NURS 225 EXAM 2 ASSESSMENT TEST 2026
TESTED QUESTIONS WITH FULL SOLUTION
GRADED A+
◉ A nurse is measuring intake and output for a patient who has
congestive heart failure. What does not need to be recorded?
Answer: Fluid consumption
◉ A client is brought into the emergency department with a
suspected opioid overdose. The nurse would anticipate that the
client would most likely experience which acid-base imbalance?
Answer: Respiratory acidosis
◉ A nurse is caring for a patient who has a PICC line. Which nursing
action is recommended? Answer: Flush using normal saline and/or
heparin solution according to facility policy.
◉ A nurse measures a client's 24-hour fluid intake and documents
the findings. To be an accurate indicator of fluid status, what must
the nurse also do with the information? Answer: Compare the total
intake and output of fluids for the 24 hours.
◉ A nurse who has diagnosed a patient as having "fluid volume
excess" related to compromised regulatory mechanism (kidneys)
,may have been alerted by what symptom? Answer: Distended neck
veins
◉ A nurse caring for a female client notes a number of laceration
wounds around the cervix of the uterus due to childbirth. How could
the nurse describe the laceration wound in the client's medical
record? Answer: A separation of skin and tissue in which the edges
are torn and irregular
◉ A nurse is caring for a client with dehydration at the health care
facility. The client is receiving glucose intravenously. What type of
dressing should the nurse use to cover the IV insertion site? Answer:
Transparent
◉ Dehiscence is the softening of tissue due to excessive moisture.
Answer: False
◉ A nurse caring for a client who has a surgical wound following a
cesarean section notes dehiscence of the wound and contacts the
surgeon. Which of the following is a finding related to this condition?
Answer: There is an accidental separation of the wound.
◉ When patients are pulled up in bed rather than lifted, they are at
increased risk for the development of a decubitus ulcer. What is the
name given to the factor responsible for this risk? Answer: shearing
force
, ◉ A medical-surgical nurse is assisting a wound care nurse with the
debridement of a client's coccyx wound. What is the primary goal of
this action? Answer: Removing dead or infected tissue to promote
wound healing
◉ Which of the following actions should the nurse perform when
applying negative pressure wound therapy? Answer: Cut foam to the
shape of the wound and place it in the wound.
◉ T/F: A Penrose drain typically exits a patient's skin through a stab
wound created by the surgeon. Answer: True
◉ What nursing diagnosis would be a priority for a client who has a
large wound from colon surgery, is obese, and is taking
corticosteroid medications? Answer: Risk for Infection
◉ The nurse considers the impact of shearing forces in the
development of pressure ulcers in patients. Which patient would be
most likely to develop a pressure ulcer from shearing forces?
Answer: A patient sitting in a chair who slides down
◉ A nurse is assessing a client with a stage IV pressure ulcer. What
assessment of the ulcer would be expected? Answer: Full-thickness
skin loss
TESTED QUESTIONS WITH FULL SOLUTION
GRADED A+
◉ A nurse is measuring intake and output for a patient who has
congestive heart failure. What does not need to be recorded?
Answer: Fluid consumption
◉ A client is brought into the emergency department with a
suspected opioid overdose. The nurse would anticipate that the
client would most likely experience which acid-base imbalance?
Answer: Respiratory acidosis
◉ A nurse is caring for a patient who has a PICC line. Which nursing
action is recommended? Answer: Flush using normal saline and/or
heparin solution according to facility policy.
◉ A nurse measures a client's 24-hour fluid intake and documents
the findings. To be an accurate indicator of fluid status, what must
the nurse also do with the information? Answer: Compare the total
intake and output of fluids for the 24 hours.
◉ A nurse who has diagnosed a patient as having "fluid volume
excess" related to compromised regulatory mechanism (kidneys)
,may have been alerted by what symptom? Answer: Distended neck
veins
◉ A nurse caring for a female client notes a number of laceration
wounds around the cervix of the uterus due to childbirth. How could
the nurse describe the laceration wound in the client's medical
record? Answer: A separation of skin and tissue in which the edges
are torn and irregular
◉ A nurse is caring for a client with dehydration at the health care
facility. The client is receiving glucose intravenously. What type of
dressing should the nurse use to cover the IV insertion site? Answer:
Transparent
◉ Dehiscence is the softening of tissue due to excessive moisture.
Answer: False
◉ A nurse caring for a client who has a surgical wound following a
cesarean section notes dehiscence of the wound and contacts the
surgeon. Which of the following is a finding related to this condition?
Answer: There is an accidental separation of the wound.
◉ When patients are pulled up in bed rather than lifted, they are at
increased risk for the development of a decubitus ulcer. What is the
name given to the factor responsible for this risk? Answer: shearing
force
, ◉ A medical-surgical nurse is assisting a wound care nurse with the
debridement of a client's coccyx wound. What is the primary goal of
this action? Answer: Removing dead or infected tissue to promote
wound healing
◉ Which of the following actions should the nurse perform when
applying negative pressure wound therapy? Answer: Cut foam to the
shape of the wound and place it in the wound.
◉ T/F: A Penrose drain typically exits a patient's skin through a stab
wound created by the surgeon. Answer: True
◉ What nursing diagnosis would be a priority for a client who has a
large wound from colon surgery, is obese, and is taking
corticosteroid medications? Answer: Risk for Infection
◉ The nurse considers the impact of shearing forces in the
development of pressure ulcers in patients. Which patient would be
most likely to develop a pressure ulcer from shearing forces?
Answer: A patient sitting in a chair who slides down
◉ A nurse is assessing a client with a stage IV pressure ulcer. What
assessment of the ulcer would be expected? Answer: Full-thickness
skin loss
