NUR 101 | NUR 101 Nursing Fundamentals Exam 3
Version 2 Questions with Correct Answers and
Expert Explanation for Each Question
1. A patient has not voided for 8 hours following abdominal surgery. Which nursing
action should be performed first?
A. Perform a bladder scan to assess for retention.
B. Encourage the patient to increase fluid intake.
C. Request an order for an indwelling catheter.
D. Assist the patient to the bathroom to attempt voiding.
Correct Answer: A
Expert Explanation: Urinary retention is a common post-operative complication
that requires immediate assessment. A bladder scan provides non-invasive
objective data regarding the volume of urine in the bladder. This step allows the
nurse to determine if the issue is a lack of production or retention. Documentation
of these findings is essential for clinical decision-making and provider notification.
Proper assessment ensures that invasive interventions like catheterization are only
used when necessary.
2. When providing perineal care for a female patient with an indwelling catheter,
which technique is correct?
A. Clean the catheter from the drainage bag toward the meatus.
,B. Apply antiseptic powder to the meatus after cleaning.
C. Use a circular motion to clean around the urinary meatus.
D. Cleanse from the area of least contamination to most contamination.
Correct Answer: D
Expert Explanation: Effective hygiene practices are vital for preventing catheter-
associated urinary tract infections. Cleaning from the front to the back reduces the
risk of introducing fecal bacteria into the urethra. The catheter itself should be
cleaned starting at the meatus and moving outward. Nurses must ensure that the
drainage bag remains below the level of the bladder at all times. Consistent
adherence to these protocols significantly improves patient outcomes regarding
infection control.
3. A patient reports frequent small amounts of liquid stool and abdominal discomfort.
What is the most likely cause?
A. Fecal impaction
B. Acute infectious diarrhea
C. Food intolerance
D. Irritable bowel syndrome
Correct Answer: A
,Expert Explanation: Fecal impaction often presents as the seepage of liquid stool
around a hard, lodged mass. This condition requires a digital rectal examination to
confirm the presence of hardened stool. Nurses should assess for symptoms like
bloating, nausea, and the loss of appetite. Digital removal of stool must be
performed cautiously to avoid stimulating the vagus nerve. Preventive strategies
such as high-fiber diets and adequate hydration are essential for long-term
management.
4. Which type of urinary incontinence is characterized by the loss of urine when
sneezing or coughing?
A. Urge incontinence
B. Reflex incontinence
C. Stress incontinence
D. Functional incontinence
Correct Answer: C
Expert Explanation: Stress incontinence occurs when increased intra-abdominal
pressure overcomes the strength of the urinary sphincter. It is commonly seen in
women after multiple pregnancies or in older adults with weakened pelvic floors.
Education for these patients often includes instructions on performing pelvic floor
muscle exercises. The nurse should also discuss lifestyle modifications such as
, weight management and smoking cessation. Outcomes for stress incontinence are
generally improved through consistent adherence to behavioral interventions.
5. The nurse is preparing to administer a cleansing enema. In which position should
the patient be placed?
A. Left side-lying Sims’ position with the right knee flexed.
B. Prone position with a pillow under the hips.
C. Right side-lying with the left leg extended.
D. Supine position with the knees slightly bent.
Correct Answer: A
Expert Explanation: The left Sims’ position allows the enema solution to flow by
gravity into the sigmoid colon. This positioning facilitates the distribution of fluid
throughout the lower bowel for better results. Nurses must ensure the enema
container is held at the correct height to control the flow rate. If the patient
complains of cramping, the nurse should lower the bag to slow the administration.
Proper technique ensures both patient safety and the effectiveness of the bowel
elimination intervention.
6. A patient has a new prescription for bulk-forming laxatives. What is the most
important teaching point?
A. Take the medication immediately before bedtime.
Version 2 Questions with Correct Answers and
Expert Explanation for Each Question
1. A patient has not voided for 8 hours following abdominal surgery. Which nursing
action should be performed first?
A. Perform a bladder scan to assess for retention.
B. Encourage the patient to increase fluid intake.
C. Request an order for an indwelling catheter.
D. Assist the patient to the bathroom to attempt voiding.
Correct Answer: A
Expert Explanation: Urinary retention is a common post-operative complication
that requires immediate assessment. A bladder scan provides non-invasive
objective data regarding the volume of urine in the bladder. This step allows the
nurse to determine if the issue is a lack of production or retention. Documentation
of these findings is essential for clinical decision-making and provider notification.
Proper assessment ensures that invasive interventions like catheterization are only
used when necessary.
2. When providing perineal care for a female patient with an indwelling catheter,
which technique is correct?
A. Clean the catheter from the drainage bag toward the meatus.
,B. Apply antiseptic powder to the meatus after cleaning.
C. Use a circular motion to clean around the urinary meatus.
D. Cleanse from the area of least contamination to most contamination.
Correct Answer: D
Expert Explanation: Effective hygiene practices are vital for preventing catheter-
associated urinary tract infections. Cleaning from the front to the back reduces the
risk of introducing fecal bacteria into the urethra. The catheter itself should be
cleaned starting at the meatus and moving outward. Nurses must ensure that the
drainage bag remains below the level of the bladder at all times. Consistent
adherence to these protocols significantly improves patient outcomes regarding
infection control.
3. A patient reports frequent small amounts of liquid stool and abdominal discomfort.
What is the most likely cause?
A. Fecal impaction
B. Acute infectious diarrhea
C. Food intolerance
D. Irritable bowel syndrome
Correct Answer: A
,Expert Explanation: Fecal impaction often presents as the seepage of liquid stool
around a hard, lodged mass. This condition requires a digital rectal examination to
confirm the presence of hardened stool. Nurses should assess for symptoms like
bloating, nausea, and the loss of appetite. Digital removal of stool must be
performed cautiously to avoid stimulating the vagus nerve. Preventive strategies
such as high-fiber diets and adequate hydration are essential for long-term
management.
4. Which type of urinary incontinence is characterized by the loss of urine when
sneezing or coughing?
A. Urge incontinence
B. Reflex incontinence
C. Stress incontinence
D. Functional incontinence
Correct Answer: C
Expert Explanation: Stress incontinence occurs when increased intra-abdominal
pressure overcomes the strength of the urinary sphincter. It is commonly seen in
women after multiple pregnancies or in older adults with weakened pelvic floors.
Education for these patients often includes instructions on performing pelvic floor
muscle exercises. The nurse should also discuss lifestyle modifications such as
, weight management and smoking cessation. Outcomes for stress incontinence are
generally improved through consistent adherence to behavioral interventions.
5. The nurse is preparing to administer a cleansing enema. In which position should
the patient be placed?
A. Left side-lying Sims’ position with the right knee flexed.
B. Prone position with a pillow under the hips.
C. Right side-lying with the left leg extended.
D. Supine position with the knees slightly bent.
Correct Answer: A
Expert Explanation: The left Sims’ position allows the enema solution to flow by
gravity into the sigmoid colon. This positioning facilitates the distribution of fluid
throughout the lower bowel for better results. Nurses must ensure the enema
container is held at the correct height to control the flow rate. If the patient
complains of cramping, the nurse should lower the bag to slow the administration.
Proper technique ensures both patient safety and the effectiveness of the bowel
elimination intervention.
6. A patient has a new prescription for bulk-forming laxatives. What is the most
important teaching point?
A. Take the medication immediately before bedtime.
