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    Exam Review

    1. The nurse notes that a client with a Foley catheter has a distended bladder and no urine output for the past 3 hours. What is the first action?
      A)
      Remove and reinsert the catheter
      B)
      Notify the healthcare provider
      C)
      Assess tubing for kinks or obstruction
      D)
      Increase the client's oral fluid intake
    2. The nurse is caring for a client with a colostomy. What should the nurse expect the stool to look like?
      A)
      Scrotal-shaped stool
      B)
      Formed stool
      C)
      Loose stool
      D)
      Liquid stool
    3. A nurse is caring for a client with pseudoconstipation. What can cause pseudoconstipation in a client?
      A)
      Insufficient fluid intake
      B)
      Eating fruits and vegetables
      C)
      Overuse of suppositories
      D)
      Intake of fibrous foods
    4. An older adult client's small bowel obstruction has resolved, and the intestinal decompression tube has been prescribed for removal. When performing this nursing action, what should the nurse prioritize when removing a nasointestinal tube?
      A)
      Aspirate the tube while removing it in order to normalize pressure.
      B)
      Change from continuous to intermittent suction during removal.
      C)
      Remove the tube slowly to avoid injuring the client.
      D)
      Instill a small amount of water to provide lubrication while withdrawing the tube.
    Page 1 of 7

    Exam Review

    1. A client tells the nurse, "I increased my fiber, but I am still very constipated." What additional information should the nurse provide to the client?
      A)
      "Well, that shouldn't happen. Let me recommend a good laxative for you."
      B)
      "Just give it a few more weeks and you should be fine."
      C)
      "I will tell the doctor you are having problems. Maybe he can help."
      D)
      "When you increase fiber in your diet, you also need to increase fluids."
    2. A nurse understands that which of the following will happen if the volume of tube feeding through a G-tube exceeds the client's stomach's physiologic capacity?
      A)
      Gastric reflux
      B)
      Obesity
      C)
      Pallor
      D)
      Diarrhea
    3. A 60-year-old client is experiencing pain that can be attributed to distension of the veins in her rectum. What condition is this client most likely experiencing?
      A)
      Diarrhea
      B)
      Bowel obstruction
      C)
      Hemorrhoids
      D)
      Aspiration
    4. The nurse understands the primary purpose of inserting an orogastric tube is which one of the following?
      A)
      To provide long-term enteral nutrition
      B)
      To control constipation
      C)
      To prevent vomiting, aspiration, and intestinal distention post endotracheal intubation
      D)
      To provide short-term enteral nutrition
    Page 2 of 7

    Exam Review

    1. A 60-year-old client is experiencing pain that can be attributed to distension of the veins in her rectum. What condition is this client most likely experiencing?
      A)
      Diarrhea
      B)
      Bowel obstruction
      C)
      Hemorrhoids
      D)
      Aspiration
    2. The nurse is caring for a client with an ostomy. The nurse understands the need to monitor closely for which of the following?
      A)
      Decreased output
      B)
      Constipation
      C)
      Peristomal skin breakdown
      D)
      Urinary retention
    3. A client is receiving enteral feeding due to progressive weight loss and dysphagia. The nurse understands which is the priority nursing diagnosis for this client:
      A)
      Impaired nutrition: greater than body requirement
      B)
      Impaired mobility
      C)
      Risk for aspiration
      D)
      Risk for falls
    4. A nurse administers a prescribed hypertonic saline enema to a client with constipation. Which is a function of hypertonic saline enema?
      A)
      Promotes bowel movement due to irritation effects
      B)
      Lubricates and softens the stool
      C)
      Draws fluid from body tissues into the bowel
      D)
      Causes chemical irritation of the mucous membranes
    Page 3 of 7

    Exam Review

    1. A nurse is caring for a client with an ileostomy. The nurse understands the need to monitor closely for which of the following?
      A)
      Increased urine output
      B)
      Constipation
      C)
      Dysuria
      D)
      Peristomal skin breakdown
    2. Which nursing intervention is correct for a client with an indwelling urinary catheter?
      A)
      Keep the drainage bag on top of the bed during repositioning
      B)
      Irrigate the catheter every 2 hours to maintain patency
      C)
      Secure the catheter tubing to the client's inner thigh
      D)
      Empty the drainage bag when it is completely full
    3. A nurse is removing a client's Foley catheter. What instructions should be given to the client following removal of the catheter?
      A)
      "Call the nurse if you can't void within 1 hour of catheter being removed."
      B)
      "Limit fluid intake to 1 liter per day."
      C)
      "Report if your urine output is less than ___ mL in the next 24 hours."
      D)
      "Void within 6–8 hours and report any burning, urgency, or discomfort."
    4. A nurse understands that which of the following will happen if the volume of tube feeding through a G-tube exceeds the client's stomach's physiologic capacity?
      A)
      Gastric reflux
      B)
      Obesity
      C)
      Pallor
      D)
      Diarrhea
    Page 4 of 7

    Exam Review

    1. A nurse is preparing discharge instructions for a client with constipation. Which of the following suggestions should the nurse incorporate into the discharge instructions?
      A)
      Avoid fiber in the diet
      B)
      Decrease fluid intake
      C)
      Use laxative regularly
      D)
      Drink 8 to 10 glasses of liquid daily
    2. A nurse is assessing the nasal passages of a client before inserting a nasointestinal tube. Which finding excludes nostril use for tube insertion?
      A)
      Nasal growth
      B)
      Wide nasal passage
      C)
      Undeviated nasal septum
      D)
      Small growths or obstructions such as polyps
    3. A nurse has an order for continuous tube feedings via PEG tube. The order is for Jevity 50 mL per hour with an automatic water flush on a feeding pump. The nurse notes her unit is out of Jevity and is informed by central supply that the facility is out of this formula. The nurse should do which of the following actions?
      A)
      Administer only the water flush but hold the tube feeding until the ordered tube feeding is in stock
      B)
      Use Nutren as a replacement but double the rate from 50 mL per hour to 100 mL per hour
      C)
      Hold the tube feeding until the next day when the tube feed is expected to be in stock again
      D)
      Inform the physician and/or dietitian who ordered the tube feeding that it is unavailable
    4. A client is receiving enteral feeding due to progressive weight loss and dysphagia. The nurse understands which is the priority nursing diagnosis for this client:
      A)
      Impaired nutrition: greater than body requirement
      B)
      Impaired mobility
      C)
      Risk for aspiration
      D)
      Risk for falls
    Page 5 of 7

    Exam Review

    1. A nurse provides liquid nourishment 4 to 6 times a day in feedings of less than 30 minutes to a client being tube fed. To which of the following tube-feeding schedules is the nurse adhering?
      A)
      Cyclic
      B)
      Variable
      C)
      Continuous
      D)
      Bolus
    2. A nurse checks the placement of a nasogastric tube and aspirates fluid to test the pH. Which result would the nurse expect, indicating likely proper placement?
      A)
      pH 7
      B)
      pH 6
      C)
      pH 1–5
      D)
      pH 8
    3. A nurse is assessing a stoma of a client with a colostomy. Which finding would the nurse interpret as indicating that the stoma is healthy?
      A)
      Pallor in color
      B)
      Bluish color
      C)
      Pinkish to reddish color
      D)
      Yellowish color
    4. A nurse is caring for a client who recently had abdominal surgery. The client reports his stools are "very dark". Which nursing action is most appropriate at this time?
      A)
      Save a sample of the stool in a container
      B)
      Inform the client to report the occurrence if it happens again
      C)
      Send the stool sample to the laboratory
      D)
      Perform a hemoccult test of the stool
    Page 6 of 7