NU 136
EXAM 2
Fundamentals of Nursing
Actual Questions w/Correct Answers
Galen College of Nursing
What you Will Get:
• 50+ verified questions
• Correct answers with Rationales.
• Ideal for exam preparation and concept
reinforcement.
,1. What is the primary reason for using a warm solution when administering an
enema?
a. A cold solution can cause cramping
b. It increases peristalsis
c. It reduces the risk of fluid overload
d. It soothes the intestinal muscles
Correct Answer:
a. A cold solution can cause cramping
Rationale: Warm enema solutions (approximately 105°F or 40.5°C) are used to prevent
intestinal cramping and patient discomfort. Cold solutions can trigger vasoconstriction
and spasms of the intestinal muscles, making administration difficult and painful. While
warmth may mildly soothe muscles, the primary clinical reason is to avoid cramping.
2. A nurse identifies an immobile patient as high risk for constipation. Which
intervention is most effective?
a. Administering sleep medication
b. Keeping the patient in bed
c. Limiting fluid intake
d. Encouraging a high-fiber diet
Correct Answer:
d. Encouraging a high-fiber diet
Rationale: Immobility decreases gastrointestinal motility and increases constipation
risk. A high-fiber diet adds bulk to stool and promotes regular bowel elimination. Limiting
fluids or encouraging bed rest worsens constipation. Sleep medications may have
constipating side effects and do not address the underlying risk.
3. Which position is MOST appropriate for a patient to assume when receiving an
enema?
a. Prone
b. Supine
c. Fowler's position
d. Left Sims' (side-lying)
,Correct Answer:
d. Left Sims' (side-lying)
Rationale: The left Sims' position (left lateral with the right knee flexed) allows gravity to
direct the enema solution along the anatomical path of the colon—into the sigmoid and
descending colon. This position facilitates retention of the solution and effective
stimulation of defecation.
4. A patient with chronic constipation should be educated on the potential risks of
frequent use of stimulant laxatives, such as:
a. Sudden diarrhea
b. Hyperkalemia
c. Dependency for bowel movements
d. Increased appetite
Correct Answer:
c. Dependency for bowel movements
Rationale: Chronic use of stimulant laxatives (e.g., senna, bisacodyl) can lead to
laxative dependence, where the bowel loses its natural ability to evacuate without
chemical stimulation. This can also cause electrolyte imbalances (particularly
hypokalemia, not hyperkalemia) and dehydration. Patients should be counseled to use
laxatives only as directed.
5. What is the primary purpose of using a wound VAC in wound management?
a. To provide antibiotic treatment
b. To suture wounds
c. To debride necrotic tissue
d. To remove exudate and reduce edema
Correct Answer:
d. To remove exudate and reduce edema
Rationale: Negative Pressure Wound Therapy (NPWT/VAC) applies sub-atmospheric
pressure to the wound bed to remove excess exudate, reduce edema, increase
localized blood flow, and promote granulation tissue formation. It does not deliver
antibiotics, suture wounds, or directly debride tissue.
, 6. A patient who is non-weight bearing on the left leg needs to learn to use
crutches. The nurse instructs the patient to:
a. Place all weight on the right foot
b. Bear weight equally on both feet
c. Alternate weight between feet when moving
d. Use the left foot for balance only
Correct Answer:
a. Place all weight on the right foot
Rationale: With a non-weight bearing (NWB) order, the patient must not place any
weight on the affected limb. All weight is borne on the unaffected leg and through the
hands on the crutch hand grips. The axillae should never bear weight to prevent
brachial plexus injury.
7. A nurse is preparing to apply an elastic bandage to a patient's sprained ankle.
Which action is most appropriate?
a. Leaving the toes exposed for observations
b. Using even pressure when wrapping the bandage
c. Starting the wrap at the upper calf and moving downward
d. Wrapping the bandage loosely to allow for swelling
Correct Answer:
b. Using even pressure when wrapping the bandage
Rationale: Even pressure prevents constriction while providing adequate support and
compression. Wrapping too loosely provides no support, while uneven or excessive
pressure compromises circulation. The wrap should begin distally and move proximally
to promote venous return, and distal neurovascular status must be assessed frequently.
8. Which phase of wound healing involves the formation of collagen and
granulation tissue to fill the wound?
a. Maturation phase
b. Proliferative phase
c. Inflammatory phase
Correct Answer:
b. Proliferative phase
EXAM 2
Fundamentals of Nursing
Actual Questions w/Correct Answers
Galen College of Nursing
What you Will Get:
• 50+ verified questions
• Correct answers with Rationales.
• Ideal for exam preparation and concept
reinforcement.
,1. What is the primary reason for using a warm solution when administering an
enema?
a. A cold solution can cause cramping
b. It increases peristalsis
c. It reduces the risk of fluid overload
d. It soothes the intestinal muscles
Correct Answer:
a. A cold solution can cause cramping
Rationale: Warm enema solutions (approximately 105°F or 40.5°C) are used to prevent
intestinal cramping and patient discomfort. Cold solutions can trigger vasoconstriction
and spasms of the intestinal muscles, making administration difficult and painful. While
warmth may mildly soothe muscles, the primary clinical reason is to avoid cramping.
2. A nurse identifies an immobile patient as high risk for constipation. Which
intervention is most effective?
a. Administering sleep medication
b. Keeping the patient in bed
c. Limiting fluid intake
d. Encouraging a high-fiber diet
Correct Answer:
d. Encouraging a high-fiber diet
Rationale: Immobility decreases gastrointestinal motility and increases constipation
risk. A high-fiber diet adds bulk to stool and promotes regular bowel elimination. Limiting
fluids or encouraging bed rest worsens constipation. Sleep medications may have
constipating side effects and do not address the underlying risk.
3. Which position is MOST appropriate for a patient to assume when receiving an
enema?
a. Prone
b. Supine
c. Fowler's position
d. Left Sims' (side-lying)
,Correct Answer:
d. Left Sims' (side-lying)
Rationale: The left Sims' position (left lateral with the right knee flexed) allows gravity to
direct the enema solution along the anatomical path of the colon—into the sigmoid and
descending colon. This position facilitates retention of the solution and effective
stimulation of defecation.
4. A patient with chronic constipation should be educated on the potential risks of
frequent use of stimulant laxatives, such as:
a. Sudden diarrhea
b. Hyperkalemia
c. Dependency for bowel movements
d. Increased appetite
Correct Answer:
c. Dependency for bowel movements
Rationale: Chronic use of stimulant laxatives (e.g., senna, bisacodyl) can lead to
laxative dependence, where the bowel loses its natural ability to evacuate without
chemical stimulation. This can also cause electrolyte imbalances (particularly
hypokalemia, not hyperkalemia) and dehydration. Patients should be counseled to use
laxatives only as directed.
5. What is the primary purpose of using a wound VAC in wound management?
a. To provide antibiotic treatment
b. To suture wounds
c. To debride necrotic tissue
d. To remove exudate and reduce edema
Correct Answer:
d. To remove exudate and reduce edema
Rationale: Negative Pressure Wound Therapy (NPWT/VAC) applies sub-atmospheric
pressure to the wound bed to remove excess exudate, reduce edema, increase
localized blood flow, and promote granulation tissue formation. It does not deliver
antibiotics, suture wounds, or directly debride tissue.
, 6. A patient who is non-weight bearing on the left leg needs to learn to use
crutches. The nurse instructs the patient to:
a. Place all weight on the right foot
b. Bear weight equally on both feet
c. Alternate weight between feet when moving
d. Use the left foot for balance only
Correct Answer:
a. Place all weight on the right foot
Rationale: With a non-weight bearing (NWB) order, the patient must not place any
weight on the affected limb. All weight is borne on the unaffected leg and through the
hands on the crutch hand grips. The axillae should never bear weight to prevent
brachial plexus injury.
7. A nurse is preparing to apply an elastic bandage to a patient's sprained ankle.
Which action is most appropriate?
a. Leaving the toes exposed for observations
b. Using even pressure when wrapping the bandage
c. Starting the wrap at the upper calf and moving downward
d. Wrapping the bandage loosely to allow for swelling
Correct Answer:
b. Using even pressure when wrapping the bandage
Rationale: Even pressure prevents constriction while providing adequate support and
compression. Wrapping too loosely provides no support, while uneven or excessive
pressure compromises circulation. The wrap should begin distally and move proximally
to promote venous return, and distal neurovascular status must be assessed frequently.
8. Which phase of wound healing involves the formation of collagen and
granulation tissue to fill the wound?
a. Maturation phase
b. Proliferative phase
c. Inflammatory phase
Correct Answer:
b. Proliferative phase
