Fundamentals of Nursing Quiz 3b Fall 2025 at Jersey College School of Nursing
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Free Fundamentals of Nursing Quiz 3b Fall 2025 at Jersey College School of Nursing Questions
A client has just been diagnosed with severe hypovolemia. Which of the following interventions would be appropriate? (Select all that apply)
- A. Strict monitoring of intake and output
- B. Encourage the patient to ambulate in the hallway frequently
- C. Anticipate the MD will place the patient on fluid restrictions
- D. Place the patient on NPO status
- E. Notify the MD if the patient does not void at least once every 8 hours
Explanation
A. Strict monitoring of intake and output:
In severe hypovolemia, careful monitoring of fluid intake and output is crucial to assess fluid balance, kidney function, and the effectiveness of fluid replacement therapy. This helps detect worsening dehydration or signs of renal hypoperfusion early, guiding the provider in adjusting treatment.
E. Notify the MD if the patient does not void at least once every 8 hours:
Oliguria (low urine output) is an important indicator of inadequate renal perfusion and worsening hypovolemia. Promptly notifying the healthcare provider allows for timely intervention, such as fluid resuscitation, to prevent kidney injury or shock.
As the nurse, you are evaluating your patient’s lab values, which show a blood pH of 7.25. As the nurse, you have determined that your patient is in a state of:
- A. Acidosis
- B. Alkalosis
- C. Homeostasis
- D. A state of dehydration
Explanation
Normal blood pH ranges from 7.35 to 7.45. A pH below 7.35 indicates acidosis, meaning the blood is more acidic than normal due to excess hydrogen ions or decreased bicarbonate. This imbalance can result from respiratory causes (CO₂ retention, as in COPD) or metabolic causes (lactic acid buildup, renal failure, or diabetic ketoacidosis). Prompt recognition and treatment are essential to restore acid-base balance and prevent organ dysfunction.
Which of the following is a good type of cholesterol that is responsible for taking excess cholesterol back to the liver from the cells?
- A. High-density lipoprotein (HDL)
- B. Trans fat
- C. Triglycerides
- D. Low-density lipoprotein (LDL)
Explanation
High-density lipoprotein (HDL) is known as the “good” cholesterol because it helps remove excess cholesterol from the bloodstream and peripheral tissues, transporting it back to the liver for metabolism and excretion. This process, called reverse cholesterol transport, helps reduce plaque buildup in arteries, lowering the risk of atherosclerosis, heart attack, and stroke. Higher HDL levels are associated with better cardiovascular health and overall lipid balance.
Fat-soluble vitamins can become toxic due to which of the following factors?
- A. Fat-soluble vitamins are not needed in the body, so do not need to be consumed in large amounts.
- B. Fat-soluble vitamins are stored in the kidneys and can become toxic when not enough water is consumed.
- C. Fat-soluble vitamins are dissolvable in water and are stored into the bloodstream from the GI tract.
- D. Fat-soluble vitamins are stored in body fat and can become toxic when consumed in excess.
Explanation
Fat-soluble vitamins (A, D, E, and K) are absorbed with dietary fat and stored in adipose (fat) tissue and the liver. Because the body does not excrete them readily through urine, excessive intake over time can lead to toxicity. For example, too much vitamin A can cause liver damage and vision problems, while excess vitamin D can lead to hypercalcemia. Therefore, supplementation should be monitored carefully.
Which of the following would be a possible observation related to fluid volume deficit? (Select all that apply)
- A. Low blood pressure
- B. Increased urine output
- C. Strong, bounding pulse
- D. Flushed, pale, hot, dry skin
- E. Decreased urine output
Explanation
A. Low blood pressure:
In fluid volume deficit (hypovolemia), there is a decrease in circulating blood volume, which leads to reduced venous return and cardiac output. This causes a drop in blood pressure, especially orthostatic hypotension when standing. The body compensates by increasing heart rate to maintain perfusion, but sustained low blood pressure is a hallmark sign of dehydration or fluid loss.
E. Decreased urine output:
The kidneys respond to decreased fluid volume by conserving water, leading to oliguria (low urine output). This compensatory mechanism helps preserve circulating blood volume and prevent further dehydration. Urine also becomes more concentrated and darker in color due to reduced fluid excretion.
The primary function of carbohydrates as a food source is to:
- A. Build body tissue
- B. Increase blood sugar in the body
- C. Regulate metabolic processes
- D. Supply energy
Explanation
The main function of carbohydrates is to supply energy to the body. They are the body’s primary and most efficient energy source, providing 4 calories per gram. Once digested, carbohydrates are broken down into glucose, which fuels cellular activities, brain function, and muscle contraction. The body stores excess glucose as glycogen in the liver and muscles for later use, ensuring a steady energy supply between meals or during physical activity.
The nurse has been assigned to care for a patient who had a PEG tube placed 1 week ago. The patient receives intermittent feedings. The nurse understands her responsibility when she performs what interventions prior to each feeding? (Select all that apply)
- A. Assess abdomen for distention
- B. Check placement and residual
- C. Elevate the head of the bed during feedings
- D. Inspect skin integrity around insertion site
- E. Offer sips of water prior to feeding
Explanation
A. Assess abdomen for distention:
Abdominal distention may indicate feeding intolerance, delayed gastric emptying, or bowel obstruction. Assessing the abdomen ensures safe continuation of enteral nutrition and helps prevent complications such as aspiration or vomiting.
B. Check placement and residual:
Verifying tube placement before each feeding ensures the PEG tube remains in the stomach and has not migrated. Checking residual volume assesses gastric emptying; large residuals may indicate delayed digestion and increase the risk of aspiration.
C. Elevate the head of the bed during feedings:
Raising the head of the bed at least 30–45 degrees prevents aspiration of gastric contents into the lungs, a major risk associated with enteral feeding.
D. Inspect skin integrity around insertion site:
The PEG site should be assessed for redness, drainage, swelling, or infection. Early identification of skin breakdown or infection helps prevent more serious complications such as peritonitis.
When a nurse inserts a nasogastric (NG) tube, the client becomes cyanotic, coughs incessantly, and is unable to speak. The nurse should do which of the following immediately?
- A. Continue to insert the tube quickly.
- B. Use a tongue blade to view the posterior pharynx.
- C. Tape the tube to the client’s nares.
- D. Stop and withdraw the tube.
Explanation
If a client becomes cyanotic, coughs uncontrollably, or cannot speak during NG tube insertion, the tube has likely entered the trachea instead of the esophagus, obstructing the airway. The immediate action is to stop the procedure and withdraw the tube to prevent aspiration or respiratory arrest. Once the client’s breathing returns to normal, reassess and reattempt only after ensuring airway patency and following proper insertion technique.
The nurse recognizes that the process that gently propels the food bolus into the small intestine is called:
- A. Absorption
- B. Indigestion
- C. Digestion
- D. Peristalsis
Explanation
Peristalsis is the coordinated, wave-like contraction and relaxation of the smooth muscles in the gastrointestinal tract that propels the food bolus forward through the esophagus, stomach, and intestines. This rhythmic motion ensures the continuous movement of food along the digestive tract, allowing for proper mixing with digestive enzymes and eventual passage into the small intestine for nutrient absorption. It is an involuntary process controlled by the autonomic nervous system.
The nurse reviews a client’s electrolyte levels on a laboratory report and notes the client has hyponatremia. Which symptoms will the nurse expect to find during assessment?
- A. Edema in lower extremities
- B. Respiratory crackles in all lobes
- C. Blood pressure of 100/58 mm Hg
- D. Bounding pulse at 54 beats/minute
Explanation
Hyponatremia (low sodium level, usually <135 mEq/L) often results in low blood pressure due to decreased circulating volume and impaired water balance. Sodium helps regulate extracellular fluid and maintain blood pressure; when sodium is low, water shifts into cells, reducing vascular volume. This can cause hypotension, dizziness, weakness, and confusion. The nurse should monitor neurological status and serum sodium closely, as severe hyponatremia may cause seizures or coma.
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