Nursing Fundamentals
3 MAXE
NF Foundations of Professional Nursing Practice
CARING · COMPETENCE · COMPASSION
FUNDAMENTALS
NURSING FUNDAMENTALS — EXAM #3
E N T E R A L F E E D I N G , G I , E L I M I N AT I O N , W O U N D S , P R E SS U R E I N J U R I E S & S K I N A SS E SS M E N T
INSTITUTION Nursing Fundamentals Program COURSE CODE NURS 101 — Fundamentals
PROGRAM Associate / Bachelor of Science in Nursing ACADEMIC YEAR
EXAM TITLE Exam #3 — Fundamentals of Nursing TOTAL QUESTIONS 90+ Questions (Complete)
COURSE TITLE Fundamentals of Nursing FORMAT Multiple Choice — Select the Single Best
Answer
EXAMINATION INSTRUCTIONS
▸ Select the single best answer for each question.
▸ All 90+ questions from the provided study material are included with correct answers and clinical rationales.
ENTERAL, GI, ELIMINATION, WOUNDS & SKIN INTEGRITY Questions 1 – 90+
1. Significant weight loss or gain is defined as:
A. 2% change in 1 month or 5% in 6 months.
B. 5% change in 1 month or 10% change in 6 months.
C. 10% change in 1 month or 15% in 6 months.
D. 1% change in 1 month or 3% in 6 months.
CORRECT ANSWER B — 5% weight change in 1 month or 10% in 6 months is clinically significant and requires nutritional
intervention.
RATIONALE Unintentional weight loss/gain of this magnitude indicates potential malnutrition, fluid imbalance, or disease
progression.
2. The correct procedure for enteral tube feeding includes:
A. Positioning the patient flat for optimal digestion.
B. Verify order, assess abdomen, confirm tube placement (X-ray is gold standard), check gastric residual, HOB 30-45°,
flush before and after feeding, keep HOB elevated 30-60 min post-feeding.
C. Auscultation alone to confirm tube placement.
D. No need to check residual volume.
CORRECT ANSWER B — The gold standard for tube placement verification is portable chest X-ray, NOT auscultation alone.
HOB must remain elevated.
RATIONALE Acceptable GRV: <500 mL generally acceptable if asymptomatic. Hold feeding and notify provider if GRV
exceeds 500 mL. Intermittent/bolus feedings: larger volume over 15-30 min. Continuous: slow pump rate,
flush Q4H.
, 3. Aspiration precautions during feeding include all EXCEPT:
A. Assist with feeding and avoid straws.
B. Place food on the unaffected side of the mouth.
C. Use large bites and sips to finish quickly.
D. Keep chin parallel to floor, take small bites and sips slowly.
CORRECT ANSWER C — Large bites and sips INCREASE aspiration risk. Small bites, slow pace, chin parallel to floor, and no
straws reduce aspiration risk.
RATIONALE Diet progression: Clear liquid (broth, clear juice, gelatin) → Full liquid (milk, cream soups, pudding, ice cream)
→ Soft/Pureed (mechanical, low residue) → Regular. Continually assess for N/V, bowel sounds, and
distention.
4. The correct GI assessment sequence is:
A. Palpation, Percussion, Auscultation, Inspection.
B. Inspection, Auscultation, Percussion, Palpation. Always palpate LAST to avoid stimulating peristalsis.
C. Auscultation, Inspection, Palpation, Percussion.
D. Percussion, Palpation, Inspection, Auscultation.
CORRECT ANSWER B — Inspect → Auscultate → Percuss → Palpate. Palpation stimulates bowel activity and can alter
sounds if performed before auscultation.
RATIONALE Normal bowel sounds: every 5-20 seconds. Hyperactive: <5 sec. Hypoactive: >30 sec. Absent: no sounds for 1-
2 min. Paralytic ileus: no sounds for 72 hours. Tympany = hollow organs. Dullness = solid
organs/masses/ascites.
5. Black/tarry stool indicates:
A. Lower GI bleed.
B. Upper GI bleed (melena).
C. Fat malabsorption.
D. Normal stool variation.
CORRECT ANSWER B — Black/tarry = melena (digested blood from upper GI). Bright red = lower GI bleed. Clay/gray = no
bile (liver/gallbladder). Yellow-green = fat malabsorption or leafy greens.
RATIONALE FOBT (Fecal Occult Blood Test) detects hidden GI bleeding. Ileostomy = liquid stool, high electrolyte loss →
increased fluid needs. Colostomy = soft/formed stool depending on location. Transverse colostomy = pastier.
Sigmoid colostomy = firm/formed.
6. Ostomy care instructions include:
A. Empty pouch when completely full to save supplies.
B. Empty pouch when 1/3 to 1/2 full; clean/dry skin around stoma; cut wafer 1/8 inch larger than stoma; healthy stoma
= pink/red, moist, shiny. Report pale, dark purple, or black/brown stoma.
C. Cut the wafer exactly the same size as the stoma.
D. A healthy stoma is pale and dry.
CORRECT ANSWER B — Stoma should be pink/red, moist, shiny. Pale/dusky/black = ischemia → emergency. Wafer cut
1/8" larger prevents skin breakdown. Ileostomy patients need increased fluids due to liquid stool
losses.
RATIONALE Enemas: Small volume (100-150 mL) after failed laxatives. Large volume (750-1000 mL) for bowel cleansing —
use NS (3x max) or tap water (1-2x/day), WARM. Return flow enema for flatus. Slow if patient cramps. Never
use cold water.
3 MAXE
NF Foundations of Professional Nursing Practice
CARING · COMPETENCE · COMPASSION
FUNDAMENTALS
NURSING FUNDAMENTALS — EXAM #3
E N T E R A L F E E D I N G , G I , E L I M I N AT I O N , W O U N D S , P R E SS U R E I N J U R I E S & S K I N A SS E SS M E N T
INSTITUTION Nursing Fundamentals Program COURSE CODE NURS 101 — Fundamentals
PROGRAM Associate / Bachelor of Science in Nursing ACADEMIC YEAR
EXAM TITLE Exam #3 — Fundamentals of Nursing TOTAL QUESTIONS 90+ Questions (Complete)
COURSE TITLE Fundamentals of Nursing FORMAT Multiple Choice — Select the Single Best
Answer
EXAMINATION INSTRUCTIONS
▸ Select the single best answer for each question.
▸ All 90+ questions from the provided study material are included with correct answers and clinical rationales.
ENTERAL, GI, ELIMINATION, WOUNDS & SKIN INTEGRITY Questions 1 – 90+
1. Significant weight loss or gain is defined as:
A. 2% change in 1 month or 5% in 6 months.
B. 5% change in 1 month or 10% change in 6 months.
C. 10% change in 1 month or 15% in 6 months.
D. 1% change in 1 month or 3% in 6 months.
CORRECT ANSWER B — 5% weight change in 1 month or 10% in 6 months is clinically significant and requires nutritional
intervention.
RATIONALE Unintentional weight loss/gain of this magnitude indicates potential malnutrition, fluid imbalance, or disease
progression.
2. The correct procedure for enteral tube feeding includes:
A. Positioning the patient flat for optimal digestion.
B. Verify order, assess abdomen, confirm tube placement (X-ray is gold standard), check gastric residual, HOB 30-45°,
flush before and after feeding, keep HOB elevated 30-60 min post-feeding.
C. Auscultation alone to confirm tube placement.
D. No need to check residual volume.
CORRECT ANSWER B — The gold standard for tube placement verification is portable chest X-ray, NOT auscultation alone.
HOB must remain elevated.
RATIONALE Acceptable GRV: <500 mL generally acceptable if asymptomatic. Hold feeding and notify provider if GRV
exceeds 500 mL. Intermittent/bolus feedings: larger volume over 15-30 min. Continuous: slow pump rate,
flush Q4H.
, 3. Aspiration precautions during feeding include all EXCEPT:
A. Assist with feeding and avoid straws.
B. Place food on the unaffected side of the mouth.
C. Use large bites and sips to finish quickly.
D. Keep chin parallel to floor, take small bites and sips slowly.
CORRECT ANSWER C — Large bites and sips INCREASE aspiration risk. Small bites, slow pace, chin parallel to floor, and no
straws reduce aspiration risk.
RATIONALE Diet progression: Clear liquid (broth, clear juice, gelatin) → Full liquid (milk, cream soups, pudding, ice cream)
→ Soft/Pureed (mechanical, low residue) → Regular. Continually assess for N/V, bowel sounds, and
distention.
4. The correct GI assessment sequence is:
A. Palpation, Percussion, Auscultation, Inspection.
B. Inspection, Auscultation, Percussion, Palpation. Always palpate LAST to avoid stimulating peristalsis.
C. Auscultation, Inspection, Palpation, Percussion.
D. Percussion, Palpation, Inspection, Auscultation.
CORRECT ANSWER B — Inspect → Auscultate → Percuss → Palpate. Palpation stimulates bowel activity and can alter
sounds if performed before auscultation.
RATIONALE Normal bowel sounds: every 5-20 seconds. Hyperactive: <5 sec. Hypoactive: >30 sec. Absent: no sounds for 1-
2 min. Paralytic ileus: no sounds for 72 hours. Tympany = hollow organs. Dullness = solid
organs/masses/ascites.
5. Black/tarry stool indicates:
A. Lower GI bleed.
B. Upper GI bleed (melena).
C. Fat malabsorption.
D. Normal stool variation.
CORRECT ANSWER B — Black/tarry = melena (digested blood from upper GI). Bright red = lower GI bleed. Clay/gray = no
bile (liver/gallbladder). Yellow-green = fat malabsorption or leafy greens.
RATIONALE FOBT (Fecal Occult Blood Test) detects hidden GI bleeding. Ileostomy = liquid stool, high electrolyte loss →
increased fluid needs. Colostomy = soft/formed stool depending on location. Transverse colostomy = pastier.
Sigmoid colostomy = firm/formed.
6. Ostomy care instructions include:
A. Empty pouch when completely full to save supplies.
B. Empty pouch when 1/3 to 1/2 full; clean/dry skin around stoma; cut wafer 1/8 inch larger than stoma; healthy stoma
= pink/red, moist, shiny. Report pale, dark purple, or black/brown stoma.
C. Cut the wafer exactly the same size as the stoma.
D. A healthy stoma is pale and dry.
CORRECT ANSWER B — Stoma should be pink/red, moist, shiny. Pale/dusky/black = ischemia → emergency. Wafer cut
1/8" larger prevents skin breakdown. Ileostomy patients need increased fluids due to liquid stool
losses.
RATIONALE Enemas: Small volume (100-150 mL) after failed laxatives. Large volume (750-1000 mL) for bowel cleansing —
use NS (3x max) or tap water (1-2x/day), WARM. Return flow enema for flatus. Slow if patient cramps. Never
use cold water.
