NURS 355 Exam 3 questions with correct answers
The nurse is caring for a 47-yr-old female patient who is comatose and is
receiving continuous enteral nutrition through a soft nasogastric tube.
The nurse notes the presence of new crackles in the patient's lungs. In
which order will the nurse take action? (Put a comma and a space
between each answer choice [A, B, C, D].)
a. Check the patient's oxygen saturation.
b. Notify the patient's health care provider.
c. Stop administering the continuous feeding.
d. Measure the gastric residual volume per agency policy. Correct
Answer-Answers:
C. Stop administering the continuous feeding
A. Check the patient's oxygen saturation
D. Measure the gastric residual volume per agency policy.
B. Notify the patient's health care provider
Rationale: The assessment data indicate that aspiration may have
occurred. The nurse's first action should be to turn off the enteral feeding
to avoid further aspiration. The next action should be to check the
oxygen saturation because this may indicate the need for immediate
respiratory suctioning or oxygen administration. The residual volume
provides data about possible causes of aspiration. Finally, the health care
provider should be notified and informed of all the assessment data the
nurse has just obtained.
,Which information about an 80-yr-old male patient at the senior center is
of most concern to the nurse?
a. Decreased appetite
b. Occasional indigestion
c. Unintended weight loss
d. Difficulty chewing food Correct Answer-Answer: Unintended weight
loss
Rationale: Unintentional weight loss is not a normal finding and may
indicate a problem such as cancer or depression. Poor appetite, difficulty
in chewing, and indigestion are common in older patients. These will
need to be addressed but are not of as much concern as the weight loss.
2. An older patient reports chronic constipation. To promote bowel
evacuation, when should the nurse suggest that the patient attempt
defecation?
a. In the mid-afternoon
b. After eating breakfast
c. Right after awakening in the morning
d. Immediately before the first daily meal Correct Answer-Answer:
After eating breakfast
,Rationale: The gastrocolic reflex is most active after the first daily meal.
Awakening, the anticipation of eating, and mid-afternoon timing do not
stimulate these reflexes.
What condition should the nurse anticipate when caring for a patient
with a history of a total gastrectomy?
a. Constipation
b. Dehydration
c. Elevated total serum cholesterol
d. Cobalamin (vitamin B12) deficiency Correct Answer-Answer:
Cobalamin
Rationale: The patient with a total gastrectomy does not secrete intrinsic
factor, which is needed for cobalamin (vitamin B12) absorption.
Because the stomach absorbs only small amounts of water and nutrients,
the patient is not at higher risk for dehydration, elevated cholesterol, or
constipation.
The nurse is caring for a patient with an obstructed common bile duct.
What condition should the nurse expect?
a. Melena
b. Steatorrhea
c. Decreased serum cholesterol level
, d. Increased serum indirect bilirubin level Correct Answer-Answer:
Steatorrhea
Rationale: A common bile duct obstruction will reduce the absorption of
fat in the small intestine, leading to fatty stools. Gastrointestinal
bleeding is not caused by common bile duct obstruction. Serum
cholesterol levels are increased with biliary obstruction. Direct bilirubin
level is increased with biliary obstruction.
The nurse receives the following information about a patient who is
scheduled for a colonoscopy. Which information should be
communicated to the health care provider before sending the patient for
the procedure?
a. The patient declined to drink the prescribed laxative solution.
b. The patient has had an allergic reaction to shellfish and iodine.
c. The patient has a permanent pacemaker to prevent bradycardia.
d. The patient is worried about discomfort during the examination.
Correct Answer-Answer: The patient declined to drink the prescribed
laxative solution.
Rationale: If the patient has had inadequate bowel preparation, the colon
cannot be visualized and the procedure would be rescheduled. Because
contrast solution is not used during colonoscopy,
The nurse is caring for a 47-yr-old female patient who is comatose and is
receiving continuous enteral nutrition through a soft nasogastric tube.
The nurse notes the presence of new crackles in the patient's lungs. In
which order will the nurse take action? (Put a comma and a space
between each answer choice [A, B, C, D].)
a. Check the patient's oxygen saturation.
b. Notify the patient's health care provider.
c. Stop administering the continuous feeding.
d. Measure the gastric residual volume per agency policy. Correct
Answer-Answers:
C. Stop administering the continuous feeding
A. Check the patient's oxygen saturation
D. Measure the gastric residual volume per agency policy.
B. Notify the patient's health care provider
Rationale: The assessment data indicate that aspiration may have
occurred. The nurse's first action should be to turn off the enteral feeding
to avoid further aspiration. The next action should be to check the
oxygen saturation because this may indicate the need for immediate
respiratory suctioning or oxygen administration. The residual volume
provides data about possible causes of aspiration. Finally, the health care
provider should be notified and informed of all the assessment data the
nurse has just obtained.
,Which information about an 80-yr-old male patient at the senior center is
of most concern to the nurse?
a. Decreased appetite
b. Occasional indigestion
c. Unintended weight loss
d. Difficulty chewing food Correct Answer-Answer: Unintended weight
loss
Rationale: Unintentional weight loss is not a normal finding and may
indicate a problem such as cancer or depression. Poor appetite, difficulty
in chewing, and indigestion are common in older patients. These will
need to be addressed but are not of as much concern as the weight loss.
2. An older patient reports chronic constipation. To promote bowel
evacuation, when should the nurse suggest that the patient attempt
defecation?
a. In the mid-afternoon
b. After eating breakfast
c. Right after awakening in the morning
d. Immediately before the first daily meal Correct Answer-Answer:
After eating breakfast
,Rationale: The gastrocolic reflex is most active after the first daily meal.
Awakening, the anticipation of eating, and mid-afternoon timing do not
stimulate these reflexes.
What condition should the nurse anticipate when caring for a patient
with a history of a total gastrectomy?
a. Constipation
b. Dehydration
c. Elevated total serum cholesterol
d. Cobalamin (vitamin B12) deficiency Correct Answer-Answer:
Cobalamin
Rationale: The patient with a total gastrectomy does not secrete intrinsic
factor, which is needed for cobalamin (vitamin B12) absorption.
Because the stomach absorbs only small amounts of water and nutrients,
the patient is not at higher risk for dehydration, elevated cholesterol, or
constipation.
The nurse is caring for a patient with an obstructed common bile duct.
What condition should the nurse expect?
a. Melena
b. Steatorrhea
c. Decreased serum cholesterol level
, d. Increased serum indirect bilirubin level Correct Answer-Answer:
Steatorrhea
Rationale: A common bile duct obstruction will reduce the absorption of
fat in the small intestine, leading to fatty stools. Gastrointestinal
bleeding is not caused by common bile duct obstruction. Serum
cholesterol levels are increased with biliary obstruction. Direct bilirubin
level is increased with biliary obstruction.
The nurse receives the following information about a patient who is
scheduled for a colonoscopy. Which information should be
communicated to the health care provider before sending the patient for
the procedure?
a. The patient declined to drink the prescribed laxative solution.
b. The patient has had an allergic reaction to shellfish and iodine.
c. The patient has a permanent pacemaker to prevent bradycardia.
d. The patient is worried about discomfort during the examination.
Correct Answer-Answer: The patient declined to drink the prescribed
laxative solution.
Rationale: If the patient has had inadequate bowel preparation, the colon
cannot be visualized and the procedure would be rescheduled. Because
contrast solution is not used during colonoscopy,
