NUR3227C PPNC2 Exam 1
What should the nurse teach family caregivers when a patient has fecal incontinence
because of cognitive impairment?
1. Cleanse the skin with antibacterial soap, and apply talcum powder to the buttocks.
2. Initiate bowel or habit training program to promote continence.
3. Help the patient to toilet once every hour.
4. Use sanitary pads in the patient's underwear. - CORRECT ANSWER-2. Initiate bowel
or habit training program to promote continence.
The patient states, "I have diarrhea and cramping every time I have ice cream. I am
sure this is because the food is cold." Based on this assessment data, which health
problem does the nurse suspect?
1. A food allergy
2. Irritable bowel syndrome
3. Increased peristalsis
4. Lactose intolerance - CORRECT ANSWER-4. Lactose intolerance
A nurse is taking a health history of a newly admied 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 experienced frequent, small liquid stools recently? - CORRECT ANSWER-
4. Have you experienced frequent, small liquid stools recently?
When repositioning an immobile patient, the nurse notices redness over the hip bone.
What is indicated when a reddened area blanches on fingertip touch?
1. A local skin infection requiring antibiotics
2. Sensitive skin that requires special bed linen
3. A stage 3 pressure injury needing the appropriate dressing
4. Blanching hyperemia, indicating the attempt by the body to overcome the ischemic
episode - CORRECT ANSWER-4. Blanching hyperemia, indicating the attempt by the
body to overcome the ischemic episode
,During the administration of a warm tap-water enema, a patient complains of cramping
abdominal pain that he rates 6 out of 10. What nursing intervention should the nurse do
first?
1. Stop the instillation.
2. Ask the patient to take deep breaths to decrease the pain.
3. Tell the patient to bear down as he would when having a bowel movement.
4. Continue the instillation; then administer a pain medication. - CORRECT ANSWER-1.
Stop the instillation.
Which instructions do you include when educating a person with chronic constipation?
(Select all that apply.)
1. Increase fiber and fluids in the diet.
2. Use a low-volume enema daily.
3. Avoid gluten in the diet.
4. Take laxatives twice a day.
5. Exercise for 30 minutes every day.
6. Schedule time to use the toilet at the same time every day.
7. Take probiotics 5 times a week. - CORRECT ANSWER-1. Increase fiber and fluids in
the diet.
5. Exercise for 30 minutes every day.
6. Schedule time to use the toilet at the same time every day.
Which skills does the nurse teach a patient with a new colostomy before discharge from
the hospital? (Select all that apply.)
1. How to change the pouch
2. How to empty the pouch
3. How to open and close the pouch
4. How to irrigate the colostomy
5. How to determine whether the ostomy is healing appropriately - CORRECT
ANSWER-1. How to change the pouch
2. How to empty the pouch
3. How to open and close the pouch
5. How to determine whether the ostomy is healing appropriately
Which nursing actions do you take when placing a bedpan under an immobilized
patient? (Select all that apply.)
1. Lift the patient's hips off the bed and slide the bedpan under the patient.
2. After positioning the patient on the bedpan, elevate the head of the bed to a 45-
degree angle.
3. Adjust the head of the bed so that it is lower than the feet, and use gentle but firm
pressure to push the bedpan under the patient.
,4. Have the patient stand beside the bed, and then have him or her sit on the bedpan on
the edge of the bed.
5. Make sure the patient has a nurse call system in reach to notify the nurse when he or
she is ready to have the bedpan removed. - CORRECT ANSWER-2. After positioning
the patient on the bedpan, elevate the head of the bed to a 45-degree angle.
5. Make sure the patient has a nurse call system in reach to notify the nurse when he or
she is ready to have the bedpan removed.
Place the steps for an ileostomy pouch change in the correct order.
1. Close the end of the pouch.
2. Measure the stoma.
3. Cut the hole in the wafer to fit around the stoma and not leave skin exposed to the
effluent.
4. Press the pouch in place over the stoma.
5. Remove the old pouch.
6. Trace the correct measurement onto the back of the wafer.
7. Assess the stoma and the skin around it. 8. Cleanse and dry the peristomal skin. -
CORRECT ANSWER-5, 8, 7, 2, 6, 3, 4, 1
Which symptoms are warning signs of possible colorectal cancer according to the
American Cancer Society
guidelines? (Select all that apply.)
1. Change in bowel habits
2. Blood in the stool
3. A larger-than-normal bowel movement
4. Fecal impaction
5. Muscle aches
6. Incomplete emptying of the colon
7. Food particles in the stool
8. Unexplained abdominal or back pain - CORRECT ANSWER-1. Change in bowel
habits
2. Blood in the stool
6. Incomplete emptying of the colon
8. Unexplained abdominal or back pain
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
collect 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
ANSWER-3. Collect one fecal smear from three separate bowel movements.
Match the pressure injury stages with the correct definition:
Stage 1
Stage 2
Stage 3
Stage 4
a. partial thickness loss of skin with exposed dermis. the wound bed is viable, pink or
red, most, and may also present as an intact or ruptured serum-filled blister. Adipose
(fat) is not viable, and deeper tissues are not visible. Granulation tissue, slough, and
eschar are not present. These injuries commonly result from adverse microclimate and
sheer in the skin over the pelvis and shear of the heel. This stage should not be used to
describe moisture associated skin damage (MASD), including incontinent associated
dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive related skin injury
(MARSI), or traumatic wounds (skin tears, Burns, abrasions)
b. Intact skin with a localized area of non-blanchable erythema, which may appear
differently in darkly pigmented skin. Presence of blanchable erythema or changes in -
CORRECT ANSWER-Stage 1- b
Stage 2 - a
Stage 3 - d
Stage 4 - c
After surgery the patient with a closed abdominal wound reports a sudden "pop" after
coughing. When the nurse examines the surgical wound site, the sutures are open, and
pieces of small bowel are noted at the boom of the now- opened wound. Which are the
priority nursing interventions? (Select all that apply.)
1. Notify the health care provider.
2. Allow the area to be exposed to air until all drainage has stopped.
3. Place several cold packs over the area, protecting the skin around the wound.
4. Cover the area with sterile, saline-soaked towels immediately.
5. Cover the area with sterile gauze and apply an abdominal binder. - CORRECT
ANSWER-1. Notify the health care provider.
4. Cover the area with sterile, saline-soaked towels immediately.
What is the correct sequence of steps when performing wound irrigation to a large open
wound?
1. Use slow, continuous pressure to irrigate wound.
2. Attach 19-gauge angiocatheter to syringe.
3. Fill syringe with irrigation fluid.
4. Place biohazard bag near bed.
What should the nurse teach family caregivers when a patient has fecal incontinence
because of cognitive impairment?
1. Cleanse the skin with antibacterial soap, and apply talcum powder to the buttocks.
2. Initiate bowel or habit training program to promote continence.
3. Help the patient to toilet once every hour.
4. Use sanitary pads in the patient's underwear. - CORRECT ANSWER-2. Initiate bowel
or habit training program to promote continence.
The patient states, "I have diarrhea and cramping every time I have ice cream. I am
sure this is because the food is cold." Based on this assessment data, which health
problem does the nurse suspect?
1. A food allergy
2. Irritable bowel syndrome
3. Increased peristalsis
4. Lactose intolerance - CORRECT ANSWER-4. Lactose intolerance
A nurse is taking a health history of a newly admied 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 experienced frequent, small liquid stools recently? - CORRECT ANSWER-
4. Have you experienced frequent, small liquid stools recently?
When repositioning an immobile patient, the nurse notices redness over the hip bone.
What is indicated when a reddened area blanches on fingertip touch?
1. A local skin infection requiring antibiotics
2. Sensitive skin that requires special bed linen
3. A stage 3 pressure injury needing the appropriate dressing
4. Blanching hyperemia, indicating the attempt by the body to overcome the ischemic
episode - CORRECT ANSWER-4. Blanching hyperemia, indicating the attempt by the
body to overcome the ischemic episode
,During the administration of a warm tap-water enema, a patient complains of cramping
abdominal pain that he rates 6 out of 10. What nursing intervention should the nurse do
first?
1. Stop the instillation.
2. Ask the patient to take deep breaths to decrease the pain.
3. Tell the patient to bear down as he would when having a bowel movement.
4. Continue the instillation; then administer a pain medication. - CORRECT ANSWER-1.
Stop the instillation.
Which instructions do you include when educating a person with chronic constipation?
(Select all that apply.)
1. Increase fiber and fluids in the diet.
2. Use a low-volume enema daily.
3. Avoid gluten in the diet.
4. Take laxatives twice a day.
5. Exercise for 30 minutes every day.
6. Schedule time to use the toilet at the same time every day.
7. Take probiotics 5 times a week. - CORRECT ANSWER-1. Increase fiber and fluids in
the diet.
5. Exercise for 30 minutes every day.
6. Schedule time to use the toilet at the same time every day.
Which skills does the nurse teach a patient with a new colostomy before discharge from
the hospital? (Select all that apply.)
1. How to change the pouch
2. How to empty the pouch
3. How to open and close the pouch
4. How to irrigate the colostomy
5. How to determine whether the ostomy is healing appropriately - CORRECT
ANSWER-1. How to change the pouch
2. How to empty the pouch
3. How to open and close the pouch
5. How to determine whether the ostomy is healing appropriately
Which nursing actions do you take when placing a bedpan under an immobilized
patient? (Select all that apply.)
1. Lift the patient's hips off the bed and slide the bedpan under the patient.
2. After positioning the patient on the bedpan, elevate the head of the bed to a 45-
degree angle.
3. Adjust the head of the bed so that it is lower than the feet, and use gentle but firm
pressure to push the bedpan under the patient.
,4. Have the patient stand beside the bed, and then have him or her sit on the bedpan on
the edge of the bed.
5. Make sure the patient has a nurse call system in reach to notify the nurse when he or
she is ready to have the bedpan removed. - CORRECT ANSWER-2. After positioning
the patient on the bedpan, elevate the head of the bed to a 45-degree angle.
5. Make sure the patient has a nurse call system in reach to notify the nurse when he or
she is ready to have the bedpan removed.
Place the steps for an ileostomy pouch change in the correct order.
1. Close the end of the pouch.
2. Measure the stoma.
3. Cut the hole in the wafer to fit around the stoma and not leave skin exposed to the
effluent.
4. Press the pouch in place over the stoma.
5. Remove the old pouch.
6. Trace the correct measurement onto the back of the wafer.
7. Assess the stoma and the skin around it. 8. Cleanse and dry the peristomal skin. -
CORRECT ANSWER-5, 8, 7, 2, 6, 3, 4, 1
Which symptoms are warning signs of possible colorectal cancer according to the
American Cancer Society
guidelines? (Select all that apply.)
1. Change in bowel habits
2. Blood in the stool
3. A larger-than-normal bowel movement
4. Fecal impaction
5. Muscle aches
6. Incomplete emptying of the colon
7. Food particles in the stool
8. Unexplained abdominal or back pain - CORRECT ANSWER-1. Change in bowel
habits
2. Blood in the stool
6. Incomplete emptying of the colon
8. Unexplained abdominal or back pain
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
collect 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
ANSWER-3. Collect one fecal smear from three separate bowel movements.
Match the pressure injury stages with the correct definition:
Stage 1
Stage 2
Stage 3
Stage 4
a. partial thickness loss of skin with exposed dermis. the wound bed is viable, pink or
red, most, and may also present as an intact or ruptured serum-filled blister. Adipose
(fat) is not viable, and deeper tissues are not visible. Granulation tissue, slough, and
eschar are not present. These injuries commonly result from adverse microclimate and
sheer in the skin over the pelvis and shear of the heel. This stage should not be used to
describe moisture associated skin damage (MASD), including incontinent associated
dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive related skin injury
(MARSI), or traumatic wounds (skin tears, Burns, abrasions)
b. Intact skin with a localized area of non-blanchable erythema, which may appear
differently in darkly pigmented skin. Presence of blanchable erythema or changes in -
CORRECT ANSWER-Stage 1- b
Stage 2 - a
Stage 3 - d
Stage 4 - c
After surgery the patient with a closed abdominal wound reports a sudden "pop" after
coughing. When the nurse examines the surgical wound site, the sutures are open, and
pieces of small bowel are noted at the boom of the now- opened wound. Which are the
priority nursing interventions? (Select all that apply.)
1. Notify the health care provider.
2. Allow the area to be exposed to air until all drainage has stopped.
3. Place several cold packs over the area, protecting the skin around the wound.
4. Cover the area with sterile, saline-soaked towels immediately.
5. Cover the area with sterile gauze and apply an abdominal binder. - CORRECT
ANSWER-1. Notify the health care provider.
4. Cover the area with sterile, saline-soaked towels immediately.
What is the correct sequence of steps when performing wound irrigation to a large open
wound?
1. Use slow, continuous pressure to irrigate wound.
2. Attach 19-gauge angiocatheter to syringe.
3. Fill syringe with irrigation fluid.
4. Place biohazard bag near bed.
