Transcript MCQs on Fundamentals of Nursing students 1

MCQ On Fundamentals of
Nursing 1
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
The answer is : 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. Which statement provides evidence that an older adult who is prone toconstipation 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.”
The answer is : 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
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
The answer is : 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. 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
The answer is : 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. 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.
The answer is : B.
pattern.
The client will return to his or her previous fecal elimination
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
6. A client with a new stoma who has not had a bowel movement since surgerylast 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.
The answer is : B.
surgeon.
After assessing the stoma and surrounding skin, notify the
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. 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
The answer is : 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. 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
The answer is : 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. 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
The answer is : 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. 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
The answer is : 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. 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
The answer is : 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. 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.”
The answer is : C.
every morning”
“I’m going to have to irrigate my stoma so I have a bowel movement
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
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.
The answer is : D.
solution.
Lower the solution container after instilling about 150 mL of
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
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
The answer is : 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
it’s 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
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.
The answer is : 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. 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
The answer is : 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. 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
The answer is : 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. 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
The answer is : 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. 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.
The answer is : 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. 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
The answer is : 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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