Question 1

During preparation for removal of a nasogastric (NG) tube, the patient becomes anxious.Which action does the nurse take to reassure the patient?

Accepted Answer

A)  Grasp the tube and remove it quickly. 
B)  Medicate the patient with an analgesic. 
C)  Tell the patient this procedure is painless. 
D)  Inform the patient that it only takes a few seconds. 
A)  Grasp the tube and remove it quickly. 
B)  Medicate the patient with an analgesic. 
C)  Tell the patient this procedure is painless. 
D)  Inform the patient that it only takes a few seconds. D

Question 2

The nurse records a patient's intake and output for an 8-hour period and notes nasogastric (NG) tube irrigation with 50 mL of normal saline solution every 4 hours and lactulose syrup, 30 mL, instilled through the NG tube with 30 mL of normal saline solution.Which total should the nurse record as the patient's intake over 8 hours?

Accepted Answer

A)  30 mL 
B)  160 mL 
C)  110 mL 
D)  210 mL 
A)  30 mL 
B)  160 mL 
C)  110 mL 
D)  210 mL B

Question 3

A student nurse has placed a patient on a bedpan.What assessment requires the faculty to intervene?

Accepted Answer

A)  The fracture pan has the deep, lower open end under the back. 
B)  The patient has helped lift the hip by using overhead traction. 
C)  The rim of the regular bedpan is towards the foot of the bed. 
D)  The head of the patient's bed is raised to 30°. 
A)  The fracture pan has the deep, lower open end under the back. 
B)  The patient has helped lift the hip by using overhead traction. 
C)  The rim of the regular bedpan is towards the foot of the bed. 
D)  The head of the patient's bed is raised to 30°. A

Question 4

The nurse is inserting a nasogastric (NG) tube and assessing the patient during the procedure.Which assessment finding indicates a potentially serious problem?

Accepted Answer

A)  Restlessness 
B)  Drop in SaO2 
C)  Nasal pressure 
D)  Mouth breathing 
A)  Restlessness 
B)  Drop in SaO2 
C)  Nasal pressure 
D)  Mouth breathing

Question 5

A patient's nasogastric tube needs to be irrigated.Which action does the nurse implement first to prevent complications?

Accepted Answer

A)  Introduces 30 mL of sterile fluid. 
B)  Verifies the placement of the tube. 
C)  Aspirates gastric contents. 
D)  Positions the patient on the left side. 
A)  Introduces 30 mL of sterile fluid. 
B)  Verifies the placement of the tube. 
C)  Aspirates gastric contents. 
D)  Positions the patient on the left side.

Question 6

The patient's nasogastric (NG) tube drains approximately 400 mL/day of yellow-green drainage.When the patient reports nausea, which intervention should the nurse implement first?

Accepted Answer

A)  Irrigate the tube with 50 mL of water. 
B)  Assess the patency of the NG tube. 
C)  Replace the NG tube with a larger tube. 
D)  Elevate the patient's head and reassess. 
A)  Irrigate the tube with 50 mL of water. 
B)  Assess the patency of the NG tube. 
C)  Replace the NG tube with a larger tube. 
D)  Elevate the patient's head and reassess.

Question 7

The nurse is providing routine care for a patient with a nasogastric (NG) tube.Care by the nurse is correct if which technique is used?

Accepted Answer

A)  Alternates NG tube placement between the nares daily. 
B)  Provides patient oral care daily and lubricant to the lips. 
C)  Keeps the head of the bed flat with the tube in place. 
D)  Prevents pressure on the nasal tissue. 
A)  Alternates NG tube placement between the nares daily. 
B)  Provides patient oral care daily and lubricant to the lips. 
C)  Keeps the head of the bed flat with the tube in place. 
D)  Prevents pressure on the nasal tissue.

Question 8

During insertion of a nasogastric (NG) tube, the patient begins to cough and gag.Which intervention should the nurse implement for the patient's benefit?

Accepted Answer

A)  Withdraw the tube into the posterior pharynx. 
B)  Stop the procedure, anchor the tube, and request an x-ray film. 
C)  Tell the patient that the gagging will pass, and advance the tube. 
D)  Remove the tube and allow the patient to regain composure. 
A)  Withdraw the tube into the posterior pharynx. 
B)  Stop the procedure, anchor the tube, and request an x-ray film. 
C)  Tell the patient that the gagging will pass, and advance the tube. 
D)  Remove the tube and allow the patient to regain composure.

Question 9

The nursing assistive personnel (NAP) informs the nurse that the patient with a nasogastric tube has a reddened area on the naris.What action by the nurse is best?

Accepted Answer

A)  Remove the tube and assess the patient for nausea and distention. 
B)  Instruct the NAP to clean off the holding device and apply a new one. 
C)  Assess the patient's skin condition and reposition the tube at the naris. 
D)  Request a consultation by the Wound Ostomy and Continence Nurse. 
A)  Remove the tube and assess the patient for nausea and distention. 
B)  Instruct the NAP to clean off the holding device and apply a new one. 
C)  Assess the patient's skin condition and reposition the tube at the naris. 
D)  Request a consultation by the Wound Ostomy and Continence Nurse.

Question 10

The nurse is preparing to insert a nasogastric (NG) tube in an adult patient.Which technique does the nurse use to measure the length of the tube before gastric intubation?

Accepted Answer

A)  Measure and mark a point 72 cm (30 inches) from the end. 
B)  Measure from the nose to the middle of the sternum. 
C)  Measure from the nose to the ear to the patient's navel. 
D)  Measure from the nose to the earlobe to the xiphoid process. 
A)  Measure and mark a point 72 cm (30 inches) from the end. 
B)  Measure from the nose to the middle of the sternum. 
C)  Measure from the nose to the ear to the patient's navel. 
D)  Measure from the nose to the earlobe to the xiphoid process.

Question 11

The nurse prepares to irrigate a patient's nasogastric (NG) tube.Which intervention does the nurse implement to irrigate the NG tube?

Accepted Answer

A)  Observe sterile technique for each irrigation. 
B)  Inject 50 mL of warm tap water into the tube. 
C)  Gently instill 30 mL of normal saline solution. 
D)  Delegate the procedure to nursing assistive personnel (NAP). 
A)  Observe sterile technique for each irrigation. 
B)  Inject 50 mL of warm tap water into the tube. 
C)  Gently instill 30 mL of normal saline solution. 
D)  Delegate the procedure to nursing assistive personnel (NAP).

Question 12

A patient in skeletal traction for a fractured pelvis needs to use the bedpan.Which technique does the nurse use to position the patient on the bedpan?

Accepted Answer

A)  Logroll the patient and maintain skeletal traction. 
B)  Place a bedpan under the patient while the hips are lifted. 
C)  Remove weights on the traction and turn the patient. 
D)  Warm the bedpan before placing it under the patient. 
A)  Logroll the patient and maintain skeletal traction. 
B)  Place a bedpan under the patient while the hips are lifted. 
C)  Remove weights on the traction and turn the patient. 
D)  Warm the bedpan before placing it under the patient.

Question 13

The nurse is inserting a fecal management system for a patient with severe diarrhea.What action shows good technique during this procedure?

Accepted Answer

A)  Uses the index finger to guide the tube's placement. 
B)  Inflates the cuff balloon prior to insertion. 
C)  Inflates the cuff with 75 mL of saline. 
D)  Attaches collection bag after tube is inserted. 
A)  Uses the index finger to guide the tube's placement. 
B)  Inflates the cuff balloon prior to insertion. 
C)  Inflates the cuff with 75 mL of saline. 
D)  Attaches collection bag after tube is inserted.

Question 14

The nursing assistive personnel reports to the nurse that a patient getting an enema cannot hold the solution.What recommendation does the nurse provide?

Accepted Answer

A)  Have the patient sit on the toilet for the enema. 
B)  Give the enema while the patient is on a bedpan. 
C)  Use a fecal management system instead. 
D)  Slow the infusion rate and use absorbent pads. 
A)  Have the patient sit on the toilet for the enema. 
B)  Give the enema while the patient is on a bedpan. 
C)  Use a fecal management system instead. 
D)  Slow the infusion rate and use absorbent pads.

Question 15

The patient is alert and cooperative for insertion of a nasogastric (NG) tube.In which position will the nurse place the patient for the procedure?

Accepted Answer

A)  In high Fowler's position 
B)  In left lateral Sims' position 
C)  Leaning forward on the over-bed table 
D)  Any position that is comfortable 
A)  In high Fowler's position 
B)  In left lateral Sims' position 
C)  Leaning forward on the over-bed table 
D)  Any position that is comfortable

Question 16

A patient is weak, has diarrhea, and is refusing to use the bedpan but is on bed rest and unable to get out of bed.Which is the best nursing intervention to maintain patient dignity?

Accepted Answer

A)  Keep the bedpan out of the patient's sight until it is needed. 
B)  Reassure the patient that most people use the bedpan willingly. 
C)  Instruct the patient that the only alternative for elimination is to use the bedpan. 
D)  Explain how the nurse will ensure privacy and safety. 
A)  Keep the bedpan out of the patient's sight until it is needed. 
B)  Reassure the patient that most people use the bedpan willingly. 
C)  Instruct the patient that the only alternative for elimination is to use the bedpan. 
D)  Explain how the nurse will ensure privacy and safety.

Question 17

A right-handed nurse needs to remove the patient's nasogastric (NG) tube.Which intervention maintains patient safety during removal of the NG tube?

Accepted Answer

A)  Leaving the suction on the low setting 
B)  Clamping and then pulling out the tube 
C)  Standing on the patient's left side 
D)  Asking the patient to inhale deeply 
A)  Leaving the suction on the low setting 
B)  Clamping and then pulling out the tube 
C)  Standing on the patient's left side 
D)  Asking the patient to inhale deeply

Question 18

A nurse and nursing assistive personnel are working with four patients who need enemas.Which patient is the priority for the nurse to assess before and after the procedure?

Accepted Answer

A)  Older and confused 
B)  On cardiac medications 
C)  Chronically constipated 
D)  Has postoperative pain 
A)  Older and confused 
B)  On cardiac medications 
C)  Chronically constipated 
D)  Has postoperative pain

Question 19

A student nurse is preparing to administer a cleansing enema to an adult patient.How much fluid does the student anticipate needing for one enema?

Accepted Answer

A)  250-350 mL 
B)  300-500 mL 
C)  750-1000 mL 
D)  1500-1800 mL 
A)  250-350 mL 
B)  300-500 mL 
C)  750-1000 mL 
D)  1500-1800 mL

Question 20

The nurse is caring for several patients with severe diarrhea.Which patient is an appropriate candidate for the fecal management system?

Accepted Answer

A)  On anticoagulants. 
B)  Has severe hemorrhoids. 
C)  Is 13 years of age. 
D)  Has Clostridium difficile diarrhea. 
A)  On anticoagulants. 
B)  Has severe hemorrhoids. 
C)  Is 13 years of age. 
D)  Has Clostridium difficile diarrhea.

Exam 20: Bowel Elimination

During preparation for removal of a nasogastric (NG) tube, the patient becomes anxious.Which action does the nurse take to reassure the patient?

A student nurse has placed a patient on a bedpan.What assessment requires the faculty to intervene?

The nurse is inserting a nasogastric (NG) tube and assessing the patient during the procedure.Which assessment finding indicates a potentially serious problem?

A patient's nasogastric tube needs to be irrigated.Which action does the nurse implement first to prevent complications?

The patient's nasogastric (NG) tube drains approximately 400 mL/day of yellow-green drainage.When the patient reports nausea, which intervention should the nurse implement first?

The nurse is providing routine care for a patient with a nasogastric (NG) tube.Care by the nurse is correct if which technique is used?

During insertion of a nasogastric (NG) tube, the patient begins to cough and gag.Which intervention should the nurse implement for the patient's benefit?

The nursing assistive personnel (NAP) informs the nurse that the patient with a nasogastric tube has a reddened area on the naris.What action by the nurse is best?

The nurse is preparing to insert a nasogastric (NG) tube in an adult patient.Which technique does the nurse use to measure the length of the tube before gastric intubation?

The nurse prepares to irrigate a patient's nasogastric (NG) tube.Which intervention does the nurse implement to irrigate the NG tube?

A patient in skeletal traction for a fractured pelvis needs to use the bedpan.Which technique does the nurse use to position the patient on the bedpan?

The nurse is inserting a fecal management system for a patient with severe diarrhea.What action shows good technique during this procedure?

The nursing assistive personnel reports to the nurse that a patient getting an enema cannot hold the solution.What recommendation does the nurse provide?

The patient is alert and cooperative for insertion of a nasogastric (NG) tube.In which position will the nurse place the patient for the procedure?

A patient is weak, has diarrhea, and is refusing to use the bedpan but is on bed rest and unable to get out of bed.Which is the best nursing intervention to maintain patient dignity?

A right-handed nurse needs to remove the patient's nasogastric (NG) tube.Which intervention maintains patient safety during removal of the NG tube?

A nurse and nursing assistive personnel are working with four patients who need enemas.Which patient is the priority for the nurse to assess before and after the procedure?

A student nurse is preparing to administer a cleansing enema to an adult patient.How much fluid does the student anticipate needing for one enema?

The nurse is caring for several patients with severe diarrhea.Which patient is an appropriate candidate for the fecal management system?

Using Evidence in Nursing Practice

Communication and Collaboration

Documentation and Informatics

Patient Safety and Quality Improvement

Infection Control

Disaster Preparedness

Vital Signs

Health Assessment

Specimen Collection

Diagnostic Procedures

Bathing and Personal Hygiene

Care of the Eye and EAR

Promoting Nutrition

Parenteral Nutrition

Pain Management

Promoting Oxygenation

Safe Patient Handling

Exercise, Mobility, Immobilization Devices

Urinary Elimination

Ostomy Care

Preparation for Safe Medication Administration

Nonparenteral Medications

Parenteral Medications

Wound Care and Irrigation

Pressure Injury Prevention and Care

Dressings, Bandages, and Binders

Intravenous Therapy

Pre-Operative and Post-Operative Care

Emergency Measures for Life Support

End-Of-Life Care

Home Care Safety

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