,NU 160 Exam 2 | Comprehensive Questions & Verified
1. Which of the following best describes primary intention wound healing?
A) Wound edges are approximated with minimal tissue loss and scarring
B) The wound is left open and fills with granulation tissue
C) The wound is surgically debrided and left open
D) The wound heals from the bottom up with contraction
Correct Answer: Wound edges are approximated with minimal tissue loss and scarring
Rationale: Primary intention occurs when wound edges are closely approximated (sutures, staples) with
little tissue loss, resulting in a thin scar. Secondary intention involves open wounds that fill with
granulation tissue from the base upward.
2. The nurse is instructing a patient on the use of an incentive spirometer. Which instruction is correct?
A) Exhale forcefully into the mouthpiece
B) Inhale slowly and deeply, then hold the breath for 3 to 5 seconds
C) Use the device only once daily
D) Lie flat while using the device
Correct Answer: Inhale slowly and deeply, then hold the breath for 3 to 5 seconds
Rationale: Incentive spirometry encourages sustained maximal inspiration to open alveoli and prevent
atelectasis. Holding the breath maintains alveolar expansion. The device is used every 1 to 2 hours while
awake.
3. The nurse is caring for a patient receiving continuous bladder irrigation. The outflow is significantly
less than the inflow. What is the priority nursing action?
A) Increase the irrigation flow rate
B) Manually irrigate the catheter with a syringe
C) Assess for bladder distention and check for kinks in the tubing
,D) Remove the catheter and replace it
Correct Answer: Assess for bladder distention and check for kinks in the tubing
Rationale: Reduced outflow suggests obstruction, often from clots or kinked tubing. The nurse should
first check the system for mechanical issues and assess the patient for discomfort before performing
manual irrigation.
4. A nursing student asks the instructor to explain "serosanguineous drainage." The instructor responds
that it is
A) thick, yellow, and purulent
B) bright red and active bleeding
C) clear and watery
D) pink-tinged, thin, and watery
Correct Answer: Pink-tinged, thin, and watery
Rationale: Serosanguineous drainage is a mixture of serum and blood, appearing pink to light red and
thin. Purulent drainage is thick and yellow/green; sanguineous is bright red; serous is clear.
5. Which of the following is an appropriate nursing intervention to prevent atelectasis in a postoperative
patient?
A) Encourage early ambulation and use of an incentive spirometer
B) Maintain the patient on strict bedrest
C) Administer cough suppressants regularly
D) Limit fluid intake to minimize secretions
Correct Answer: Encourage early ambulation and use of an incentive spirometer
, Rationale: Early ambulation and incentive spirometry promote lung expansion and prevent alveolar
collapse. Bedrest, cough suppressants, and fluid restriction increase the risk of atelectasis and
pneumonia.
6. When monitoring a patient receiving a blood transfusion, the nurse notes hives and itching. The first
action is to
A) continue the transfusion and monitor
B) stop the transfusion and maintain the IV line with normal saline, then notify the provider
C) administer an antipyretic
D) increase the transfusion rate
Correct Answer: Stop the transfusion and maintain the IV line with normal saline, then notify the
provider
Rationale: Hives and itching suggest a possible allergic reaction. The transfusion must be stopped, the IV
line kept open with saline, and the provider notified. Antihistamines may be ordered.
7. The nurse is caring for a patient with a fecal impaction. Which intervention is expected?
A) Administer a cleansing enema
B) Insert a nasogastric tube
C) Perform digital removal of the impaction
D) Restrict all oral intake
Correct Answer: Perform digital removal of the impaction
Rationale: Fecal impaction requires manual removal by a qualified nurse; enemas alone may not
dislodge hardened stool. This procedure requires a provider order and careful technique due to vagal
stimulation risk.
8. The nurse is teaching a patient how to collect a 24-hour urine specimen. The collection should begin
A) with the first morning void
1. Which of the following best describes primary intention wound healing?
A) Wound edges are approximated with minimal tissue loss and scarring
B) The wound is left open and fills with granulation tissue
C) The wound is surgically debrided and left open
D) The wound heals from the bottom up with contraction
Correct Answer: Wound edges are approximated with minimal tissue loss and scarring
Rationale: Primary intention occurs when wound edges are closely approximated (sutures, staples) with
little tissue loss, resulting in a thin scar. Secondary intention involves open wounds that fill with
granulation tissue from the base upward.
2. The nurse is instructing a patient on the use of an incentive spirometer. Which instruction is correct?
A) Exhale forcefully into the mouthpiece
B) Inhale slowly and deeply, then hold the breath for 3 to 5 seconds
C) Use the device only once daily
D) Lie flat while using the device
Correct Answer: Inhale slowly and deeply, then hold the breath for 3 to 5 seconds
Rationale: Incentive spirometry encourages sustained maximal inspiration to open alveoli and prevent
atelectasis. Holding the breath maintains alveolar expansion. The device is used every 1 to 2 hours while
awake.
3. The nurse is caring for a patient receiving continuous bladder irrigation. The outflow is significantly
less than the inflow. What is the priority nursing action?
A) Increase the irrigation flow rate
B) Manually irrigate the catheter with a syringe
C) Assess for bladder distention and check for kinks in the tubing
,D) Remove the catheter and replace it
Correct Answer: Assess for bladder distention and check for kinks in the tubing
Rationale: Reduced outflow suggests obstruction, often from clots or kinked tubing. The nurse should
first check the system for mechanical issues and assess the patient for discomfort before performing
manual irrigation.
4. A nursing student asks the instructor to explain "serosanguineous drainage." The instructor responds
that it is
A) thick, yellow, and purulent
B) bright red and active bleeding
C) clear and watery
D) pink-tinged, thin, and watery
Correct Answer: Pink-tinged, thin, and watery
Rationale: Serosanguineous drainage is a mixture of serum and blood, appearing pink to light red and
thin. Purulent drainage is thick and yellow/green; sanguineous is bright red; serous is clear.
5. Which of the following is an appropriate nursing intervention to prevent atelectasis in a postoperative
patient?
A) Encourage early ambulation and use of an incentive spirometer
B) Maintain the patient on strict bedrest
C) Administer cough suppressants regularly
D) Limit fluid intake to minimize secretions
Correct Answer: Encourage early ambulation and use of an incentive spirometer
, Rationale: Early ambulation and incentive spirometry promote lung expansion and prevent alveolar
collapse. Bedrest, cough suppressants, and fluid restriction increase the risk of atelectasis and
pneumonia.
6. When monitoring a patient receiving a blood transfusion, the nurse notes hives and itching. The first
action is to
A) continue the transfusion and monitor
B) stop the transfusion and maintain the IV line with normal saline, then notify the provider
C) administer an antipyretic
D) increase the transfusion rate
Correct Answer: Stop the transfusion and maintain the IV line with normal saline, then notify the
provider
Rationale: Hives and itching suggest a possible allergic reaction. The transfusion must be stopped, the IV
line kept open with saline, and the provider notified. Antihistamines may be ordered.
7. The nurse is caring for a patient with a fecal impaction. Which intervention is expected?
A) Administer a cleansing enema
B) Insert a nasogastric tube
C) Perform digital removal of the impaction
D) Restrict all oral intake
Correct Answer: Perform digital removal of the impaction
Rationale: Fecal impaction requires manual removal by a qualified nurse; enemas alone may not
dislodge hardened stool. This procedure requires a provider order and careful technique due to vagal
stimulation risk.
8. The nurse is teaching a patient how to collect a 24-hour urine specimen. The collection should begin
A) with the first morning void
