RNSG 1517 PROTECTION &
REGULATION EXAM 5 3220 PRACTICE
QUESTIONS AND ANWERS WITH
DETAILED RATIONALES
Questions 1–50
1. The nurse is caring for an older client during the intraoperative stage. The
anesthesia process has already begun and the nurse has already removed the
dentures, eyeglasses, and hearing aids. What is the FIRST intraoperative
nursing intervention the nurse should perform?
A. Cover the client's head and feet
B. Use a warming device to prevent hypothermia
C. Use a small pillow under the client's head
D. Pad bony prominences to prevent pressure sores
Correct Answer: C
Rationale: After anesthesia has begun and dentures, eyeglasses, and hearing
aids have been removed, the nurse should first place a small pillow under the
client's head to maintain proper airway alignment and comfort. This is
followed by positioning to prevent shearing forces, protecting
,arthritic/artificial joints, padding bony prominences, using warming devices,
covering head and feet, warming IV fluids, and finally following aseptic
technique.
2. Which method is correct for assessing a distended bladder in an
intraoperative client?
A. Inspect and palpate in the epigastric region
B. Auscultate and percuss in the inguinal areas
C. Percuss and palpate in the hypogastric region
D. Percuss and palpate bilaterally in the lumbar areas
Correct Answer: C
Rationale: To detect a distended bladder, percussion and palpation should be
performed over the hypogastric region of the abdomen. The hypogastric
region is located in the lower midline area above the pubic symphysis, where
the bladder is located when distended.
3. A client in the postanesthesia care unit received intrathecal morphine
intraoperatively to control pain. What should the nurse include as part of the
client's initial 24-hour postoperative care?
A. Monitoring of respiratory rate hourly
B. Assessing the client for tachycardia
C. Administering naloxone every 3 to 4 hours
D. Observing the client for signs of CNS excitement
Correct Answer: A
,Rationale: Intrathecal morphine can cause delayed respiratory depression,
which may occur up to 24 hours after administration. Hourly monitoring of
respiratory rate is essential to detect early signs of respiratory depression.
Tachycardia is not a primary concern, and naloxone should be administered
only if respiratory depression occurs, not routinely.
4. A postoperative client reports severe pain despite receiving prescribed
analgesics. The nurse notes the client's vital signs are stable. What is the
nurse's priority action?
A. Administer an additional dose of the prescribed analgesic
B. Notify the healthcare provider immediately
C. Reassess the client's pain using a standardized pain scale
D. Encourage the client to use nonpharmacological pain relief methods
Correct Answer: C
Rationale: The priority action is to reassess the client's pain using a
standardized pain scale to determine the effectiveness of current
interventions and identify any changes in pain characteristics. This
reassessment guides further interventions and ensures patient safety.
5. Which client is at highest risk for fluid volume overload as a nursing safety
priority?
A. A 25-year-old with pneumonia
B. A 45-year-old with hypertension
C. A 70-year-old with heart failure
D. A 30-year-old with diabetes mellitus
, Correct Answer: C
Rationale: An older adult with heart failure is at highest risk for fluid volume
overload due to the heart's decreased ability to pump effectively. This
population is particularly vulnerable to complications from fluid overload,
including pulmonary edema and worsening heart failure.
6. The nurse is preparing to position a client for surgery. Which action
demonstrates correct body mechanics to prevent shearing forces?
A. Pulling the client across the bed sheets
B. Lifting the client into position
C. Sliding the client on a draw sheet
D. Rolling the client without assistance
Correct Answer: B
Rationale: The client should be lifted into position to prevent shearing forces,
which can cause tissue damage and pressure injuries. Pulling or sliding the
client increases friction and shearing forces that can damage skin and
underlying tissues.
7. A client is 2 hours post-surgery and has not voided. The nurse percusses the
hypogastric region and notes dullness. What is the most appropriate nursing
intervention?
A. Insert a Foley catheter immediately
B. Encourage the client to drink more fluids
C. Continue to monitor and reassess in 2 hours
REGULATION EXAM 5 3220 PRACTICE
QUESTIONS AND ANWERS WITH
DETAILED RATIONALES
Questions 1–50
1. The nurse is caring for an older client during the intraoperative stage. The
anesthesia process has already begun and the nurse has already removed the
dentures, eyeglasses, and hearing aids. What is the FIRST intraoperative
nursing intervention the nurse should perform?
A. Cover the client's head and feet
B. Use a warming device to prevent hypothermia
C. Use a small pillow under the client's head
D. Pad bony prominences to prevent pressure sores
Correct Answer: C
Rationale: After anesthesia has begun and dentures, eyeglasses, and hearing
aids have been removed, the nurse should first place a small pillow under the
client's head to maintain proper airway alignment and comfort. This is
followed by positioning to prevent shearing forces, protecting
,arthritic/artificial joints, padding bony prominences, using warming devices,
covering head and feet, warming IV fluids, and finally following aseptic
technique.
2. Which method is correct for assessing a distended bladder in an
intraoperative client?
A. Inspect and palpate in the epigastric region
B. Auscultate and percuss in the inguinal areas
C. Percuss and palpate in the hypogastric region
D. Percuss and palpate bilaterally in the lumbar areas
Correct Answer: C
Rationale: To detect a distended bladder, percussion and palpation should be
performed over the hypogastric region of the abdomen. The hypogastric
region is located in the lower midline area above the pubic symphysis, where
the bladder is located when distended.
3. A client in the postanesthesia care unit received intrathecal morphine
intraoperatively to control pain. What should the nurse include as part of the
client's initial 24-hour postoperative care?
A. Monitoring of respiratory rate hourly
B. Assessing the client for tachycardia
C. Administering naloxone every 3 to 4 hours
D. Observing the client for signs of CNS excitement
Correct Answer: A
,Rationale: Intrathecal morphine can cause delayed respiratory depression,
which may occur up to 24 hours after administration. Hourly monitoring of
respiratory rate is essential to detect early signs of respiratory depression.
Tachycardia is not a primary concern, and naloxone should be administered
only if respiratory depression occurs, not routinely.
4. A postoperative client reports severe pain despite receiving prescribed
analgesics. The nurse notes the client's vital signs are stable. What is the
nurse's priority action?
A. Administer an additional dose of the prescribed analgesic
B. Notify the healthcare provider immediately
C. Reassess the client's pain using a standardized pain scale
D. Encourage the client to use nonpharmacological pain relief methods
Correct Answer: C
Rationale: The priority action is to reassess the client's pain using a
standardized pain scale to determine the effectiveness of current
interventions and identify any changes in pain characteristics. This
reassessment guides further interventions and ensures patient safety.
5. Which client is at highest risk for fluid volume overload as a nursing safety
priority?
A. A 25-year-old with pneumonia
B. A 45-year-old with hypertension
C. A 70-year-old with heart failure
D. A 30-year-old with diabetes mellitus
, Correct Answer: C
Rationale: An older adult with heart failure is at highest risk for fluid volume
overload due to the heart's decreased ability to pump effectively. This
population is particularly vulnerable to complications from fluid overload,
including pulmonary edema and worsening heart failure.
6. The nurse is preparing to position a client for surgery. Which action
demonstrates correct body mechanics to prevent shearing forces?
A. Pulling the client across the bed sheets
B. Lifting the client into position
C. Sliding the client on a draw sheet
D. Rolling the client without assistance
Correct Answer: B
Rationale: The client should be lifted into position to prevent shearing forces,
which can cause tissue damage and pressure injuries. Pulling or sliding the
client increases friction and shearing forces that can damage skin and
underlying tissues.
7. A client is 2 hours post-surgery and has not voided. The nurse percusses the
hypogastric region and notes dullness. What is the most appropriate nursing
intervention?
A. Insert a Foley catheter immediately
B. Encourage the client to drink more fluids
C. Continue to monitor and reassess in 2 hours
