube drainage may be dark
brown to dark red. Later, the drainage should change to a light yellowish-brown color. The presence
of bile may cause a green-tinge. The HCP should be notified if dark red drainage, a sign of hemorrhage,
is noted 24 hours postoperatively.
10) A nurse is assessing a patient who has had diarrhea for 4 days. Which of the following findings
should the nurse expect? (Select all that apply)
a. Bradycardia
b. Hypotension
c. Elevated temperature
d. Poor skin turgor
e. Peripheral edema - ✔✔✔ - b, c, d
Rationale: Prolonged diarrhea leads to dehydration, expect the client to have an elevated
temperature, a decrease in blood pressure, poor skin turgor, tachycardia, and weakened peripheral
pulses. Peripheral edema results from a fluid overload.
11) While a nurse is performing a cleansing enema, the client reports abdominal cramping. Which of
the following actions should the nurse take?
a. Have the client hold their breath briefly and bear down
b. Clamp the enema tubing
