NR 224 FUNDAMENTALS QUESTIONS AND ANSWERS/ A+ GRADE
What is the most effective method to prevent the transfer of clostridium difficile
(C. Difficile) ?
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?
Valsalva Manuever
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 manuever and MUST avoid straining to pass stool?
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?
Fecal Impaction
Where does fecal impaction occur in the colon?
Rectum
Least formed stool is present in which portion of the digestive tract?
Ascending Colon
Most formed stool is present in which portion of the digestive tract?
Descending Colon
Which position should the patient be in while administering an enema?
Left Side-Lying or Sim's Position
Which factors would contribute to stopping enema administration?
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?
Normal Saline [Isotonic Solution]
Which enema solution is contraindicated in patients who are dehydrated or
young infants because of risk for fluid imbalance?
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?
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?
,Oil Retention
Which enema solution creates intestinal irritation to stimulate peristalsis by using
castile soap?
Soapsuds
Which enema solution should used in caution in pregnant women and elderly
because it may cause an electrolyte imbalance or damage to intestinal mucosa?
Soapsuds
Which laboratory test is used to measure microscopic amounts of blood in the
feces (blood that cannot be seen)
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?
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)?
Cathartic Suppositories
Which foods induce a constipating effect?
cheese, lean meats, eggs, and pasta
Which food induce a laxative effect?
fruits, vegetables, bran, chocolate, alcohol, and coffee
What are the assessment findings of a normal stoma?
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?
Tip of the nose --> earlobe --> xiphoid process
What is the most reliable method of verification for placement of the NG tube?
X-ray
Other methods include: pH test (aspirate and inspect color)
What are the ranges for body mass index?
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?
Weight does not change
When kcal intake in food is LESS THAN energy requirements what occurs?
Loose weight
When kcal intake in food is GREATER THAN energy requirements what occurs?
Gain weight
Nutrients are absorbed in what portion of the digestive tract?
Small intestine [duodenum]
Proteins are necessary for _________ balance
Positive protein and nitrogen balance for healing, growth, and tissue repair
1 gram of carbohydrates = ____ kcal
4 kcal
1 gram of fat = ____ kcal
9 kcal
Most calorie dense
< ___ % of fat intake of daily nutrition is considered a nutritional deficiency
< 10%
1 gram of protein = ___ kcal
4 kcal
Which amino acids are NOT manufactured by the body and MUST be obtained
through diet or external source are known as?
Indispensable amino acids
Which amino acids ARE manufactured by the body?
Dispensable amino acids
The ChooseMyPlate program was developed by whom?
U.S. Department of Agriculture
Which program established guidelines for balancing calories?
ChooseMyPlate
What are the goals of ChooseMyPlate?
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?
Body Mass Index [BMI]
Vegans are at risk for which nutritional deficiency?
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
4 to 6 months
Breast milk benefits: fewer food allergies and intolerances; fewer infant infections;
What is the most effective method to prevent the transfer of clostridium difficile
(C. Difficile) ?
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?
Valsalva Manuever
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 manuever and MUST avoid straining to pass stool?
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?
Fecal Impaction
Where does fecal impaction occur in the colon?
Rectum
Least formed stool is present in which portion of the digestive tract?
Ascending Colon
Most formed stool is present in which portion of the digestive tract?
Descending Colon
Which position should the patient be in while administering an enema?
Left Side-Lying or Sim's Position
Which factors would contribute to stopping enema administration?
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?
Normal Saline [Isotonic Solution]
Which enema solution is contraindicated in patients who are dehydrated or
young infants because of risk for fluid imbalance?
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?
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?
,Oil Retention
Which enema solution creates intestinal irritation to stimulate peristalsis by using
castile soap?
Soapsuds
Which enema solution should used in caution in pregnant women and elderly
because it may cause an electrolyte imbalance or damage to intestinal mucosa?
Soapsuds
Which laboratory test is used to measure microscopic amounts of blood in the
feces (blood that cannot be seen)
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?
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)?
Cathartic Suppositories
Which foods induce a constipating effect?
cheese, lean meats, eggs, and pasta
Which food induce a laxative effect?
fruits, vegetables, bran, chocolate, alcohol, and coffee
What are the assessment findings of a normal stoma?
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?
Tip of the nose --> earlobe --> xiphoid process
What is the most reliable method of verification for placement of the NG tube?
X-ray
Other methods include: pH test (aspirate and inspect color)
What are the ranges for body mass index?
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?
Weight does not change
When kcal intake in food is LESS THAN energy requirements what occurs?
Loose weight
When kcal intake in food is GREATER THAN energy requirements what occurs?
Gain weight
Nutrients are absorbed in what portion of the digestive tract?
Small intestine [duodenum]
Proteins are necessary for _________ balance
Positive protein and nitrogen balance for healing, growth, and tissue repair
1 gram of carbohydrates = ____ kcal
4 kcal
1 gram of fat = ____ kcal
9 kcal
Most calorie dense
< ___ % of fat intake of daily nutrition is considered a nutritional deficiency
< 10%
1 gram of protein = ___ kcal
4 kcal
Which amino acids are NOT manufactured by the body and MUST be obtained
through diet or external source are known as?
Indispensable amino acids
Which amino acids ARE manufactured by the body?
Dispensable amino acids
The ChooseMyPlate program was developed by whom?
U.S. Department of Agriculture
Which program established guidelines for balancing calories?
ChooseMyPlate
What are the goals of ChooseMyPlate?
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?
Body Mass Index [BMI]
Vegans are at risk for which nutritional deficiency?
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
4 to 6 months
Breast milk benefits: fewer food allergies and intolerances; fewer infant infections;
