FUNDAMENTALS II 2026 EXAM STUDY
GUIDE QUESTIONS AND ANSWERS
GRADED A+
◉. A nurse is pouching an ostomy on a patient with an ileostomy.
Which action by the nurse is most appropriate?
a. Changing the skin barrier portion of the ostomy pouch daily
b. Emptying the pouch if it is more than one-third to one-half full
c. Thoroughly cleansing the skin around the stoma with soap and
water to remove excess stool and adhesive
d. Measuring the correct size for the barrier device while leaving a
1/2-inch space around the stoma. Answer: ANS: B
Pouches must be emptied when they are one-third to one-half full
because the weight of the pouch may disrupt the seal of the adhesive
on the skin. The barrier device should be changed every 3 to 7 days
unless it is leaking or is no longer effective. Peristomal skin should
be gently cleansed; vigorous rubbing can cause further irritation or
skin breakdown. Avoid soap. It leaves a residue on skin, which may
irritate the skin. The pouch opening should fit around the stoma and
cover the peristomal skin to prevent contact with the effluent.
Excess space, like 1/2 inch, allows fecal matter to have prolonged
exposure to skin, resulting in skin breakdown
,◉Which action will the nurse take to reduce the risk of excoriation
to the mucosal lining of the patient's nose from a nasogastric tube?
a. Instill Xylocaine into the nares once a shift.
b. Tape tube securely with light pressure on nare.
c. Lubricate the nares with water-soluble lubricant.
d. Apply a small ice bag to the nose for 5 minutes every 4 hours..
Answer: ANS: C
The tube constantly irritates the nasal mucosa, increasing the risk of
excoriation. Frequent lubrication with a water-soluble lubricant
decreases the likelihood of excoriation and is less toxic than oil-
based if aspirated. Xylocaine is used to treat sore throat, not nasal
mucosal excoriation. While the tape should be secure, pressure will
increase excoriation. Ice is not applied to the nose
◉The nurse is caring for a patient with Clostridium difficile. Which
nursing actions will have the greatest impact in preventing the
spread of the bacteria?
a. Appropriate disposal of contaminated items in biohazard bags
b. Monthly in-services about contact precautions
c. Mandatory cultures on all patients
d. Proper hand hygiene techniques. Answer: ANS: D
Proper hand hygiene is the best way to prevent the spread of
bacteria. Soap and water are mandatory. Monthly in-services place
emphasis on education, not on action. Biohazard bags are
,appropriate but cannot be used on every item that C. difficile comes
in contact with, such as a human. Mandatory cultures are expensive
and unnecessary and would not prevent the spread of bacteria.
◉The nurse is caring for a patient who had a colostomy placed
yesterday. The nurse should report which assessment finding
immediately?
a. Stoma is protruding from the abdomen.
b. Stoma is flush with the skin.
c. Stoma is purple.
d. Stoma is moist.. Answer: ANS: C
A purple stoma may indicate strangulation/necrosis or poor
circulation to the stoma and may require surgical intervention. A
stoma should be reddish-pink and moist in appearance. It can be
flush with the skin, or it can protrude
◉A nurse is preparing a bowel training program for a patient. Which
actions will the nurse take? (Select all that apply.)
a. Record times when the patient is incontinent.
b. Help the patient to the toilet at the designated time.
c. Lean backward on the hips while sitting on the toilet.
d. Maintain normal exercise within the patient's physical ability.
e. Apply pressure with hands over the abdomen, and strain while
pushing.
, f. Choose a time based on the patient's pattern to initiate defecation-
control measures.. Answer: ANS: A, B, D, F
A successful program includes the following: Assessing the normal
elimination pattern and recording times when the patient is
incontinent. Choosing a time based on the patient's pattern to
initiate defecation-control measures. Maintaining normal exercise
within the patient's physical ability. Helping the patient to the toilet
at the designated time. Offering a hot drink (hot tea) or fruit juice
(prune juice) (or whatever fluids normally stimulate peristalsis for
the patient) before the defecation time. Instructing the patient to
lean forward at the hips while sitting on the toilet, apply manual
pressure with the hands over the abdomen, and bear down but do
not strain to stimulate colon emptying.
◉The nurse is devising a plan of care for a patient with the nursing
diagnosis of Constipation related to opioid use. Which outcome will
the nurse evaluate as successful for the patient to establish normal
defecation?
a. The patient reports eliminating a soft, formed stool.
b. The patient has quit taking opioid pain medication.
c. The patient's lower left quadrant is tender to the touch.
d. The nurse hears bowel sounds in all four quadrants.
.. Answer: ANS: A
The nurse's goal is for the patient to take opioid medication and to
have normal bowel elimination. Normal stools are soft and formed.
Ceasing pain medication is not a desired outcome for the patient.
GUIDE QUESTIONS AND ANSWERS
GRADED A+
◉. A nurse is pouching an ostomy on a patient with an ileostomy.
Which action by the nurse is most appropriate?
a. Changing the skin barrier portion of the ostomy pouch daily
b. Emptying the pouch if it is more than one-third to one-half full
c. Thoroughly cleansing the skin around the stoma with soap and
water to remove excess stool and adhesive
d. Measuring the correct size for the barrier device while leaving a
1/2-inch space around the stoma. Answer: ANS: B
Pouches must be emptied when they are one-third to one-half full
because the weight of the pouch may disrupt the seal of the adhesive
on the skin. The barrier device should be changed every 3 to 7 days
unless it is leaking or is no longer effective. Peristomal skin should
be gently cleansed; vigorous rubbing can cause further irritation or
skin breakdown. Avoid soap. It leaves a residue on skin, which may
irritate the skin. The pouch opening should fit around the stoma and
cover the peristomal skin to prevent contact with the effluent.
Excess space, like 1/2 inch, allows fecal matter to have prolonged
exposure to skin, resulting in skin breakdown
,◉Which action will the nurse take to reduce the risk of excoriation
to the mucosal lining of the patient's nose from a nasogastric tube?
a. Instill Xylocaine into the nares once a shift.
b. Tape tube securely with light pressure on nare.
c. Lubricate the nares with water-soluble lubricant.
d. Apply a small ice bag to the nose for 5 minutes every 4 hours..
Answer: ANS: C
The tube constantly irritates the nasal mucosa, increasing the risk of
excoriation. Frequent lubrication with a water-soluble lubricant
decreases the likelihood of excoriation and is less toxic than oil-
based if aspirated. Xylocaine is used to treat sore throat, not nasal
mucosal excoriation. While the tape should be secure, pressure will
increase excoriation. Ice is not applied to the nose
◉The nurse is caring for a patient with Clostridium difficile. Which
nursing actions will have the greatest impact in preventing the
spread of the bacteria?
a. Appropriate disposal of contaminated items in biohazard bags
b. Monthly in-services about contact precautions
c. Mandatory cultures on all patients
d. Proper hand hygiene techniques. Answer: ANS: D
Proper hand hygiene is the best way to prevent the spread of
bacteria. Soap and water are mandatory. Monthly in-services place
emphasis on education, not on action. Biohazard bags are
,appropriate but cannot be used on every item that C. difficile comes
in contact with, such as a human. Mandatory cultures are expensive
and unnecessary and would not prevent the spread of bacteria.
◉The nurse is caring for a patient who had a colostomy placed
yesterday. The nurse should report which assessment finding
immediately?
a. Stoma is protruding from the abdomen.
b. Stoma is flush with the skin.
c. Stoma is purple.
d. Stoma is moist.. Answer: ANS: C
A purple stoma may indicate strangulation/necrosis or poor
circulation to the stoma and may require surgical intervention. A
stoma should be reddish-pink and moist in appearance. It can be
flush with the skin, or it can protrude
◉A nurse is preparing a bowel training program for a patient. Which
actions will the nurse take? (Select all that apply.)
a. Record times when the patient is incontinent.
b. Help the patient to the toilet at the designated time.
c. Lean backward on the hips while sitting on the toilet.
d. Maintain normal exercise within the patient's physical ability.
e. Apply pressure with hands over the abdomen, and strain while
pushing.
, f. Choose a time based on the patient's pattern to initiate defecation-
control measures.. Answer: ANS: A, B, D, F
A successful program includes the following: Assessing the normal
elimination pattern and recording times when the patient is
incontinent. Choosing a time based on the patient's pattern to
initiate defecation-control measures. Maintaining normal exercise
within the patient's physical ability. Helping the patient to the toilet
at the designated time. Offering a hot drink (hot tea) or fruit juice
(prune juice) (or whatever fluids normally stimulate peristalsis for
the patient) before the defecation time. Instructing the patient to
lean forward at the hips while sitting on the toilet, apply manual
pressure with the hands over the abdomen, and bear down but do
not strain to stimulate colon emptying.
◉The nurse is devising a plan of care for a patient with the nursing
diagnosis of Constipation related to opioid use. Which outcome will
the nurse evaluate as successful for the patient to establish normal
defecation?
a. The patient reports eliminating a soft, formed stool.
b. The patient has quit taking opioid pain medication.
c. The patient's lower left quadrant is tender to the touch.
d. The nurse hears bowel sounds in all four quadrants.
.. Answer: ANS: A
The nurse's goal is for the patient to take opioid medication and to
have normal bowel elimination. Normal stools are soft and formed.
Ceasing pain medication is not a desired outcome for the patient.
