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Home NCLEX Practice Questions

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Fundamentals of Nursing NCLEX Practice

Quiz 7 (20 Items)
By

Gil Wayne, BSN, R.N.

January 25, 2016

0
 ADVERTISEMENT

Fundamentals of nursing involves basic things that a nurse has to do in the course of his or
her duty. This exam highlights the significance of the fundamental needs of humans and
competence in fundamental skillsas prerequisites to providing extensive nursing care.
Accomplish this 20-item NCLEX-style exam and do good on your actual NCLEX!

Failure defeats losers. Failure inspires Winners

~ Robert Kiyosaki

Topics

Topics or concepts included in this exam are:

 Various questions about Fundamentals of Nursing

Guidelines

To make the most out of this exam, follow the guidelines below:

 Read each question carefully and choose the best answer.

 You are given one minute per question. Spend your time wisely!
 Answers and rationales (if any) are given below. Be sure to read them.
 If you need more clarifications, please direct them to the comments section.

Questions

 EXAM MODE
 PRACTICE MODE
 TEXT MODE
In Text Mode: All questions and answers are given for reading and answering at your own
pace. You can also copy this exam and make a print out.

1. Clients should be taught that repeatedly ignoring the sensation of needing to

defecate could result in which of the following?

A. Constipation
B. Diarrhea
C. Incontinence
D. Hemorrhoids

2. Which statement provides evidence that an older adult who is prone to

constipation is in need of further teaching?

A. “I need to drink one and a half to 2 quarts of liquid each day.”

B. “I need to take a laxative such as milk of magnesia or if I don’t have a BM every day.”
C. “If my bowel pattern changes on its own, I should call you.”
D. “Eating my meals at regular times is likely to result in regular bowel movements.”

3. A client is scheduled for a colonoscopy. The nurse will provide information to the
client about which type of enema?

A. Oil retention
B. Return flow
C. High large volume
D. Low, small volume

4. The nurse is most likely to report which finding to the primary care provider for a
client who has an established colostomy?

A. The stoma extends 1/2 inch above the abdomen.

B. The skin under the appliance looks red briefly after removing the appliance.
C. The stoma color is a deep red purple.
D. An ascending colostomy just delivers liquid feces

5. Which goal is the most appropriate for clients with diarrhea related to ingestion of
an antibiotic for an upper respiratory infection?

A. The client will wear a medical alert bracelet for antibiotic allergy.
B. The client will return to his or her previous fecal elimination pattern.
C. The client verbalizes the need to take an antidiarrheal medication PRN.
D. The client will increase intake of insoluble fiber such as grains, rice, and cereals.

6. A client with a new stoma who has not had a bowel movement since surgery last
week reports feeling nauseous. What is the appropriate nursing action?

A. Prepare to irrigate the colostomy.

B. After assessing the stoma and surrounding skin, notify the surgeon.
C. Assess bowel sounds and administer antiemetic.
D. Administer a bulk forming laxative, and encourage increased fluids and exercise.

7. The nurse assesses a client’s abdomen several days after abdominal surgery. It is
firm, distended, and painful to palpate. The client reports feeling “bloated” the nurse
consult with the surgeon, who orders an enema. The nurse prepares to give what
kind of enema?

A. Soapsuds
B. Retention
C. Return flow
D. Oil retention

8. Which of the following is most likely to validate that a client is experiencing

intestinal bleeding?
A. Large quantities of fat mixed with pale yellow liquid stool.
B. Brown, formed stool.
C. Semi soft tar colored stools.
D. Narrow, Pencil shaped stool

9. Which nursing diagnoses is/are most applicable to a client with fecal

incontinence? Select all that apply.

A. Bowel incontinence
B. Risk for deficient fluid volume
C. Disturbed body image
D. Social isolation
E. Risk for impaired skin integrity

10. A nurse determines that a fracture bedpan should be used for the patient who:

A. has a spinal cord injury.

B. is on bedrest.
C. has dementia.
D. is obese

11. A patient with the diagnosis of diverticulosis is advised to eat a diet high in fiber.
What should the nurse recommend that the patient eat to best increase the bulk and
fecal material?

A. Whole wheat bread

B. White rice
C. Pasta
D. Kale

12. Which statement by a patient with an ileostomy alert the nurse to the need for
further education?
A. “I don’t expect to have much of a problem with fecal odor.”
B. “I will have to take special precaution to protect my skin around the stoma.”
C. “I’m going to have to irrigate my stoma so I have a bowel movement every morning.”
D. “I should avoid gas forming foods like beans to limit funny noises from the stoma.”

13. A practitioner orders a return flow enema (Harris flush drip) for an adult patient
with flatulence. When preparing to administer this enema The nurse compares the
steps of a return flow enema with cleansing enemas. What should the nurse do that
is unique to a return flow enema?

A. Lubricate the last 2 inches of the rectal tube.

B. Insert the rectal tube about 4 inches into the anus.
C. Raise the solution container about 12 inches above the anus.
D. Lower the solution container after instilling about 150 mL of solution.

14. A nurse discourages a patient from straining excessively when attempting to

have a bowel movement. What physiological response primarily may be prevented by
avoiding straining on defecation?

A. Incontinence
B. Dysrhythmias
C. Fecal impaction
D. Rectal hemorrhoids

15. A nurse is caring for a client who will perform fecal occult blood testing at home.
Which of the following information should the nurse include when explaining the
procedure to the client?

A. Eating more protein is optimal prior to testing.

B. One stool specimen is sufficient for testing.
C. A red color changes indicates a positive test.
D. The specimen cannot be contaminated with urine.
16. A nurse is talking with a client who reports constipation. When the nurse
discusses dietary changes that can help prevent constipation, which of the following
foods should the nurse recommend?

A. Macaroni and cheese

B. Fresh food and whole wheat toast
C. Rice pudding and ripe bananas
D. Roast chicken and white rice

17. A nurse is caring for a client who has diarrhea for the past four days. When
assessing a client, the nurse should expect which of the following findings? Select
all that apply.

A. Bradycardia
B. Hypotension
C. Fever
D. Poor skin turgor
E. Peripheral edema

18. A nurse is preparing to administer a cleansing enema to an adult client in

preparation for a diagnostic procedure. Which of the following are appropriate steps
for the nurse to take? Select all that apply.

A. Warm the enema solution prior to installation.

B. Position the client on the left side with the right leg flexed forward.
C. Lubricate the rectal tube or nozzle.
D. Slowly insert the rectal tube about 2 inches.
E. Hang the enema container 24 inches above the clients anus

19. While a nurse is administering a cleansing enema, the client reports abdominal
cramping. Which of the following is the appropriate intervention?
A. Have a client hold his breath briefly.
B. Discontinue the fluid installation.
C. Remind the client that cramping is common at this time.
D. Lower the enema fluid container.

20. A client with chronic pulmonary disease has a bluish tinge around the lips. The
nurse charts which term to most accurately describe the client’s condition?

A. Hypoxia
B. Hypoxemia
C. Dyspnea
D. Cyanosis

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Answers and Rationale

1. Answer: A. Constipation

Habitually ignoring the urge to defecate can lead to constipation through loss of the natural
urge and the accumulation of feces. Diarrhea will not result-if anything, there is increased
opportunity for water reabsorption because the stool remains in the colon, leading to firmer
stool. Ignoring the urge shows a strong voluntary sphincter, not a weak one that could result
in incontinence. Hemorrhoids would only occur only if severe drying out of the stool occurs,
and thus repeated need to strain to pass stool.

2. Answer: B. “I need to take a laxative such as milk of magnesium or if I don’t have a

BM every day”

The standard of practice in assisting the older adults to maintain normal function of the
gastrointestinal tract is regular ingestion of a well-balanced diet, adequate fluid intake, and
regular exercise. If the bowel pattern is not regular with these activities, this abnormality
should be reported. Stimulant laxatives can be very irritating and are not the preferred
treatment for occasional constipation in older adults. In addition, a normal stool pattern for
an older adult may not be daily elimination.

3. Answer: D. Low, small volume

Small volume enemas along with other preparations are used to prepare the client for this
procedure. An oil retention enema is used to soften hard stool. Return flow enemas help
expel flatus because of the risk of loss of fluid and electrolytes high,large volume enemas
are seldom used.

4. Answer: C. The stoma color is a deep red purple.

An established stoma should be dark pink like the color of the buccal mucosa and is slightly
raised above the abdomen. The skin under the appliance may remain pink/red for a while
after the adhesive is pulled off feces from an ascending ostomy are very liquid, less so from
a transverse ostomy, and more solid from a descending or sigmoid stoma.

5. Answer: B. The client will return to his or her previous fecal elimination pattern.

Once the cause of diarrhea has been identified and corrected, the client to return to his or
her previous elimination pattern. This is not an example of an allergy to the antibiotic but a
common consequence of overgrowth of bowel organisms not killed by the drug.
Antidiarrheal medications are usually prescribed according to the number of stools, not
routinely around the clock. Increasing intake of soluble fiber such as oatmeal or potatoes
may help absorb excess liquid and decrease the diarrhea, but insoluble fiber will not.

6. Answer: B. After assessing the stoma and surrounding skin, notify the surgeon.

The client has assessment findings consistent with complications of surgery. Option A:
irrigating the stoma is a dependent nursing action, and is also intervention without
appropriate assessment. Option C: assessing the peristomal skin area is an independent
action, but administering an antiemetic is an intervention without appropriate assessment.
antiemetics are generally ordered to treat immediate postoperative nausea, not several
days postoperative. Option D: administering a bulk forming laxative to a nauseated
postoperative client is contraindicated

7. Answer: C. Return flow

This provides relief of postoperative flatus, stimulating bowel motility. Options one, two, and
four manage constipation and do not provide flatus relief.

8. Answer: C. Semi soft tar colored stools.

Blood in the upper G.I. tract is black and tarry. Option one can be a sign of malabsorption in
an infant, option two is normal stool, and option four is characteristic of an obstructive
condition of the rectum.

9. Answer: A, C, D, and E

Option A is the most appropriate. The client is unable to decide when stool evacuation will
occur. In option C, client thoughts about self may be altered if unable to control stool
evacuation. In option E, increased tissue contact with fecal material may result in
impairment. Option B is more appropriate for a client with diarrhea. Incontinence is the
inability to control feces of normal consistency.

10. Answer: A. has a spinal cord injury.

A fracture bedpan has a low back that promotes function of the patient’s lower back while
on the bedpan.

11. Answer: D. Kale

Kayle is an excellent source of dietary fiber. A serving of 3 1/2 ounces of kale contain 6.6 g
of dietary fiber. One slice of whole wheat bread contains only 1.5 g of dietary fiber. A
serving of a 1/2 cup of white rice contains only 0.8 g of dietary fiber. A serving of 3 1/2
ounces of cooked pasta contains only 1.6 g of dietary fiber.

12. Answer: C. “I’m going to have to irrigate my stoma so I have a bowel movement
every morning”

This statement is inaccurate in relation to an ileostomy and indicates that the patient needs
more teaching. And ileostomy produces liquid fecal drainage that is constant and cannot be
regulated. The odor from drainage is minimal because fewer bacteria are present in the
ileum compared with the large intestine. And ileostomy is an opening into the ileum (distal
small intestine from the jejunum to the cecum). Cleansing the skin, skin barriers, and a well
fitted appliance are precautions to protect the skin around the ileostomy stoma. The
drainage from ileostomy contains enzymes that can damage the skin. An ileostomy stoma
does not have a sphincter that can control the flow of flatus or drainage, resulting in noise.

13. Answer: D. Lower the solution container after instilling about 150 mL of solution.

Lowering the container of solution create a siphon effect that pulls the instilled fluid back out
through the rectal tube into the solution container. The return flow promotes the evacuation
of gas from the intestines. This technique is used only with a return flow enema. All rectal
tube should be lubricated to facilitate entry of the tube into the anus and rectum and prevent
mucosal trauma.The anal canal is 1 to 2 inches long. Inserting the rectal tube 3 to 4 inches
ensures that the tip of the tube is beyond the anal Sphincter. This action is appropriate for
all types of enemas. The solution container should be raised no higher than 12 inches for all
enemas; this allows the solution to instill slowly, which limits discomfort and intestinal
spasms.

14. Answer: B. Dysrhythmias

Straining on defecation requires the person to hold the breath while bearing down. This
maneuver increases the intrathoracic and intracranial pressures, which can precipitate
dysrhythmias, brain attack, and respiratory difficulties; all of these can be life threatening.
The loss of the voluntary ability to control the passage of fecal or gaseous discharges
through the anus is caused by impaired functioning of the anal sphincter or its nerve supply,
not straining on defecation. Fecal impaction is caused by prolonged retention and the
accumulation of fecal material in the large intestine, not straining on defecation. Although
straining on defecation can contribute to the formation of hemorrhoids, this is not the
primary reason straining on defecation is discouraged. Hemorrhoids, although painful, are
not life-threatening.

15. Answer: D. The specimen cannot be contaminated with urine.

For fecal occult blood testing at home, the stool specimens cannot be contaminated with
water or urine. Some proteins such as red meat, fish, and poultry can alter the test results.
Three specimens from three different bowel movements are required. A blue color indicates
blood in the stool.

16. Answer: B. Fresh food and whole wheat toast.

A high fiber diet promotes normal bowel elimination. The choice of fruit and toast is the
highest fiber option. Macaroni and cheese is a low residue option that could actually worse
and constipation. Rice pudding and ripe bananas are low residue options that could actually
worsen constipation. Roast chicken and white rice or low residue options that could actually
worsen constipation.

17. Answer: B, C and D

Prolonged diarrhea lead to dehydration, which causes a decrease in blood pressure.

Prolonged diarrhea leads to dehydration, which causes fever. Prolonged diarrhea is more
likely to cause take a tachycardia than bradycardia. Peripheral edema results from a fluid
overload. Prolonged diarrhea is more likely to cause a fluid deficit.

18. Answer: A, B, and C

The nurse should warm the enema solution because cold fluid can cause abdominal
cramping and hot fluid can injure the intestinal mucosa. Option B allows a downward flow of
solution by gravity along the natural anatomical curve of the sigmoid colon. Lubrication
prevents trauma or irritation to the rectal mucosa. Option D is an appropriate length
of insertion for a child. For an adult client, the nurse should insert a tube 3 to 4 inches. The
height of the fluid container affects the speed of installation. The maximum recommended
height is 18 inches. Hanging the container higher than that could cause rapid installation
and possibly painful distention of the colon.

19. Answer: D. Lower the enema fluid container.

To relieve the client’s discomfort, the nurse should slow the rate of installation by reducing
the height of the enema solution container. Taking slow, deep breaths is more therapeutic
for easing discomfort than holding the breath. The nurse should stop the installation if the
client’s abdomen becomes a rigid and distended or if the nurse notes bleeding from the
rectum.
Option C is not therapeutic as it implies that the client must tolerate the discomfort and that
the nurse cannot or will not do anything to ease it.

20. Answer: D. Cyanosis

A bluish tinge to mucous membranes is called cyanosis. This is most accurate because it is
what the nurse observes. The nurse can only observe signs/symptoms of hypoxia. More
information is needed to validate this conclusion. Hypoxemia requires blood oxygenation
saturation data to be confirmed and dyspnea is difficulty breathing.

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Last updated on April 10, 2019

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 Gil Wayne, BSN, R.N.
https://nurseslabs.com

Gil Wayne graduated in 2008 with a bachelor of science in nursing and during the same year,
earned his license to practice as a registered nurse. His drive for educating people stemmed from
working as a community health nurse where he conducted first aid training and health seminars and
workshops to teachers, community members, and local groups. Wanting to reach a bigger audience
in teaching, he is now a writer and contributor for Nurseslabs since 2012 while working part-time as
a nurse instructor. His goal is to expand his horizon in nursing-related topics, as he wants to guide
the next generation of nurses to achieve their goals and empower the nursing profession.

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