NURS 355 Exam 3 Questions and Answers 2026 Verified
and Detailed
The nurse is caring for a 47-yr-old female patient who is comatose and is receiving continuous
enteral nutrition through a soft nasogastric tube. The nurse notes the presence of new crackles
in the patient's lungs. In which order will the nurse take action? (Put a comma and a space
between each answer choice [A, B, C, D].)
a. Check the patient's oxygen saturation.
b. Notify the patient's health care provider.
c. Stop administering the continuous feeding.
d. Measure the gastric residual volume per agency policy. - Correct Answers Answers:
C. Stop administering the continuous feeding
A. Check the patient's oxygen saturation
D. Measure the gastric residual volume per agency policy.
B. Notify the patient's health care provider
Rationale: The assessment data indicate that aspiration may have occurred. The nurse's first
action should be to turn off the enteral feeding to avoid further aspiration. The next action
should be to check the oxygen saturation because this may indicate the need for immediate
respiratory suctioning or oxygen administration. The residual volume provides data about
possible causes of aspiration. Finally, the health care provider should be notified and informed
of all the assessment data the nurse has just obtained.
,Which information about an 80-yr-old male patient at the senior center is of most concern to
the nurse?
a. Decreased appetite
b. Occasional indigestion
c. Unintended weight loss
d. Difficulty chewing food - Correct Answers Answer: Unintended weight loss
Rationale: Unintentional weight loss is not a normal finding and may indicate a problem such as
cancer or depression. Poor appetite, difficulty in chewing, and indigestion are common in older
patients. These will need to be addressed but are not of as much concern as the weight loss.
2. An older patient reports chronic constipation. To promote bowel evacuation, when should
the nurse suggest that the patient attempt defecation?
a. In the mid-afternoon
b. After eating breakfast
c. Right after awakening in the morning
d. Immediately before the first daily meal - Correct Answers Answer: After eating breakfast
Rationale: The gastrocolic reflex is most active after the first daily meal. Awakening, the
anticipation of eating, and mid-afternoon timing do not stimulate these reflexes.
What condition should the nurse anticipate when caring for a patient with a history of a total
gastrectomy?
a. Constipation
,b. Dehydration
c. Elevated total serum cholesterol
d. Cobalamin (vitamin B12) deficiency - Correct Answers Answer: Cobalamin
Rationale: The patient with a total gastrectomy does not secrete intrinsic factor, which is
needed for cobalamin (vitamin B12) absorption. Because the stomach absorbs only small
amounts of water and nutrients, the patient is not at higher risk for dehydration, elevated
cholesterol, or constipation.
The nurse is caring for a patient with an obstructed common bile duct. What condition should
the nurse expect?
a. Melena
b. Steatorrhea
c. Decreased serum cholesterol level
d. Increased serum indirect bilirubin level - Correct Answers Answer: Steatorrhea
Rationale: A common bile duct obstruction will reduce the absorption of fat in the small
intestine, leading to fatty stools. Gastrointestinal bleeding is not caused by common bile duct
obstruction. Serum cholesterol levels are increased with biliary obstruction. Direct bilirubin level
is increased with biliary obstruction.
The nurse receives the following information about a patient who is scheduled for a
colonoscopy. Which information should be communicated to the health care provider before
sending the patient for the procedure?
a. The patient declined to drink the prescribed laxative solution.
b. The patient has had an allergic reaction to shellfish and iodine.
c. The patient has a permanent pacemaker to prevent bradycardia.
, d. The patient is worried about discomfort during the examination. - Correct Answers Answer:
The patient declined to drink the prescribed laxative solution.
Rationale: If the patient has had inadequate bowel preparation, the colon cannot be visualized
and the procedure would be rescheduled. Because contrast solution is not used during
colonoscopy,
the iodine allergy is not pertinent. A pacemaker is a contraindication to magnetic resonance
imaging but not to colonoscopy. The nurse should instruct the patient about the sedation used
during the examination to decrease the patient's anxiety about discomfort.
Which statement to the nurse from a patient with jaundice indicates a need for teaching?
a. "I used cough syrup several times a day last week."
b. "I take a baby aspirin every day to prevent strokes."
c. "I take an antacid for indigestion several times a week"
d. "I use acetaminophen (Tylenol) every 4 hours for pain." - Correct Answers Answer: "I use
acetaminophen (Tylenol) every 4 hours for pain."
Rationale: Chronic use of high doses of acetaminophen can be hepatotoxic and may have
caused the patient's jaundice. The other patient statements require further assessment by the
nurse but do not indicate a need for patient education.
Which is the correct technique for the nurse to palpate the liver during a head-to-toe physical
assessment?
and Detailed
The nurse is caring for a 47-yr-old female patient who is comatose and is receiving continuous
enteral nutrition through a soft nasogastric tube. The nurse notes the presence of new crackles
in the patient's lungs. In which order will the nurse take action? (Put a comma and a space
between each answer choice [A, B, C, D].)
a. Check the patient's oxygen saturation.
b. Notify the patient's health care provider.
c. Stop administering the continuous feeding.
d. Measure the gastric residual volume per agency policy. - Correct Answers Answers:
C. Stop administering the continuous feeding
A. Check the patient's oxygen saturation
D. Measure the gastric residual volume per agency policy.
B. Notify the patient's health care provider
Rationale: The assessment data indicate that aspiration may have occurred. The nurse's first
action should be to turn off the enteral feeding to avoid further aspiration. The next action
should be to check the oxygen saturation because this may indicate the need for immediate
respiratory suctioning or oxygen administration. The residual volume provides data about
possible causes of aspiration. Finally, the health care provider should be notified and informed
of all the assessment data the nurse has just obtained.
,Which information about an 80-yr-old male patient at the senior center is of most concern to
the nurse?
a. Decreased appetite
b. Occasional indigestion
c. Unintended weight loss
d. Difficulty chewing food - Correct Answers Answer: Unintended weight loss
Rationale: Unintentional weight loss is not a normal finding and may indicate a problem such as
cancer or depression. Poor appetite, difficulty in chewing, and indigestion are common in older
patients. These will need to be addressed but are not of as much concern as the weight loss.
2. An older patient reports chronic constipation. To promote bowel evacuation, when should
the nurse suggest that the patient attempt defecation?
a. In the mid-afternoon
b. After eating breakfast
c. Right after awakening in the morning
d. Immediately before the first daily meal - Correct Answers Answer: After eating breakfast
Rationale: The gastrocolic reflex is most active after the first daily meal. Awakening, the
anticipation of eating, and mid-afternoon timing do not stimulate these reflexes.
What condition should the nurse anticipate when caring for a patient with a history of a total
gastrectomy?
a. Constipation
,b. Dehydration
c. Elevated total serum cholesterol
d. Cobalamin (vitamin B12) deficiency - Correct Answers Answer: Cobalamin
Rationale: The patient with a total gastrectomy does not secrete intrinsic factor, which is
needed for cobalamin (vitamin B12) absorption. Because the stomach absorbs only small
amounts of water and nutrients, the patient is not at higher risk for dehydration, elevated
cholesterol, or constipation.
The nurse is caring for a patient with an obstructed common bile duct. What condition should
the nurse expect?
a. Melena
b. Steatorrhea
c. Decreased serum cholesterol level
d. Increased serum indirect bilirubin level - Correct Answers Answer: Steatorrhea
Rationale: A common bile duct obstruction will reduce the absorption of fat in the small
intestine, leading to fatty stools. Gastrointestinal bleeding is not caused by common bile duct
obstruction. Serum cholesterol levels are increased with biliary obstruction. Direct bilirubin level
is increased with biliary obstruction.
The nurse receives the following information about a patient who is scheduled for a
colonoscopy. Which information should be communicated to the health care provider before
sending the patient for the procedure?
a. The patient declined to drink the prescribed laxative solution.
b. The patient has had an allergic reaction to shellfish and iodine.
c. The patient has a permanent pacemaker to prevent bradycardia.
, d. The patient is worried about discomfort during the examination. - Correct Answers Answer:
The patient declined to drink the prescribed laxative solution.
Rationale: If the patient has had inadequate bowel preparation, the colon cannot be visualized
and the procedure would be rescheduled. Because contrast solution is not used during
colonoscopy,
the iodine allergy is not pertinent. A pacemaker is a contraindication to magnetic resonance
imaging but not to colonoscopy. The nurse should instruct the patient about the sedation used
during the examination to decrease the patient's anxiety about discomfort.
Which statement to the nurse from a patient with jaundice indicates a need for teaching?
a. "I used cough syrup several times a day last week."
b. "I take a baby aspirin every day to prevent strokes."
c. "I take an antacid for indigestion several times a week"
d. "I use acetaminophen (Tylenol) every 4 hours for pain." - Correct Answers Answer: "I use
acetaminophen (Tylenol) every 4 hours for pain."
Rationale: Chronic use of high doses of acetaminophen can be hepatotoxic and may have
caused the patient's jaundice. The other patient statements require further assessment by the
nurse but do not indicate a need for patient education.
Which is the correct technique for the nurse to palpate the liver during a head-to-toe physical
assessment?
