NRS - FUNDAMENTALS OF NURSING - QUIZ

QUESTIONS FOR EXAM 2 2025

A dietitian is providing an in-service for the nurses on a

medical-surgical unit. During the in-service, the dietitian
informs the group that there are six classes of nutrients, and
three supply the body with energy. What are the three sources of
energy? - Precise Answer ✔✔carbohydrates, protein, and lipids

Explanation:
Of the six classes of nutrients, three supply energy
(carbohydrates, protein, and lipids), and three are needed to
regulate body processes (vitamins, minerals, and water).

In planning to meet the nutritional needs of a critically ill client

in the intensive care unit, which factor will increase the client's
basal metabolic rate? - Precise Answer ✔✔Infection

Explanation:
Factors that increase a person's basal metabolic rate (BMR)
include growth, infections, fever, emotional tension, extreme
environmental temperatures, and elevated levels of certain
hormones (epinephrine and thyroid hormones). Aging,
prolonged fasting, and sleep all decrease BMR.
The nurse caring for a client for several days has assessed that
the client has been eating poorly during this hospitalization.
Which nursing measure should the nurse implement to assist the
client in improving the client's nutritional intake? - Precise
Answer ✔✔Encourage the client's adult child to prepare food at
home and bring it to the client.

Explanation:
The nurse should solicit food preferences and encourage favorite
foods from home, when possible. Be sure the foods look
attractive and the eating area is free of odors, clutter, and
distractions during mealtime. Provide small, frequent meals to
avoid overwhelming the client with large amounts of food.

A client tells the nurse, "As long as I only eat 2,400 calories per
day, it does not matter which foods I eat." Which response by
the nurse is best? - Precise Answer ✔✔"Can you share an
example of what you ate yesterday?"

Explanation:
Healthy adult client on average require 1,800 to 2,400 cal/day.
Unless the caloric intake includes an appropriate mix of
proteins, carbohydrates, and fats, the person may be marginally
nourished or malnourished. In other words, consuming 2,400
calories of chocolate, exclusive of any other food, is not
adequate to sustain a healthy state. By asking the client for an
example of the foods eaten, the nurse can help the client plan
effectively. It is important to teach clients about healthy
nutrition, so this response is most appropriate. The other
responses from the nurse are not correct.

Most nutritionists recommend having a proper amount of fiber

in the diet. In addition to other benefits, how does fiber affect
cholesterol? - Precise Answer ✔✔increases fecal excretion of
cholesterol

To help lower serum cholesterol levels, researchers recommend

limiting cholesterol intake, eating less total fat, eating more
unsaturated fat, and increasing fiber intake. Fiber increases fecal
excretion of cholesterol. Eating fats high in saturated fats and
triglycerides raises blood cholesterol levels.

A client with urine retention related to a complete prostatic

obstruction requires a urinary catheter to drain the bladder.
Which type of catheter is most appropriate for a client that has
an obstructed urethra? - Precise Answer ✔✔suprapubic catheter

A suprapubic catheter is used for long-term continuous drainage

and is inserted through a small incision above the pubic area.
Suprapubic bladder drainage diverts urine from the urethra when
injury, stricture, prostatic obstruction, or abdominal surgery has
compromised the flow of urine through the urethra. An
indwelling urethral catheter, straight, and intermittent urethral
catheter is placed in the urethra.

The nurse is attempting to insert a urinary catheter into a female

client's bladder and realizes the catheter has been inserted into
the vagina. Which action is most appropriate? - Precise Answer
✔✔Leave the catheter in place as a marker and attempt to insert
a new sterile catheter directly above the misplaced catheter.

Explanation:

Leaving the catheter in place as a marker assists in the correct

placement of the second catheter into the bladder. It is not
necessary to contact the health care provider. The vagina is not
sterile, so insertion of a sterile catheter poses little risk for
infection. Asking the client to bear down is not necessary
because the catheter is not typically completely inserted.
Removing the catheter from the vagina and attempting to insert
it into the bladder will cause cross-contamination.

Which of the following describes the term micturition? - Precise

Answer ✔✔emptying the bladder
Explanation:
The process of emptying the bladder is known as urination,
micturition, or voiding. Catheterizing the bladder is when a
urinary catheter is placed inside the urethra. Collecting a urine
specimen can be by clean catch or by use of a urinary catheter.
Incontinence is when a client voids on oneself.

A nurse is caring for older adult clients in an assisted-living

facility. Which effect of aging should the nurse consider when
performing a urinary assessment? - Precise Answer
✔✔Decreased bladder contractility may lead to urine retention
and stasis, which increase the likelihood of urinary tract
infection.

Explanation:
Decreased bladder contractility may lead to urine retention and
stasis, which increase the likelihood of urinary tract infection.
The diminished ability of the kidneys to concentrate urine may
result in nocturia (urination during the night). Decreased bladder
muscle tone may reduce the capacity of the bladder to hold
urine, resulting in increased frequency of urination.
Neuromuscular problems, degenerative joint problems,
alterations in thought processes, and weakness may interfere
with voluntary control and the ability to reach a toilet in time.
Individuals who view themselves as old, powerless, and
neglected may cease to value voluntary control over urination,
and simply find toileting too much bother no matter what the
setting. Incontinence may be the result.

A nurse is assessing the urine output of a client with Parkinson

disease who is on levodopa. Which sign is a common finding for
a client on this medication? - Precise Answer ✔✔The urine may
be brown or black.

Explanation:
Levodopa, an antiparkinsonian drug, and injectable iron
compounds can lead to brown or black urine. Anticoagulants
may cause hematuria (blood in the urine), leading to a pink or
red color. Diuretics can lighten the color of urine to pale yellow.
Phenazopyridine, a urinary tract analgesic, can cause orange or
orange-red urine.

The nurse cares for a client with a chronic neurologic condition

that decreases the peristalsis. What concern will the nurse use to
plan care for this client's most likely risk? - Precise Answer
✔✔constipation

Explanation:
Constipation related to decreased peristalsis is the best concern
for this client's care planning. Peristalsis is defined as the
contractions of the circular and longitudinal muscles of the
intestine. Decreased peristalsis will result in constipation
because the movement of the fecal mass will occur at a slower
rate and more fluid will be absorbed in the colon. Fluid intake
issues would be secondary to the primary cause. Diarrhea does
not result from peristalsis.

During defecation, the client experiences decreased cardiac

output related to the Valsalva maneuver. After the Valsalva
maneuver, the nurse assesses the client's vital signs and expects
to observe which of the following? - Precise Answer ✔✔a
slowing of client's heart rate

Explanation:
When an individual bears down to defecate, the increased
pressures in the abdominal and thoracic cavities result in a
decreased blood flow and a temporary decrease in cardiac
output. Once bearing down ceases, the pressure is lessened, and
a larger than normal amount of blood returns to the heart. This
act may cause the heart rate to slow (vagal response) and result
in syncope in some clients.

Which type of stool would the nurse assess in a client with an

illness that causes the stool to pass through the large intestine
quickly? - Precise Answer ✔✔soft, watery
Explanation:
About 800 to 1,000 mL of liquid is absorbed daily by the large
intestine. When absorption does not occur properly, such as
when the waste products pass through the large intestine rapidly,
the stool is soft and watery. A hard formed stool is likely due to
slow or sluggish colon muscle contractions resulting in stool
moving slowly through the intestine. Black and tarry stool is
indicative of bleeding within the upper gastrointestinal tract. A
dry, odorous stool is commonly caused by conditions resulting
in malabsorption.

What are two essential techniques when collecting a stool

specimen? - Precise Answer ✔✔hand hygiene and wearing
gloves

Explanation:
Use of medical aseptic techniques when collecting a stool
specimen is imperative. Hand hygiene, before and after wearing
rubber gloves, is essential. Policy and selection of containers do
not concern technique. Goggles and isolation gowns are not
essential techniques for stool sample collection. No touch
method and the use of toilet paper are not essential techniques of
stool specimen collection.

What is fecal occult blood? - Precise Answer ✔✔blood that

cannot be seen
Explanation:
Fecal occult blood is blood that is hidden in the specimen or
cannot be seen on gross examination. It can be detected with
simple screening tests, such as a benzidine-based tests.
Hematochezia is bright red blood. Melena is dark red/almost
black colored blood. Bloody mucus in stool is not occult.

A client reports taking laxatives every day but the client is still
constipated. The nurse's response is based on which reasoning? -
Precise Answer ✔✔Habitual laxative use is the most common
cause of chronic constipation.

Explanation:
Occasional use of laxatives is not harmful for most people, but
clients should not become dependent on them. Although many
people do take laxatives because they believe they are
constipated, most are unaware that habitual use of laxatives is
the most common cause of chronic constipation.

The nurse is preparing to administer an intermittent feeding to a

client who has a nasogastric feeding tube. Place the following
steps in the correct order. Use all options. - Precise Answer
✔✔Position the client with the head of bed elevated 30 to 45°
degrees.
Verify correct tube placement.
Aspirate all gastric contents.
Verify that gastric residual volume is less than 200 mL.
Flush the tube with 30 mL water.
Administer the feeding.

Explanation:
Elevating the head of the bed 30 to 45° degrees minimizes the
possibility of aspiration into the trachea. Verifying correct tube
placement ensures that the formula is being delivered to the
stomach appropriately. The nurse should aspirate all gastric
contents with the syringe and measure to check for gastric
residual, the amount of feeding remaining in the stomach from
the previous feeding. This is done to identify delayed gastric
emptying. High gastric residual volumes (200 to 250 mL or
greater) can be associated with high risk for aspiration and
aspiration-related pneumonia, so feedings should be held if
residual volumes exceed 200 mL on two successive assessments.
Flushing the tube prevents occlusion.

A nurse is caring for a client with a gastrostomy tube in place.

Which is an accurate guideline for care of the insertion site? -
Precise Answer ✔✔If the gastric tube insertion site has healed
and the sutures are removed, use soap and water to clean the
site.
Explanation:
If the gastric tube insertion site has healed and the sutures are
removed, wet a washcloth and apply a small amount of soap
onto it. Gently cleanse around the insertion site, removing any
crust or drainage. If the gastrostomy tube is new and still has
sutures holding it in place, dip a cotton-tipped applicator into
sterile saline solution and gently clean around the insertion site,
removing any crust or drainage. Avoid adjusting or lifting the
external disk for the first few days after placement, except to
clean the area.

A nurse is caring for a client who has a malabsorption disease.

The nurse should understand that which structure in the
gastrointestinal system absorbs the majority of digested food and
minerals? - Precise Answer ✔✔Small intestine

Explanation:
Most absorption of digested food and minerals occurs in the
small intestines. The stomach is responsible for storing food,
secreting digestive enzymes, and digestion. The large intestine
forms feces and absorbs water to regulate the consistency of
stool. The digestive function of the liver is the production of
bile.
The nurse is reviewing a client's most recent laboratory results,
which reveal increases in hematocrit, creatinine, and blood urea
nitrogen (BUN). After collaborating with the interdisciplinary
team, what intervention is most appropriate? - Precise Answer
✔✔Increase the client's fluid intake.

Explanation:
Dehydration can cause increases in hematocrit, BUN, and
creatinine. Calorie restriction, increased protein intake, and TPN
are not indicated by these laboratory data.

An emergency room nurse is auscultating the chest of a child

who is having an asthmatic attack. Auscultation reveals the
presence of wheezes. During what part of respirations do
wheezes occur? - Precise Answer ✔✔inspiration and expiration

Wheezes are continuous sounds heard on expiration and

sometimes on inspiration. They originate as air passes through
airways constricted by swelling (as in asthma), secretions, or
tumors. Coughing, by forcing air out of the lungs under high
pressure, attempts to clear the throat of foreign particles.

The nurse provides care for the client with chronic obstructive
pulmonary disease experiencing hypoxia. Which assessment
prompts the nurse to immediately report findings to the health
care provider? - Precise Answer ✔✔Decreased level of
consciousness

Explanation:
If a problem exists in ventilation, respiration, or perfusion,
hypoxia (a condition in which an inadequate amount of oxygen
is available to cells) may occur. The nurse providing care for the
client with chronic obstructive pulmonary disease experiencing
hypoxia will immediately report the client's decreased level of
consciousness to the health care provider because it may
indicate severe respiratory distress including respiratory failure.
The findings of cyanosis, wheezing, and frequent coughing may
not be a change from the client's usual condition.

A nurse is teaching a preoperative client how to use an incentive

spirometer. Which instruction should be included in the teaching
plan? - Precise Answer ✔✔Insnhale slowly and as deeply as
possible through the mouthpiece without using the nose.

Explanation:
The client using an incentive spirometer should exhale normally
and place the lips around the mouthpiece; inhale slowly and
deeply without using the nose; and, when unable to inhale
anymore, hold their breath and count to 3 before exhaling
normally. This should be performed 5 to 10 times every 1 to 2
hours, if possible.
A nurse is explaining a chest tube to family members who do not
understand where it is placed. What would the nurse tell them? -
Precise Answer ✔✔"It is inserted into the space between the
lining of the lungs and the ribs."

Explanation:
A nurse can teach the client that a chest tube is a firm plastic
tube with drainage holes in the proximal end that is inserted into
the pleural space, thus allowing compressed lung tissue to re-
expand. The nurse does not need to contact the health care
provider for information.

The nurse is caring for a postoperative adult client who has

developed pneumonia. The nurse should assess the client
frequently for symptoms of: - Precise Answer ✔✔atelectasis.

Explanation:
Stiffer lungs tend to collapse and also cause their alveoli to
collapse. This condition is called atelectasis.

Which client would be classified as having chronic pain? -

Precise Answer ✔✔a client with rheumatoid arthritis
Explanation:
Chronic pain is pain that may be limited, intermittent, or
persistent but that lasts beyond the normal healing period. Acute
pain is generally rapid in onset and varies in intensity from mild
to severe. After its underlying cause is resolved, acute pain
disappears. It should end once healing occurs. A client with
rheumatoid arthritis has chronic pain derived by the
inflammatory process in the joints. Pneumonia is an acute
problem that generally does not have pain associated with it.
Controlled hypertension does not have any pain associated with
it. Flu, in the beginning stages, can have acute pain and not
chronic pain associated with it.

A client who had a recent amputation below the knee tells the
nurse about feeling as though the toes are cramping in the
missing leg. Which statement will the nurse use to educate the
client? - Precise Answer ✔✔"That is called phantom pain and it
is not unusual."

Explanation:
Phantom limb pain refers to the ongoing painful sensations that
seem to be coming from the part of limb that is no longer there.
This type of pain, where receptors and nerves are clearly absent,
is a real experience for the client. Informing the client that this
type of pain is common can help reduce anxiety. Diminishing
what the client is saying, such as, "that is all in your mind" and
"that is strange" will not help to reassure the client. Medications
may be used to manage this type of pain. Other treatments may
include acupuncture or transcutaneous electrical nerve
stimulation (TENS) therapy.

A client visits the health care facility for a scheduled physical

assessment. What should the nurse do when physically assessing
the quality of the client's oxygenation? Select all that apply. -
Precise Answer ✔✔Monitor the client's respiratory rate.
Check the symmetry of the client's chest.
Observe the breathing pattern and effort.

Explanation:
When physically assessing the quality of the client's
oxygenation, the nurse should monitor the client's respiratory
rate, check the symmetry of the client's chest, and observe the
breathing pattern and effort of the client. The nurse should also
auscultate for lung sounds. Additional assessments include
recording the heart rate and blood pressure, determining the
client's level of consciousness, and observing the color of the
skin, mucous membranes, lips, and nail beds. During the
physical assessment, the nurse does not note the amount of
oxygen administered to the client or check the device that is
used to deliver oxygen to the client.
A nurse is assessing a client on the first day after major
abdominal surgery. Which of the following internal stimuli
would be increased and affect client responses? - Precise
Answer ✔✔Intravenous lines, pain

Explanation:
When assessing a client at risk for increased sensory stimulation,
it is important to consider both internal and external stimuli that
may cause sensory overload. Invasive treatments, such as
intravenous lines, and pain are internal stimuli and affect the
client early in the hospitalization. Lights, noise, visitors,
ambulation and coughing are external stimuli.

A nurse is delivering oxygen to a client via an oxygen mask.

Which guideline is recommended for this procedure? - Precise
Answer ✔✔Remove the mask and dry the skin every 2 to 3
hours if the oxygen is running continuously.

Explanation:
To apply an oxygen mask, position the facemask over the
client's nose and mouth and adjust the elastic strap so that the
mask fits snugly but comfortably on the face. For a mask with a
reservoir, be sure to allow oxygen to fill the bag before
proceeding with application. Remove the mask and dry the skin
every 2 to 3 hours if the oxygen is running continuously, and do
not use powder around the mask.
A client with cancer pain is taking morphine for pain relief.
Knowing constipation is a common side effect, what would the
nurse recommend to the client? - Precise Answer ✔✔"Increase
fluids and high-fiber foods, and use a mild laxative."

Explanation:
The most common side effects associated with opioids (e.g.,
morphine) are sedation, nausea, and constipation. If constipation
persists, it usually responds to treatment with increased fluids
and fiber, and use of a mild laxative. For many clients,
constipation makes the client irritable, so instructing about this
side effect is important for the nurse. Taking the medication only
for severe pain is not appropriate to instruct the client.
Administering an enema every third day is inappropriate.

A nurse uses a nasal cannula to deliver oxygen to a client who is

extremely hypoxic and has been diagnosed with chronic lung
disease. What is the most important thing to remember when
using a nasal cannula? - Precise Answer ✔✔It can cause the
nasal mucosa to dry in case of high flow.

Explanation:
When using a nasal cannula to deliver oxygen to a client, the
nurse should remember that the nasal cannula can cause the
nasal mucosa to dry in case of high oxygen flow. A simple mask
can cause anxiety in clients who are claustrophobic. Clients
using a partial rebreather mask are at risk of suffocation. A face
tent may deliver an inconsistent amount of oxygen, depending
on environmental loss.

In which health care setting is a client more likely to be at risk

for sensory deprivation? - Precise Answer ✔✔Long-term care

Explanation:
Sensory deprivation occurs when a client experiences decreased
sensory input or input that is monotonous, unpatterned, or
meaningless. In this question, clients in long-term care would be
most at risk for sensory deprivation.

A nurse documents the following on a client chart: "Client

exhibits difficulties with spatial orientation, memory, language,
and changes in personality." What state of arousal/awareness
does this describe? - Precise Answer ✔✔Dementia

Explanation:
Difficulties with spatial orientation, memory, language, and
changes in personality occur with dementia. Disorientation,
restlessness, confusion, hallucinations, and agitation, alternating
with other conscious states, occurs with delirium. In confusion,
the client manifests reduced awareness, is easily distracted,
easily startled by sensory stimuli, and alternates between
drowsiness and excitability. In locked-in syndrome, the client
displays full consciousness, sleep-wake cycles are present, and
auditory and visual function and emotions are preserved.

The nurse caring for a client with emphysema has determined

that a priority nursing concern for this client is the risk for
malnutrition related to difficulty breathing while eating. Which
nursing intervention is appropriate to include in the client's care
plan? - Precise Answer ✔✔Provide six small meals daily.

Explanation:
Emphysema causes an increase in metabolic demand, which
increases caloric intake. In addition, the diaphragm will impact
the lung capacity. Therefore, the nurse should consider
providing six small meals distributed over the course of the day
instead of three large meals. Meals should be eaten 1 to 2 hours
after breathing treatments and exercises to allow for rest, which
decreases the metabolic demand.

The ambulatory client is scheduled for a thoracentesis to be

performed at the bedside. What actions would the nurse take for
this procedure? Select all that apply. - Precise Answer
✔✔Ensure a consent form has been signed for the thoracentesis.
Assess the client for respiratory distress postprocedure.
Obtain a thoracentesis tray, a local anesthetic, and a partial
vacuum bottle.

For a thoracentesis, the nurse ensures a consent form has been

signed, obtains supplies for the procedure (thoracentesis tray, a
local anesthetic, and a partial vacuum bottle), and assesses the
client for respiratory distress postprocedure. The nurse would
instruct the client to breathe normally, not deeply, during the
procedure. The nurse would assist the client to a sitting position
on the edge of the bed with the legs supported and the arms
folded on a pillow on the bedside table.

The home care nurse visits a client who has dyspnea. The nurse
notes the client has pitting edema in his feet and ankles. Which
additional assessment would the nurse expect to observe? -
Precise Answer ✔✔Crackles in the lower lobes

Explanation:
People with chronic heart failure often experience shortness of
breath because of excess fluid in the lungs and low oxygen
levels. Stridor is associated with respiratory infections such as
croup. Wheezing may be heard in individuals who use tobacco
products.
What type of cognitive responses might a nurse assess in a client
with sensory deprivation? - Precise Answer ✔✔decreased
attention span, difficulty problem solving

Explanation:
Cognitive responses to sensory deprivation include an inability
to control thoughts, decreased attention span, and difficulty with
memory, problem solving, and task performance. Mood
changes, anxiety, and depression are psychological responses to
sensory deprivation.

A nurse is caring for a client with pneumonia. The client's

oxygen saturation is below normal. What abnormal respiratory
process does this demonstrate? - Precise Answer ✔✔changes in
the alveolar-capillary membrane and diffusion

Any change in the surface area of the lungs hinders diffusion of

gas exchange. Any disease or condition that results in changes in
the alveolar-capillary membrane, such as pneumonia or
pulmonary edema, makes diffusion more difficult. Diffusion is
assessed by a decreased oxygen saturation measurement. The
environmental oxygen which comprises the atmospheric
pressure, ribs, and diaphragm do not influence the diffusion of
gas exchange inside the lungs.
While the nurse is providing morning hygiene for a client who
has a chest tube, the client has rolled over quickly and the chest
tube has become disconnected from the drainage unit. How
should the nurse first respond to this event? - Precise Answer
✔✔Submerge the end of the chest tube in a container of sterile
water.

Explanation:
If a chest tube becomes disconnected from the drainage unit, the
nurse should submerge the end of the tube in a bottle of sterile
water, thus preventing a pneumothorax but still allowing air to
escape. The nurse should not clamp the tube or place on a sterile
surface as this can cause the lung to collapse. Connecting the
tube back to the drainage unit is a risk for infection; the nurse
should first submerge the end in sterile water and then prepare
for a new drainage collection system to be set up.

Which client would be most likely to have decreased anxiety

about, and response to, pain as a result of past experiences? -
Precise Answer ✔✔one who had pain but got adequate relief

Explanation:
An individual's experience of pain in the past, and the qualities
of that experience, profoundly affect new pain experiences.
Some clients have experienced severe acute or chronic pain in
the past but received immediate and adequate pain relief. These
clients are generally unafraid of pain and initiate appropriate
requests for assistance.

Pet therapy is commonly used in long-term facilities for

distraction. If a client is experiencing pain and the pain is
temporarily decreased while petting a visiting dog or cat, this is
an example of which type of distraction technique? - Precise
Answer ✔✔Tactile kinesthetic distraction

Explanation:
Examples of tactile kinesthetic distraction include holding or
stroking a loved one, pet, or toy; rocking; and slow rhythmic
breathing. Project distraction includes playing a challenging
game or performing meaningful work. Visual distraction can be
accomplished through reading or watching television. Auditory
distraction may occur when one listens to music.

Why is acute pain said to be protective in nature? - Precise

Answer ✔✔It warns an individual of tissue damage or disease.

Explanation:
Acute pain, lasting from a few minutes to less than 6 months,
warns an individual of tissue damage or organic disease. After
its underlying cause is resolved, acute pain disappears. Pain is a
subjective experience and does assist in the coping and
psychological strength of a person.

How may a nurse demonstrate cultural competence when

responding to clients in pain? - Precise Answer ✔✔Avoid
stereotypical responses to pain in clients.

Explanation:
Culture influences an individual's response to pain. It is
particularly important for nurses to avoid stereotypical responses
to pain because they frequently encounter clients who are in pain
or who anticipate that it will develop. A form of pain expression
that is frowned upon in one culture may be desirable in another
cultural group. Nurses should treat every client exactly the same
but be aware of cultural influence in providing care. Medication
knowledge is essential, but nurses should understand the cultural
influence of pain and use of medication.

Which client would be most likely to have decreased anxiety

about, and response to, pain as a result of past experiences? -
Precise Answer ✔✔one who had pain but got adequate relief

Explanation:
An individual's experience of pain in the past, and the qualities
of that experience, profoundly affect new pain experiences.
Some clients have experienced severe acute or chronic pain in
the past but received immediate and adequate pain relief. These
clients are generally unafraid of pain and initiate appropriate
requests for assistance.