NURS 6002 EXAM 1-3 LATEST 2024-2025
QUESTIONS WITH CORRECT ANSWERS
EXAM 1
A nurse is assessing the abdomen of a patient who is experiencing frequent
bouts of diarrhea. The nurse first observes the contour of the abdomen, noting
any masses, scars, or areas of distention. What action would the nurse perform
next?
A. Auscultate the abdomen using an orderly clockwise approach to all abdominal
quadrants
B. Percuss all quadrants of the abdomen in a systematic clockwise manner to
identify masses, fluid, or air in the abdomen.
C. Lightly palpate over the abdominal quadrants; first checking for any areas of
pain or discomfort.
D. Deeply palpate over the abdominal quadrants, noting muscular resistance,
tenderness, organ enlargement, or masses.
A
A nurse is administering a large-volume cleansing enema to a patient prior to
surgery. Once the enema solution is introduced, the patient complains of severe
cramping. What would be the appropriate nursing intervention in this situation.
A. Elevate the head of the bed 30 degrees and reposition the rectal tube
B. Place the patient in a supine position and modify the amount of solution
C. Lower the solution container and check the temperature and flow rate
D. Remove the rectal tube and notify the PCP
C
If the solution is too2 cold or the flow rate too fast, severe cramping may result.
A nurse working in a hospital includes abdominal assessment as part of patient
assessment. In which patients would a nurse expect to find decreased or absent
bowel sounds after listening for 5 minutes? Select all that apply.
A. A patient diagnosed with peritonitis
B. A patient who is on prolonged bedrest
C. A patient who has diarrhea
D. A patient who has gastroenteritis
E. A patient who has an early bowel obstruction
F. A patient who has paralytic ileus caused by surgery
A, B, F
Decreased or absent bowel sounds, evidenced by only after listening for 5 minutes,
signify the absence of bowel motility, commonly associated with peritonitis, paralytic
ileus, and/or prolonged immobility. Hyperactive bowel sounds indicate increased
motility, commonly caused by diarrhea, gastroenteritis, or early bowel obstruction
,A nurse assesses the stool of patients who are experiencing GI problems. In
which patients would diarrhea be a possible finding? Select all that apply.
A. A patient who is taking narcotics for pain
B. A patient who is taking laxatives
C. A patient who is taking diuretics
D. A patient who is dehydrated
E. A patient who is taking amoxicillin for an infection
F. A patient taking OTC antacids
B, E, F
Diarrhea is a potential effect of treatment with amoxicillin clavulanate, laxatives, or OTC
antacids. Narcotics, diuretics, and dehydration may lead to constipation.
A patient has a fecal impaction. The nurse correctly administers an oil-retention
enema by:
A. Administering a large volume of solution (500-1000 mL)
B. Mixing milk and molasses in equal parts for an enema
C. Instructing the patient to retain the enema for at least 30 minutes
D. Administering the enema while the patient is sitting on the toilet
C
The usual amount of solution administered with a retention enema is 150-200 mL for
enema for an adult. The milk and molasses mixture is a carminative enema that helps
expel flatus. The patient should be instructed to lie on the left side of the bed as dictated
by patient condition and comfort.
A nurse prepares to assist a patient with her newly created ileostomy. Which
recommended patient teaching points would the nurse stress. Select all that
apply.
A. "When you inspect the stoma, it should be dark purple-blue."
B. "The size of the stoma will stabilize within 2 weeks."
C. "Keep the skin around the stoma site clean and moist."
D. "The stool from an ileostomy is normally liquid."
E. "You should eat dark green vegetables to control the odor of the stool."
F. "You may have a tendency to develop food blockages."
D, E, F
The nurse should encourage the intake of dark green leafy vegetables because they
contain chlorophyll, which helps deodorize the feces. Patients wth ileostomies need to
be aware they may experience a tendency to develop food blockages, especially when
high-fiber foods are consumed. The stoma should be dark pink to red and moist. Stoma
size should stabilize within 4-6 weeks, and the skin around the stoma site should be
kept clean and dry.
A nurse is preparing a hospitalized patient for a colonoscopy. Which nursing
action is the recommended preparation for this test?
,A. Have the patient follow a clear liquid diet 24-48 hours before the test.
B. Have the patient take Dulcolax and ingest a gallon of bowel cleaner on day 1.
C. Prepare the patient for the use of general anesthesia during the test.
D. Explain that barium contrast mixture will be given to drink before the test.
A
Prep for a colonoscopy includes a clear liquid diet 24 to 48 hours before the test along
with a 2-day bowel prep of a strong cathartic and Dulcolax on day 1 and enema on day
2 or a 1-day bowel prep that consists of ingestion of a gallon of bowel cleanser in a
short period of time. Conscious sedation, not general anesthesia, will be given for a
colonoscopy. Barium contrast mixture is given to drink before an upper GI and small-
bowel series of tests.
A nurse is performing digital removal of stool on a 74-year-old female patient with
a fecal impaction. During the procedure the patient tells the nurse that she is
feeling dizzy and nauseated, and then she vomits. What should be the nurse's
next action?
A. Reassure the patient that this is a normal reaction to the procedure.
B. Stop the procedure, prepare to administer CPR, and notify the physician.
C. Stop the procedure, assess vital signs, and notify the physician.
D. Stop the procedure, wait 5 minutes, and then resume the procedure.
C
When a patient complains of dizziness or lightheadedness, nausea, and vomiting during
digital stool removal, the nurse should stop the procedure, assess heart rate and blood
pressure, and notify the physician. The vagal nerve may have been stimulated.
A nurse is scheduling tests for a patient who has been experiencing epigastric
pain. The physician ordered the following tests: a. a barium enema, b. fecal occult
blood test, and c. endoscopic studies, and D. upper GI series. What is the correct
order in which the tests would normally be performed?
A. c, b, d, a
B. d, c, a, b
C. a, b, d, c
D. b, a, d, c
D
A fecal occult blood test should be done first to detect GI bleeding. Barium studies
should be performed next to visualize GI structures and reveal inflammation, ulcers,
tumors, strictures, and other lesions. A barium enema and routine radiography should
precede an upper GI series because retained barium from an upper GI series could
take several days to pass through the GI tract and cloud anatomic detail on the barium
enema studies. Noninvasive procedures usually take precedence over invasive
procedures, such as endoscopic studies, when sufficient diagnostic data can be
obtained from them.
, A nurse is caring for a patient who has a NG tube in place for gastric
decompression. Which nursing actions are appropriate when irrigating a NG tube
connected to suction? Select all that apply.
A. Draw up 30 mL of saline solution into the syringe
B. Unclamp the suction tubing near the connection site to instill solution
C. Place the tip of the syringe in the tube to gently insert saline solution
D. Place syringe in the blue air vent of a Salem sump or double-lumen tube
E. After instilling irrigant, hold the end of the NG tube over an irrigation tray
F. Observe for return flow of NG drainage into an available container.
A, C, E, F
A nurse is teaching a patient with frequent constipation how to implement a
bowel-training program. What is the recommended teaching point?
A. Using a diet that is low in bulk
B. Decreasing fluid intake ot 1000 mL
C. Administering an enema once a day to stimulate peristalsis
D. Allowing ample time for evactuation
D
A nurse caring for patients with bowel alterations formulates a nursing diagnosis
for a patient with a new ileostomy. Which diagnosis is most appropriate?
A. Disturbed body image
B. Constipation
C. Delayed growth and development
D. Excess fluid volume
A
A nurse is irrigating the colostomy of a patient and is unable to get the irrigation
solution to flow. What would be the nurse's next action in this situation?
A. Assist the patient to a prone position on a waterproof pad and try again.
B. Check the clamp on the tubing to make sure the tubing is open.
C. Quickly pull the cone from the stoma and check for bleeding.
D. Remove the equipment and call the PCP
B
A nurse is assisting the patient to empty and change an ostomy appliance. When
the procedure is finished, the nurse notes that the stoma is protruding into the
bag. What would be the nurse's first action in this situation?
A. Reassure the patient that this is a normal finding with a new ostomy.
B. Notify the PCP that the stoma is prolapsed.
C. Have the patient rest for 30 minutes to see if the prolapse resolves.
D. Remove the appliance and redo the procedure using a larger appliance.
C
If the stoma is protruding into the bag after changing the appliance on an ostomy, the
QUESTIONS WITH CORRECT ANSWERS
EXAM 1
A nurse is assessing the abdomen of a patient who is experiencing frequent
bouts of diarrhea. The nurse first observes the contour of the abdomen, noting
any masses, scars, or areas of distention. What action would the nurse perform
next?
A. Auscultate the abdomen using an orderly clockwise approach to all abdominal
quadrants
B. Percuss all quadrants of the abdomen in a systematic clockwise manner to
identify masses, fluid, or air in the abdomen.
C. Lightly palpate over the abdominal quadrants; first checking for any areas of
pain or discomfort.
D. Deeply palpate over the abdominal quadrants, noting muscular resistance,
tenderness, organ enlargement, or masses.
A
A nurse is administering a large-volume cleansing enema to a patient prior to
surgery. Once the enema solution is introduced, the patient complains of severe
cramping. What would be the appropriate nursing intervention in this situation.
A. Elevate the head of the bed 30 degrees and reposition the rectal tube
B. Place the patient in a supine position and modify the amount of solution
C. Lower the solution container and check the temperature and flow rate
D. Remove the rectal tube and notify the PCP
C
If the solution is too2 cold or the flow rate too fast, severe cramping may result.
A nurse working in a hospital includes abdominal assessment as part of patient
assessment. In which patients would a nurse expect to find decreased or absent
bowel sounds after listening for 5 minutes? Select all that apply.
A. A patient diagnosed with peritonitis
B. A patient who is on prolonged bedrest
C. A patient who has diarrhea
D. A patient who has gastroenteritis
E. A patient who has an early bowel obstruction
F. A patient who has paralytic ileus caused by surgery
A, B, F
Decreased or absent bowel sounds, evidenced by only after listening for 5 minutes,
signify the absence of bowel motility, commonly associated with peritonitis, paralytic
ileus, and/or prolonged immobility. Hyperactive bowel sounds indicate increased
motility, commonly caused by diarrhea, gastroenteritis, or early bowel obstruction
,A nurse assesses the stool of patients who are experiencing GI problems. In
which patients would diarrhea be a possible finding? Select all that apply.
A. A patient who is taking narcotics for pain
B. A patient who is taking laxatives
C. A patient who is taking diuretics
D. A patient who is dehydrated
E. A patient who is taking amoxicillin for an infection
F. A patient taking OTC antacids
B, E, F
Diarrhea is a potential effect of treatment with amoxicillin clavulanate, laxatives, or OTC
antacids. Narcotics, diuretics, and dehydration may lead to constipation.
A patient has a fecal impaction. The nurse correctly administers an oil-retention
enema by:
A. Administering a large volume of solution (500-1000 mL)
B. Mixing milk and molasses in equal parts for an enema
C. Instructing the patient to retain the enema for at least 30 minutes
D. Administering the enema while the patient is sitting on the toilet
C
The usual amount of solution administered with a retention enema is 150-200 mL for
enema for an adult. The milk and molasses mixture is a carminative enema that helps
expel flatus. The patient should be instructed to lie on the left side of the bed as dictated
by patient condition and comfort.
A nurse prepares to assist a patient with her newly created ileostomy. Which
recommended patient teaching points would the nurse stress. Select all that
apply.
A. "When you inspect the stoma, it should be dark purple-blue."
B. "The size of the stoma will stabilize within 2 weeks."
C. "Keep the skin around the stoma site clean and moist."
D. "The stool from an ileostomy is normally liquid."
E. "You should eat dark green vegetables to control the odor of the stool."
F. "You may have a tendency to develop food blockages."
D, E, F
The nurse should encourage the intake of dark green leafy vegetables because they
contain chlorophyll, which helps deodorize the feces. Patients wth ileostomies need to
be aware they may experience a tendency to develop food blockages, especially when
high-fiber foods are consumed. The stoma should be dark pink to red and moist. Stoma
size should stabilize within 4-6 weeks, and the skin around the stoma site should be
kept clean and dry.
A nurse is preparing a hospitalized patient for a colonoscopy. Which nursing
action is the recommended preparation for this test?
,A. Have the patient follow a clear liquid diet 24-48 hours before the test.
B. Have the patient take Dulcolax and ingest a gallon of bowel cleaner on day 1.
C. Prepare the patient for the use of general anesthesia during the test.
D. Explain that barium contrast mixture will be given to drink before the test.
A
Prep for a colonoscopy includes a clear liquid diet 24 to 48 hours before the test along
with a 2-day bowel prep of a strong cathartic and Dulcolax on day 1 and enema on day
2 or a 1-day bowel prep that consists of ingestion of a gallon of bowel cleanser in a
short period of time. Conscious sedation, not general anesthesia, will be given for a
colonoscopy. Barium contrast mixture is given to drink before an upper GI and small-
bowel series of tests.
A nurse is performing digital removal of stool on a 74-year-old female patient with
a fecal impaction. During the procedure the patient tells the nurse that she is
feeling dizzy and nauseated, and then she vomits. What should be the nurse's
next action?
A. Reassure the patient that this is a normal reaction to the procedure.
B. Stop the procedure, prepare to administer CPR, and notify the physician.
C. Stop the procedure, assess vital signs, and notify the physician.
D. Stop the procedure, wait 5 minutes, and then resume the procedure.
C
When a patient complains of dizziness or lightheadedness, nausea, and vomiting during
digital stool removal, the nurse should stop the procedure, assess heart rate and blood
pressure, and notify the physician. The vagal nerve may have been stimulated.
A nurse is scheduling tests for a patient who has been experiencing epigastric
pain. The physician ordered the following tests: a. a barium enema, b. fecal occult
blood test, and c. endoscopic studies, and D. upper GI series. What is the correct
order in which the tests would normally be performed?
A. c, b, d, a
B. d, c, a, b
C. a, b, d, c
D. b, a, d, c
D
A fecal occult blood test should be done first to detect GI bleeding. Barium studies
should be performed next to visualize GI structures and reveal inflammation, ulcers,
tumors, strictures, and other lesions. A barium enema and routine radiography should
precede an upper GI series because retained barium from an upper GI series could
take several days to pass through the GI tract and cloud anatomic detail on the barium
enema studies. Noninvasive procedures usually take precedence over invasive
procedures, such as endoscopic studies, when sufficient diagnostic data can be
obtained from them.
, A nurse is caring for a patient who has a NG tube in place for gastric
decompression. Which nursing actions are appropriate when irrigating a NG tube
connected to suction? Select all that apply.
A. Draw up 30 mL of saline solution into the syringe
B. Unclamp the suction tubing near the connection site to instill solution
C. Place the tip of the syringe in the tube to gently insert saline solution
D. Place syringe in the blue air vent of a Salem sump or double-lumen tube
E. After instilling irrigant, hold the end of the NG tube over an irrigation tray
F. Observe for return flow of NG drainage into an available container.
A, C, E, F
A nurse is teaching a patient with frequent constipation how to implement a
bowel-training program. What is the recommended teaching point?
A. Using a diet that is low in bulk
B. Decreasing fluid intake ot 1000 mL
C. Administering an enema once a day to stimulate peristalsis
D. Allowing ample time for evactuation
D
A nurse caring for patients with bowel alterations formulates a nursing diagnosis
for a patient with a new ileostomy. Which diagnosis is most appropriate?
A. Disturbed body image
B. Constipation
C. Delayed growth and development
D. Excess fluid volume
A
A nurse is irrigating the colostomy of a patient and is unable to get the irrigation
solution to flow. What would be the nurse's next action in this situation?
A. Assist the patient to a prone position on a waterproof pad and try again.
B. Check the clamp on the tubing to make sure the tubing is open.
C. Quickly pull the cone from the stoma and check for bleeding.
D. Remove the equipment and call the PCP
B
A nurse is assisting the patient to empty and change an ostomy appliance. When
the procedure is finished, the nurse notes that the stoma is protruding into the
bag. What would be the nurse's first action in this situation?
A. Reassure the patient that this is a normal finding with a new ostomy.
B. Notify the PCP that the stoma is prolapsed.
C. Have the patient rest for 30 minutes to see if the prolapse resolves.
D. Remove the appliance and redo the procedure using a larger appliance.
C
If the stoma is protruding into the bag after changing the appliance on an ostomy, the
