NR 224 Fundamentals Final Review
UPDATED ACTUAL Questions and
CORRECT Answers
What is the most effective method to prevent the transfer of clostridium difficile (C. Difficile) ? -
CORRECT ANSWER - HAND HYGIENE with soap and water is effective to physically
remove C. difficile spores from the hands. (Potter 1092)
What is the term for the [abnormal] method used to assist in stool passage by exerting pressure to
expel fecal matter through voluntary contraction of the abdominal muscles while maintaining a
forced expiration against a closed airway? - CORRECT ANSWER - Valsalva Manuever
*Normal passage of bowels should be painless, passing soft formed stool*
Which patients are at greatest risk for cardiac dysrhythmia and high blood pressure with the
Valsalva manuever and MUST avoid straining to pass stool? - CORRECT ANSWER -
Patients with cardiovascular disease, glaucoma, increased intracranial pressure, or a new surgical
wound
(Potter 1089)
What is the term for a collection of hardened feces in the rectum that cannot be expelled due to
unrelieved constipation? - CORRECT ANSWER - Fecal Impaction
Where does fecal impaction occur in the colon? - CORRECT ANSWER - Rectum
Least formed stool is present in which portion of the digestive tract? - CORRECT
ANSWER - Ascending Colon
Most formed stool is present in which portion of the digestive tract? - CORRECT
ANSWER - Descending Colon
,Which position should the patient be in while administering an enema? - CORRECT
ANSWER - Left Side-Lying or Sim's Position
Which factors would contribute to stopping enema administration? - CORRECT
ANSWER - If bleeding occurs, abdomen becomes rigid and distended, pain occurs, or
resistance is felt
Which enema solution is the safest for administration because it does NOT create a danger for
excess fluid absorption? - CORRECT ANSWER - Normal Saline [Isotonic Solution]
Which enema solution is contraindicated in patients who are dehydrated or young infants
because of risk for fluid imbalance? - CORRECT ANSWER - Hypertonic Solution
Which enema solution is considered to be hypotonic and should NOT be repeated because of the
risk of water toxicity or circulatory overload if and because the body absorbs excessive amounts
of water? - CORRECT ANSWER - Tap Water [Hypotonic Solution]
Which enema solution lubricates the rectum and allows the feces to absorb the oil making them
soft and easier to pass? - CORRECT ANSWER - Oil Retention
Which enema solution creates intestinal irritation to stimulate peristalsis by using castile soap? -
CORRECT ANSWER - Soapsuds
Which enema solution should used in caution in pregnant women and elderly because it may
cause an electrolyte imbalance or damage to intestinal mucosa? - CORRECT ANSWER -
Soapsuds
Which laboratory test is used to measure microscopic amounts of blood in the feces (blood that
cannot be seen) - CORRECT ANSWER - Guaiac Fecal Occult Blood Test
,Repeat the test at least three times while the patient refrains from ingesting foods (e.g., some raw
vegetables, red meat, poultry, fish) and medications (e.g., vitamin C, aspirin, non steroidal anti-
inflammatory drugs) that cause false-positive results
(Potter 1100)
When analyzing a fecal specimens for ova and parasites, what is required of the stool? -
CORRECT ANSWER - The stool MUST be warm.
If the stool specimen remains at room temperature, bacteriological changes can alter the test
results
Which cathartic form is most effective because of its stimulant effect on the rectal mucosa
(Example: Dulcolax)? - CORRECT ANSWER - Cathartic Suppositories
Which foods induce a constipating effect? - CORRECT ANSWER - cheese, lean meats,
eggs, and pasta
Which food induce a laxative effect? - CORRECT ANSWER - fruits, vegetables, bran,
chocolate, alcohol, and coffee
What are the assessment findings of a normal stoma? - CORRECT ANSWER - bright pink
or brick red
Notify HCP of stoma is blue, purple, brown, or black which indicates circulation problem to the
stoma
How does the nurse measure the length of the NG tube for insertion? - CORRECT
ANSWER - Tip of the nose --> earlobe --> xiphoid process
, What is the most reliable method of verification for placement of the NG tube? - CORRECT
ANSWER - X-ray
Other methods include: pH test (aspirate and inspect color)
What are the ranges for body mass index? - CORRECT ANSWER - Normal = 19-24
Overweight = 25-29
Obese = 30-39
Extremely Obese = > 40
When energy requirements are completely met or EQUALS kcal intake in food what occurs? -
CORRECT ANSWER - Weight does not change
When kcal intake in food is LESS THAN energy requirements what occurs? - CORRECT
ANSWER - Loose weight
When kcal intake in food is GREATER THAN energy requirements what occurs? - CORRECT
ANSWER - Gain weight
Nutrients are absorbed in what portion of the digestive tract? - CORRECT ANSWER -
Small intestine [duodenum]
Proteins are necessary for _________ balance - CORRECT ANSWER - Positive protein
and nitrogen balance for healing, growth, and tissue repair
1 gram of carbohydrates = ____ kcal - CORRECT ANSWER - 4 kcal
1 gram of fat = ____ kcal - CORRECT ANSWER - 9 kcal
UPDATED ACTUAL Questions and
CORRECT Answers
What is the most effective method to prevent the transfer of clostridium difficile (C. Difficile) ? -
CORRECT ANSWER - HAND HYGIENE with soap and water is effective to physically
remove C. difficile spores from the hands. (Potter 1092)
What is the term for the [abnormal] method used to assist in stool passage by exerting pressure to
expel fecal matter through voluntary contraction of the abdominal muscles while maintaining a
forced expiration against a closed airway? - CORRECT ANSWER - Valsalva Manuever
*Normal passage of bowels should be painless, passing soft formed stool*
Which patients are at greatest risk for cardiac dysrhythmia and high blood pressure with the
Valsalva manuever and MUST avoid straining to pass stool? - CORRECT ANSWER -
Patients with cardiovascular disease, glaucoma, increased intracranial pressure, or a new surgical
wound
(Potter 1089)
What is the term for a collection of hardened feces in the rectum that cannot be expelled due to
unrelieved constipation? - CORRECT ANSWER - Fecal Impaction
Where does fecal impaction occur in the colon? - CORRECT ANSWER - Rectum
Least formed stool is present in which portion of the digestive tract? - CORRECT
ANSWER - Ascending Colon
Most formed stool is present in which portion of the digestive tract? - CORRECT
ANSWER - Descending Colon
,Which position should the patient be in while administering an enema? - CORRECT
ANSWER - Left Side-Lying or Sim's Position
Which factors would contribute to stopping enema administration? - CORRECT
ANSWER - If bleeding occurs, abdomen becomes rigid and distended, pain occurs, or
resistance is felt
Which enema solution is the safest for administration because it does NOT create a danger for
excess fluid absorption? - CORRECT ANSWER - Normal Saline [Isotonic Solution]
Which enema solution is contraindicated in patients who are dehydrated or young infants
because of risk for fluid imbalance? - CORRECT ANSWER - Hypertonic Solution
Which enema solution is considered to be hypotonic and should NOT be repeated because of the
risk of water toxicity or circulatory overload if and because the body absorbs excessive amounts
of water? - CORRECT ANSWER - Tap Water [Hypotonic Solution]
Which enema solution lubricates the rectum and allows the feces to absorb the oil making them
soft and easier to pass? - CORRECT ANSWER - Oil Retention
Which enema solution creates intestinal irritation to stimulate peristalsis by using castile soap? -
CORRECT ANSWER - Soapsuds
Which enema solution should used in caution in pregnant women and elderly because it may
cause an electrolyte imbalance or damage to intestinal mucosa? - CORRECT ANSWER -
Soapsuds
Which laboratory test is used to measure microscopic amounts of blood in the feces (blood that
cannot be seen) - CORRECT ANSWER - Guaiac Fecal Occult Blood Test
,Repeat the test at least three times while the patient refrains from ingesting foods (e.g., some raw
vegetables, red meat, poultry, fish) and medications (e.g., vitamin C, aspirin, non steroidal anti-
inflammatory drugs) that cause false-positive results
(Potter 1100)
When analyzing a fecal specimens for ova and parasites, what is required of the stool? -
CORRECT ANSWER - The stool MUST be warm.
If the stool specimen remains at room temperature, bacteriological changes can alter the test
results
Which cathartic form is most effective because of its stimulant effect on the rectal mucosa
(Example: Dulcolax)? - CORRECT ANSWER - Cathartic Suppositories
Which foods induce a constipating effect? - CORRECT ANSWER - cheese, lean meats,
eggs, and pasta
Which food induce a laxative effect? - CORRECT ANSWER - fruits, vegetables, bran,
chocolate, alcohol, and coffee
What are the assessment findings of a normal stoma? - CORRECT ANSWER - bright pink
or brick red
Notify HCP of stoma is blue, purple, brown, or black which indicates circulation problem to the
stoma
How does the nurse measure the length of the NG tube for insertion? - CORRECT
ANSWER - Tip of the nose --> earlobe --> xiphoid process
, What is the most reliable method of verification for placement of the NG tube? - CORRECT
ANSWER - X-ray
Other methods include: pH test (aspirate and inspect color)
What are the ranges for body mass index? - CORRECT ANSWER - Normal = 19-24
Overweight = 25-29
Obese = 30-39
Extremely Obese = > 40
When energy requirements are completely met or EQUALS kcal intake in food what occurs? -
CORRECT ANSWER - Weight does not change
When kcal intake in food is LESS THAN energy requirements what occurs? - CORRECT
ANSWER - Loose weight
When kcal intake in food is GREATER THAN energy requirements what occurs? - CORRECT
ANSWER - Gain weight
Nutrients are absorbed in what portion of the digestive tract? - CORRECT ANSWER -
Small intestine [duodenum]
Proteins are necessary for _________ balance - CORRECT ANSWER - Positive protein
and nitrogen balance for healing, growth, and tissue repair
1 gram of carbohydrates = ____ kcal - CORRECT ANSWER - 4 kcal
1 gram of fat = ____ kcal - CORRECT ANSWER - 9 kcal
