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
The nurse’s morning assessment of a client who has a history of heart failure reveals the presence of 2+ pitting edema in the client’s ankles and feet bilaterally. This assessment finding is suggestive of:
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Hyponatremia
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Metabolic acidosis
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Fluid volume excess
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Hypovolemia
Explanation
Fluid volume excess (hypervolemia) occurs when there is an abnormal retention of sodium and water in the body, leading to tissue swelling and edema. In patients with heart failure, the heart’s decreased pumping ability causes venous congestion, resulting in 2+ pitting edema—a sign of fluid accumulation in the interstitial spaces, particularly in dependent areas like the ankles and feet. The nurse should monitor daily weights, lung sounds, and intake/output closely to assess the severity of fluid overload.
Which of the following vitamins are dissolvable only in fat, and unlike water-soluble vitamins, they can be stored in body fat?
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Vitamins B, C, E, and K
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Vitamins A, B, C, and D
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Vitamins B1 (thiamine), B9 (folic acid), and B7 (biotin)
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Vitamins A, D, E, and K
Explanation
Vitamins A, D, E, and K are fat-soluble vitamins, meaning they dissolve in fat and are absorbed along with dietary lipids in the small intestine. Unlike water-soluble vitamins, they can be stored in the liver and adipose tissue, allowing for long-term reserves. However, excessive intake can lead to toxicity since they are not readily excreted in urine. These vitamins are essential for vision (A), calcium regulation (D), antioxidant protection (E), and blood clotting (K).
Fat-soluble vitamins can become toxic due to which of the following factors?
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Fat-soluble vitamins are not needed in the body, so do not need to be consumed in large amounts.
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Fat-soluble vitamins are stored in the kidneys and can become toxic when not enough water is consumed.
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Fat-soluble vitamins are dissolvable in water and are stored into the bloodstream from the GI tract.
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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.
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)
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Assess abdomen for distention
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Check placement and residual
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Elevate the head of the bed during feedings
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Inspect skin integrity around insertion site
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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.
The nurse is assessing a patient who is showing early signs of hypoxia. What should the nurse expect to find on her assessment? (Select all that apply)
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Cyanosis
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Agitation
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Tachypnea
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Restlessness
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Bradycardia
Explanation
B. Agitation:
Agitation occurs as one of the earliest signs of hypoxia due to inadequate oxygen delivery to the brain. The body and mind respond with anxiety, irritability, or confusion as oxygen levels begin to drop.
C. Tachypnea:
In response to decreased oxygen levels, the respiratory rate increases (tachypnea) to compensate and deliver more oxygen to the tissues. This is an early compensatory mechanism to prevent further hypoxia.
D. Restlessness:
Restlessness is an early neurologic sign of hypoxia. The brain is highly sensitive to oxygen deprivation, and this manifests as unease, inability to focus, or constant movement in the patient.
The nurse recognizes that the process that gently propels the food bolus into the small intestine is called:
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Absorption
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Indigestion
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Digestion
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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 client has been refusing to drink fluids and has become dehydrated. Which of the following are observation findings that you would expect to find in a client with dehydration? (Select all that apply)
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Client reports little or no urine output
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Client observed with a weak pulse
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Client observed with edema of extremities
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Client observed with full, bounding pulse
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Client complains of thirst or nausea
Explanation
A. Client reports little or no urine output:
Dehydration leads to reduced kidney perfusion, causing the body to conserve fluid by decreasing urine output (oliguria). Urine becomes concentrated and darker in color.
B. Client observed with a weak pulse:
A weak, thready pulse is a hallmark of fluid volume deficit. With less circulating volume, cardiac output drops, and the pulse becomes rapid but weak as the heart tries to compensate.
E. Client complains of thirst or nausea:
Thirst is an early compensatory response to fluid loss, signaling the body’s need for water replacement. Nausea can occur due to reduced perfusion to the gastrointestinal tract.
The nurse is providing care for a client with a history of cardiac problems. The nurse notes the client's potassium level is 2.9 mEq/L. The nurse understands that the reason the physician has ordered a daily dose of potassium is:
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The potassium is ordered in an attempt to prevent cardiac arrhythmias.
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The client’s cardiac diet is deficient in foods with high potassium levels.
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The physician is attempting to increase urinary output to decrease cardiac stress.
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The potassium is ordered to prevent the client from becoming hypoxic.
Explanation
A potassium level of 2.9 mEq/L indicates hypokalemia, which can cause serious cardiac arrhythmias such as premature ventricular contractions (PVCs), ventricular tachycardia, or even cardiac arrest. Potassium plays a vital role in maintaining normal electrical conduction within the heart. The physician orders potassium replacement to restore normal cardiac rhythm and prevent life-threatening dysrhythmias, especially in clients with a cardiac history.
The nurse is reviewing laboratory values of multiple clients with fluid and electrolyte imbalance. Which laboratory value does the nurse identify as representing a therapeutic response to treatment?
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Sodium = 136 mEq/L
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Sodium = 149 mEq/L
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Sodium = 147 mEq/L
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Sodium = 132 mEq/L
Explanation
The normal serum sodium range is 135–145 mEq/L. A level of 136 mEq/L falls within this range and indicates that sodium balance has been successfully restored. This represents a therapeutic response in a client being treated for either hyponatremia (low sodium) or hypernatremia (high sodium). Maintaining normal sodium levels is critical for fluid balance, nerve conduction, and muscle contraction.
The nurse is providing care for an older, sedentary female client. The client admits a lack of knowledge regarding a healthy diet. Which nutrition information would be appropriate for the nurse to give the patient?
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The FDA suggests minimum daily intake of nutrients to went disease.
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The "My Plate" guidelines are visually and comprehensively complex.
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"Dietary Guidelines for Americans" only covers vegetarian diets.
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The FDA suggests minimum daily intake of nutrients to prevent disease.
Explanation
The FDA (Food and Drug Administration) provides Recommended Dietary Allowances (RDAs) and Daily Values (DVs) that indicate the minimum daily intake of essential nutrients required to maintain health and prevent nutritional deficiencies or disease. This guidance helps individuals—especially older adults—make informed food choices and maintain balanced nutrition for optimal health and disease prevention. The nurse should encourage the patient to follow these standards along with resources like the USDA’s MyPlate for balanced meal planning.
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