NURS 3605 Fundamentals Exam 2 Questions With
Complete Solutions
A client is receiving an enteral feeding at 65 mL/hr. The gastric
residual volume in 4 hours was 125 mL. What is the priority
nursing intervention?
1. Assess bowel sounds
2. Raise the head of the bed to at least 45 degrees
3. Continue the feedings; this is normal gastric residual for this
feeding
4. Hold the feeding until you talk to the primary care provider
Correct Answers 3. Continue the feedings; this is normal
gastric residual for this feeding
A client who is receiving parenteral nutrition (PN) through a
central venous catheter (CVC) has an air embolus. What should
be the nurse's priority action?
1. Have the patient turn on the left side and perform a Valsalva
maneuver
2. Clamp the intravenous (IV) tubing to prevent more air from
entering the line
3. Have the patient take a deep breath and hold it
4. Notify the health care provider immediately Correct Answers
1. Have the patient turn on the left side and perform a Valsalva
maneuver
A nurse is taking a health history of a newly admitted patient
with a diagnosis of possible fecal impaction? Which question is
the priority to ask the patient or caregiver?
,1. Have you eaten more high-fiber foods lately?
2. Have you taken antibiotics recently?
3. Do you have gluten intolerance?
4. Have you experience frequent, small liquid stools recently?
Correct Answers 4. Have you experience frequent, small liquid
stools recently?
A nurse is teaching a patient to obtain a specimen for fecal
occult blood testing using fecal immunochemical testing (FIT) at
home. How does the nurse instruct the patient to remove the
specimen?
1. Get three fecal smears from one bowel movement
2. Obtain one fecal smear from an early-morning bowel
movement
3. Collect one fecal smear from three separate bowel movements
4. Get three fecal smears when you see blood in your bowel
movement Correct Answers 3. Collect one fecal smear from
three separate bowel movements
A nurse sees an assistive personnel (AP) perform the following
intervention for a patient receiving continuous enteral feedings.
Which action would require immediate attention by the nurse?
1. Fastening tube to the gown with new tape
2. Placing client supine while giving a bath
3. Monitoring the client's weight as ordered
4. Ambulating patient with enteral feedings still infusing
Correct Answers 2. Placing client supine while giving a bath
, A patient is receiving both parenteral (PN) and enteral nutrition
(EN). When would the nurse collaborate with the health care
provider and request a discontinuation of parenteral nutrition?
1. When 25% of the patient's nutritional needs are met by the
tube feedings
2. When bowel sounds return
3. When the central line has been in for 10 days
4. When 75% of the patient's nutritional needs are met by the
tube feedings Correct Answers 4. When 75% of the patient's
nutritional needs are met by the tube feedings
A patient is receiving total parenteral nutrition (TPN). What are
the primary interventions the nurse should follow to prevent a
central line infection? (Select all that apply.)
1. Change the dressing using sterile technique
2. Change TPN containers every 48 hours
3. Change the TPN tubing every 24 hours
4. Monitor glucose levels to watch and assess for glucose
intolerance
5. Elevate head of the bed 45 degrees to prevent aspiration
Correct Answers 1. Change the dressing using sterile technique
3. Change the TPN tubing every 24 hours
A patient is schedule to have an intravenous pyelogram (IVP)
the next morning. Which nursing measures should be
implemented before the test? (Select all that apply.)
1. Ask the patient about any allergies and reactions
2. Instruct the patient that a full bladder is required for the test
Complete Solutions
A client is receiving an enteral feeding at 65 mL/hr. The gastric
residual volume in 4 hours was 125 mL. What is the priority
nursing intervention?
1. Assess bowel sounds
2. Raise the head of the bed to at least 45 degrees
3. Continue the feedings; this is normal gastric residual for this
feeding
4. Hold the feeding until you talk to the primary care provider
Correct Answers 3. Continue the feedings; this is normal
gastric residual for this feeding
A client who is receiving parenteral nutrition (PN) through a
central venous catheter (CVC) has an air embolus. What should
be the nurse's priority action?
1. Have the patient turn on the left side and perform a Valsalva
maneuver
2. Clamp the intravenous (IV) tubing to prevent more air from
entering the line
3. Have the patient take a deep breath and hold it
4. Notify the health care provider immediately Correct Answers
1. Have the patient turn on the left side and perform a Valsalva
maneuver
A nurse is taking a health history of a newly admitted patient
with a diagnosis of possible fecal impaction? Which question is
the priority to ask the patient or caregiver?
,1. Have you eaten more high-fiber foods lately?
2. Have you taken antibiotics recently?
3. Do you have gluten intolerance?
4. Have you experience frequent, small liquid stools recently?
Correct Answers 4. Have you experience frequent, small liquid
stools recently?
A nurse is teaching a patient to obtain a specimen for fecal
occult blood testing using fecal immunochemical testing (FIT) at
home. How does the nurse instruct the patient to remove the
specimen?
1. Get three fecal smears from one bowel movement
2. Obtain one fecal smear from an early-morning bowel
movement
3. Collect one fecal smear from three separate bowel movements
4. Get three fecal smears when you see blood in your bowel
movement Correct Answers 3. Collect one fecal smear from
three separate bowel movements
A nurse sees an assistive personnel (AP) perform the following
intervention for a patient receiving continuous enteral feedings.
Which action would require immediate attention by the nurse?
1. Fastening tube to the gown with new tape
2. Placing client supine while giving a bath
3. Monitoring the client's weight as ordered
4. Ambulating patient with enteral feedings still infusing
Correct Answers 2. Placing client supine while giving a bath
, A patient is receiving both parenteral (PN) and enteral nutrition
(EN). When would the nurse collaborate with the health care
provider and request a discontinuation of parenteral nutrition?
1. When 25% of the patient's nutritional needs are met by the
tube feedings
2. When bowel sounds return
3. When the central line has been in for 10 days
4. When 75% of the patient's nutritional needs are met by the
tube feedings Correct Answers 4. When 75% of the patient's
nutritional needs are met by the tube feedings
A patient is receiving total parenteral nutrition (TPN). What are
the primary interventions the nurse should follow to prevent a
central line infection? (Select all that apply.)
1. Change the dressing using sterile technique
2. Change TPN containers every 48 hours
3. Change the TPN tubing every 24 hours
4. Monitor glucose levels to watch and assess for glucose
intolerance
5. Elevate head of the bed 45 degrees to prevent aspiration
Correct Answers 1. Change the dressing using sterile technique
3. Change the TPN tubing every 24 hours
A patient is schedule to have an intravenous pyelogram (IVP)
the next morning. Which nursing measures should be
implemented before the test? (Select all that apply.)
1. Ask the patient about any allergies and reactions
2. Instruct the patient that a full bladder is required for the test
