NR 224 Fundamentals Final Review
Questions and Answers (2023/ 2024 Update) - Chamberlain
What is the most effective method to prevent the transfer of clostridium difficile (C.
Difficile)? - ANSWER HAND HYGIENE with soap and water is effective to physically
remove C. difficile spores from the hands. (Potter 1092)
What is the term for the [abnormal] method used to assist in stool passage by exerting
pressure to expel fecal matter through voluntary contraction of the abdominal muscles
while maintaining a forced expiration against a closed airway? - ANSWER Valsalva
maneuver
*Normal passage of bowels should be painless, passing soft formed stool*
Which patients are at greatest risk for cardiac dysrhythmia and high blood pressure with
the Valsalva maneuver and MUST avoid straining to pass stool? - ANSWER Patients
with cardiovascular disease, glaucoma, increased intracranial pressure, or a new
surgical wound
(Potter 1089)
What is the term for a collection of hardened feces in the rectum that cannot be expelled
due to unrelieved constipation? - ANSWER Fecal Impaction
Where does fecal impaction occur in the colon? - ANSWER Rectum
Least formed stool is present in which portion of the digestive tract? - ANSWER
Ascending Colon
Most formed stool is present in which portion of the digestive tract? - ANSWER
Descending Colon
Which position should the patient be in while administering an enema? - ANSWER Left
Side-Lying or Sim's Position
Which factors would contribute to stopping enema administration? - ANSWER If
bleeding occurs, abdomen becomes rigid and distended, pain occurs, or resistance is
felt
Which enema solution is the safest for administration because it does NOT create a
danger for excess fluid absorption? - ANSWER Normal Saline [Isotonic Solution]
,Which enema solution is contraindicated in patients who are dehydrated or young
infants because of risk for fluid imbalance? - ANSWER Hypertonic Solution
Which enema solution is considered to be hypotonic and should NOT be repeated
because of the risk of water toxicity or circulatory overload if and because the body
absorbs excessive amounts of water? - ANSWER Tap Water [Hypotonic Solution]
Which enema solution lubricates the rectum and allows the feces to absorb the oil
making them soft and easier to pass? - ANSWER Oil Retention
Which enema solution creates intestinal irritation to stimulate peristalsis by using castile
soap? - ANSWER Soapsuds
Which enema solution should be used in caution in pregnant women and elderly
because it may cause an electrolyte imbalance or damage to intestinal mucosa? -
ANSWER Soapsuds
Which laboratory test is used to measure microscopic amounts of blood in the feces
(blood that cannot be seen) - ANSWER Guaiac Fecal Occult Blood Test
Repeat the test at least three times while the patient refrains from ingesting foods (e.g.,
some raw vegetables, red meat, poultry, fish) and medications (e.g., vitamin C, aspirin,
non-steroidal anti-inflammatory drugs) that cause false-positive results
(Potter 1100)
When analyzing a fecal specimens for ova and parasites, what is required of the stool? -
ANSWER The stool MUST be warm.
If the stool specimen remains at room temperature, bacteriological changes can alter
the test results
Which cathartic form is most effective because of its stimulant effect on the rectal
mucosa?
(Example: Dulcolax)? - ANSWER Cathartic Suppositories
Which foods induce a constipating effect? - ANSWER cheese, lean meats, eggs, and
pasta
Which food induce a laxative effect? - ANSWER fruits, vegetables, bran, chocolate,
alcohol, and coffee
What are the assessment findings of a normal stoma? - ANSWER bright pink or brick
red
,Notify HCP of stoma is blue, purple, brown, or black which indicates circulation problem
to the stoma
How does the nurse measure the length of the NG tube for insertion? - ANSWER Tip of
the nose --> earlobe --> xiphoid process
What is the most reliable method of verification for placement of the NG tube? -
ANSWER X-ray
Other methods include: pH test (aspirate and inspect color)
What are the ranges for body mass index? - ANSWER Normal = 19-24
Overweight = 25-29
Obese = 30-39
Extremely Obese = > 40
When energy requirements are completely met or EQUALS kcal intake in food what
occurs? - ANSWER Weight does not change
When kcal intake in food is LESS THAN energy requirements what occurs? - ANSWER
Loose weight
When kcal intake in food is GREATER THAN energy requirements what occurs? -
ANSWER Gain weight
Nutrients are absorbed in what portion of the digestive tract? - ANSWER Small intestine
[duodenum]
Proteins are necessary for _________ balance - ANSWER Positive protein and nitrogen
balance for healing, growth, and tissue repair
1 gram of carbohydrates = ____ kcal - ANSWER 4 kcal
1 gram of fat = ____ kcal - ANSWER 9 kcal
Most calorie dense
< ___ % of fat intake of daily nutrition is considered a nutritional deficiency - ANSWER <
10%
1 gram of protein = ___ kcal - ANSWER 4 kcal
Which amino acids are NOT manufactured by the body and MUST be obtained through
diet or external source are known as? - ANSWER Indispensable amino acids
, Which amino acids ARE manufactured by the body? - ANSWER Dispensable amino
acids
The ChooseMyPlate program was developed by whom? - ANSWER U.S. Department of
Agriculture
Which program established guidelines for balancing calories? - ANSWER
ChooseMyPlate
What are the goals of ChooseMyPlate? - ANSWER decreasing portion size, increasing
healthy food intake, increase water consumption, maintain body weight in a healthy
range, increase activity, decrease salt intake, increase fruit, vegetable, and whole grain
intake
Which measurement is determined by dividing the patients weight in kilograms by
height in meters squared and is considered to be the most reliable indicator of
nutritional status and health by HCP's? - ANSWER Body Mass Index [BMI]
Vegans are at risk for which nutritional deficiency? - ANSWER Vitamin B12 deficiency
b/c the vitamin is only found in animal sources and vegans ONLY consume plant
products
Breast milk or formula provides sufficient nutrition for the first _____ to _____ months of
life - ANSWER 4 to 6 months
Breast milk benefits: fewer food allergies and intolerances; fewer infant infections;
easier digestion; convenience, availability, and freshness; temperature always correct;
economical because it is less expensive than formula; and increased time for mother
and infant interaction. (Potter 1002)
Infants should not have regular cow's milk during the first year of life. It is too
concentrated for an infant's kidneys to manage, increases the risk of milk product
allergies, and is a poor source of iron and vitamins C and E. Honey and corn syrup are
potential sources of botulism toxin and should not be used in an infant's diet. This toxin
is potentially fatal in children under 1 year of age (Potter 1002)
What are the therapeutic diets? - ANSWER Clear Liquid
Clear fat-free broth, bouillon, coffee, tea, carbonated beverages, clear fruit juices,
gelatin, fruit ices, popsicles
Full Liquid
smooth-textured dairy products (e.g., ice cream), strained or blended cream soups,
custards, refined cooked cereals, vegetable juice, pureed vegetables, all fruit juices,
sherbets, puddings, frozen yogurt
Questions and Answers (2023/ 2024 Update) - Chamberlain
What is the most effective method to prevent the transfer of clostridium difficile (C.
Difficile)? - ANSWER HAND HYGIENE with soap and water is effective to physically
remove C. difficile spores from the hands. (Potter 1092)
What is the term for the [abnormal] method used to assist in stool passage by exerting
pressure to expel fecal matter through voluntary contraction of the abdominal muscles
while maintaining a forced expiration against a closed airway? - ANSWER Valsalva
maneuver
*Normal passage of bowels should be painless, passing soft formed stool*
Which patients are at greatest risk for cardiac dysrhythmia and high blood pressure with
the Valsalva maneuver and MUST avoid straining to pass stool? - ANSWER Patients
with cardiovascular disease, glaucoma, increased intracranial pressure, or a new
surgical wound
(Potter 1089)
What is the term for a collection of hardened feces in the rectum that cannot be expelled
due to unrelieved constipation? - ANSWER Fecal Impaction
Where does fecal impaction occur in the colon? - ANSWER Rectum
Least formed stool is present in which portion of the digestive tract? - ANSWER
Ascending Colon
Most formed stool is present in which portion of the digestive tract? - ANSWER
Descending Colon
Which position should the patient be in while administering an enema? - ANSWER Left
Side-Lying or Sim's Position
Which factors would contribute to stopping enema administration? - ANSWER If
bleeding occurs, abdomen becomes rigid and distended, pain occurs, or resistance is
felt
Which enema solution is the safest for administration because it does NOT create a
danger for excess fluid absorption? - ANSWER Normal Saline [Isotonic Solution]
,Which enema solution is contraindicated in patients who are dehydrated or young
infants because of risk for fluid imbalance? - ANSWER Hypertonic Solution
Which enema solution is considered to be hypotonic and should NOT be repeated
because of the risk of water toxicity or circulatory overload if and because the body
absorbs excessive amounts of water? - ANSWER Tap Water [Hypotonic Solution]
Which enema solution lubricates the rectum and allows the feces to absorb the oil
making them soft and easier to pass? - ANSWER Oil Retention
Which enema solution creates intestinal irritation to stimulate peristalsis by using castile
soap? - ANSWER Soapsuds
Which enema solution should be used in caution in pregnant women and elderly
because it may cause an electrolyte imbalance or damage to intestinal mucosa? -
ANSWER Soapsuds
Which laboratory test is used to measure microscopic amounts of blood in the feces
(blood that cannot be seen) - ANSWER Guaiac Fecal Occult Blood Test
Repeat the test at least three times while the patient refrains from ingesting foods (e.g.,
some raw vegetables, red meat, poultry, fish) and medications (e.g., vitamin C, aspirin,
non-steroidal anti-inflammatory drugs) that cause false-positive results
(Potter 1100)
When analyzing a fecal specimens for ova and parasites, what is required of the stool? -
ANSWER The stool MUST be warm.
If the stool specimen remains at room temperature, bacteriological changes can alter
the test results
Which cathartic form is most effective because of its stimulant effect on the rectal
mucosa?
(Example: Dulcolax)? - ANSWER Cathartic Suppositories
Which foods induce a constipating effect? - ANSWER cheese, lean meats, eggs, and
pasta
Which food induce a laxative effect? - ANSWER fruits, vegetables, bran, chocolate,
alcohol, and coffee
What are the assessment findings of a normal stoma? - ANSWER bright pink or brick
red
,Notify HCP of stoma is blue, purple, brown, or black which indicates circulation problem
to the stoma
How does the nurse measure the length of the NG tube for insertion? - ANSWER Tip of
the nose --> earlobe --> xiphoid process
What is the most reliable method of verification for placement of the NG tube? -
ANSWER X-ray
Other methods include: pH test (aspirate and inspect color)
What are the ranges for body mass index? - ANSWER Normal = 19-24
Overweight = 25-29
Obese = 30-39
Extremely Obese = > 40
When energy requirements are completely met or EQUALS kcal intake in food what
occurs? - ANSWER Weight does not change
When kcal intake in food is LESS THAN energy requirements what occurs? - ANSWER
Loose weight
When kcal intake in food is GREATER THAN energy requirements what occurs? -
ANSWER Gain weight
Nutrients are absorbed in what portion of the digestive tract? - ANSWER Small intestine
[duodenum]
Proteins are necessary for _________ balance - ANSWER Positive protein and nitrogen
balance for healing, growth, and tissue repair
1 gram of carbohydrates = ____ kcal - ANSWER 4 kcal
1 gram of fat = ____ kcal - ANSWER 9 kcal
Most calorie dense
< ___ % of fat intake of daily nutrition is considered a nutritional deficiency - ANSWER <
10%
1 gram of protein = ___ kcal - ANSWER 4 kcal
Which amino acids are NOT manufactured by the body and MUST be obtained through
diet or external source are known as? - ANSWER Indispensable amino acids
, Which amino acids ARE manufactured by the body? - ANSWER Dispensable amino
acids
The ChooseMyPlate program was developed by whom? - ANSWER U.S. Department of
Agriculture
Which program established guidelines for balancing calories? - ANSWER
ChooseMyPlate
What are the goals of ChooseMyPlate? - ANSWER decreasing portion size, increasing
healthy food intake, increase water consumption, maintain body weight in a healthy
range, increase activity, decrease salt intake, increase fruit, vegetable, and whole grain
intake
Which measurement is determined by dividing the patients weight in kilograms by
height in meters squared and is considered to be the most reliable indicator of
nutritional status and health by HCP's? - ANSWER Body Mass Index [BMI]
Vegans are at risk for which nutritional deficiency? - ANSWER Vitamin B12 deficiency
b/c the vitamin is only found in animal sources and vegans ONLY consume plant
products
Breast milk or formula provides sufficient nutrition for the first _____ to _____ months of
life - ANSWER 4 to 6 months
Breast milk benefits: fewer food allergies and intolerances; fewer infant infections;
easier digestion; convenience, availability, and freshness; temperature always correct;
economical because it is less expensive than formula; and increased time for mother
and infant interaction. (Potter 1002)
Infants should not have regular cow's milk during the first year of life. It is too
concentrated for an infant's kidneys to manage, increases the risk of milk product
allergies, and is a poor source of iron and vitamins C and E. Honey and corn syrup are
potential sources of botulism toxin and should not be used in an infant's diet. This toxin
is potentially fatal in children under 1 year of age (Potter 1002)
What are the therapeutic diets? - ANSWER Clear Liquid
Clear fat-free broth, bouillon, coffee, tea, carbonated beverages, clear fruit juices,
gelatin, fruit ices, popsicles
Full Liquid
smooth-textured dairy products (e.g., ice cream), strained or blended cream soups,
custards, refined cooked cereals, vegetable juice, pureed vegetables, all fruit juices,
sherbets, puddings, frozen yogurt
