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Fundamentals of Nursing Exam 2
Questions and Correct Answers/ Latest
Update / Already Graded
1) The nurse is inserting a nasogastric tube in an adult client. During
the procedure, the client begins to cough and has difficulty
breathing. What is the most appropriate action?
a. Insert the tube quickly.
b. Notify the health care provider immediately.
c. Remove the tube and reinsert it when the respiratory distress
subsides.
d. Pull back on the tube and wait until the respiratory distress
subsides.
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Ans: d
Rationale: During the insertion of the nasogastric tube, if the client
experiences difficulty breathing or any respiratory distress, withdraw the
tube slightly, stop the tube advancement, and wait until the distress
subsides. It is not necessary to notify the HCP immediately or remove the
tube completely. Quick inserting the tube is not an appropriate action
because, in this situation, it is likely that the tube has entered the
bronchus.
2) The nurse receives a telephone call from the post anesthesia care
unit stating that a client is being transferred to the surgical unit. The
nurse plans to take which action first on arrival of the client?
a. Assess the patency of the airway
b. Check tubes or drains for patency
c. Check the dressing to assess for bleeding
d. Assess the vital signs to compare with preoperative measurements
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Ans: a
Rationale: The first action of the nurse is to assess the patency of the
airway and respiratory function. If the airway is not patent, the nurse must
take immediate measures for the survival of the client. The nurse then
takes vital signs followed by checking the dressing and the tubes or drains.
The other nursing actions should be performed after a patent airway has
been established.
3) The nurse is administering a cleansing enema to a client with a
fecal impaction. Before administering the enema, the nurse should
place the client in which position?
a. Left 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.
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Ans: a
Rationale: For administering an enema, the client is placed in a left Sims'
position so that the enema solution can flow by gravity in the natural
direction of the colon. The head of the bed is not elevated in the Sims'
position.
4) The nurse is preparing to insert a nasogastric tube into a client. The
nurse should place the client in which position for insertion?
a. Right side
b. Low Fowler's
c. High fowler's
d. Supine with the head flat
Fundamentals of Nursing Exam 2
Questions and Correct Answers/ Latest
Update / Already Graded
1) The nurse is inserting a nasogastric tube in an adult client. During
the procedure, the client begins to cough and has difficulty
breathing. What is the most appropriate action?
a. Insert the tube quickly.
b. Notify the health care provider immediately.
c. Remove the tube and reinsert it when the respiratory distress
subsides.
d. Pull back on the tube and wait until the respiratory distress
subsides.
,2 | Page
Ans: d
Rationale: During the insertion of the nasogastric tube, if the client
experiences difficulty breathing or any respiratory distress, withdraw the
tube slightly, stop the tube advancement, and wait until the distress
subsides. It is not necessary to notify the HCP immediately or remove the
tube completely. Quick inserting the tube is not an appropriate action
because, in this situation, it is likely that the tube has entered the
bronchus.
2) The nurse receives a telephone call from the post anesthesia care
unit stating that a client is being transferred to the surgical unit. The
nurse plans to take which action first on arrival of the client?
a. Assess the patency of the airway
b. Check tubes or drains for patency
c. Check the dressing to assess for bleeding
d. Assess the vital signs to compare with preoperative measurements
,3 | Page
Ans: a
Rationale: The first action of the nurse is to assess the patency of the
airway and respiratory function. If the airway is not patent, the nurse must
take immediate measures for the survival of the client. The nurse then
takes vital signs followed by checking the dressing and the tubes or drains.
The other nursing actions should be performed after a patent airway has
been established.
3) The nurse is administering a cleansing enema to a client with a
fecal impaction. Before administering the enema, the nurse should
place the client in which position?
a. Left 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 | Page
Ans: a
Rationale: For administering an enema, the client is placed in a left Sims'
position so that the enema solution can flow by gravity in the natural
direction of the colon. The head of the bed is not elevated in the Sims'
position.
4) The nurse is preparing to insert a nasogastric tube into a client. The
nurse should place the client in which position for insertion?
a. Right side
b. Low Fowler's
c. High fowler's
d. Supine with the head flat
