NUR 202 EXAM 4 | COMPREHENSIVE STUDY GUIDE, NCLEX-STYLE PRACTICE QUESTIONS AND
ANSWERS 2026/2027
A student asks the nurse what is the best way to assess a clients pain. Which response by the
nurse is best?
a. Numeric pain scale
b. Behavioral assessment
c. Objective observation
d. Clients self-report - ANS ✔✔d. Many ways to measure pain are in use, including numeric pain
scales, behavioral assessments, and other objective observations. However, the most accurate
way to assess pain is to get a self-report from the client.
A new nurse reports to the precepting nurse that a client requested pain medication, and when
the nurse brought it, the client was sound asleep. The nurse states the client cannot possibly
sleep with the severe pain the client described. What response by the experienced nurse is
best?
a. Being able to sleep doesnt mean pain doesnt exist.
b. Have you ever experienced any type of pain?
c. The client should be assessed for drug addiction.
d. Youre right; I would put the medication back. - ANS ✔✔A. clients description is the most
accurate assessment of pain. The nurse should believe the client and provide pain relief.
Physiologic changes due to pain vary from client to client, and assessments of them should not
supersede the clients descriptions, especially if the pain is chronic in nature. Asking if the new
nurse has had pain is judgmental and flippant, and does not provide useful information. This
amount of information does not warrant an assessment for drug addiction. Putting the
medication back and ignoring the clients report of pain serves no useful purpose.
A faculty member explains to students the process by which pain is perceived by the client.
Which processes does the faculty member include in the discussion? (Select all that apply.)
a. Induction
b. Modulation
,c. Sensory perception
d. Transduction
e. Transmission - ANS ✔✔b, c, d, e The four processes involved in making pain a conscious
experience are modulation, sensory perception, transduction, and transmission.
A nursing student is studying pain sources. Which statements accurately describe different types
of pain? (Select all that apply.)
a. Neuropathic pain sometimes accompanies amputation.
b. Nociceptive pain originates from abnormal pain processing
.c. Deep somatic pain is pain arising from bone and connective tissues.
d. Somatic pain originates from skin and subcutaneous tissues.
e. Visceral pain is often diffuse and poorly localized. - ANS ✔✔a, c, d, e Neuropathic pain results
from abnormal pain processing and is seen in amputations and neuropathies. Somatic pain can
arise from superficial sources such as skin, or deep sources such as bone and connective tissues.
Visceral pain originates from organs or their linings and is often diffuse and poorly localized.
Nociceptive pain is normal pain processing and consists of somatic and visceral pain.
A nurse teaches a client about performing intermittent self-catheterization. The client states, I
am not sure if I will be able to afford these catheters. How should the nurse respond?
a. I will try to find out whether you qualify for money to purchase these necessary supplies.
b. Even though it is expensive, the cost of taking care of urinary tract infections would be even
higher.
c. Instead of purchasing new catheters, you can boil the catheters and reuse them up to 10
times each.
d. You can reuse the catheters at home. Clean technique, rather than sterile technique, is
acceptable. - ANS ✔✔d. At home, clean technique for intermittent self-catheterization is
sufficient to prevent cystitis and other urinary tract infections. The nurse would refer the client
to the social worker to explore financial concerns. The nurse should not threaten the client, nor
should the client be instructed to boil the catheters.
,A nurse is caring for a client who has a spinal cord injury at level T3. Which intervention should
the nurse implement to assist with bladder dysfunction?
a. Insert an indwelling urinary catheter.
b. Stroke the medial aspect of the thigh.
c. Use the Cred maneuver every 3 hours.
d. Apply a Texas catheter with a leg bag. - ANS ✔✔c. Two techniques are used to facilitate
voiding in a client with a flaccid bladder: the Valsalva maneuver and the Cred maneuver.
Indwelling urinary catheters generally are not used because of the increased incidence of
urinary tract infection. Stroking the medial aspect of the thigh facilitates voiding in clients with
upper motor neuron problems. If the spinal cord injury is above T12, the client is unaware of a
full bladder and does not void or is incontinent. Therefore, the client would not benefit from a
Texas catheter with a leg bag.
A nurse teaches a client who has a flaccid bladder. Which bladder training technique should the
nurse teach?
a. Stroking the medial aspect of the thigh
b. Valsalva maneuver
c. Self-catheterization
d. Frequent toileting - ANS ✔✔b With a flaccid bladder, the voiding reflex arc is not intact and
additional stimulation may be needed to initiate voiding, such as with the Valsalva and Cred
maneuvers. Intermittent catheterization may be used after the previous maneuvers are
attempted. In reflex bladder, the voiding arc is intact and voiding can be initiated by any
stimulus, such as stroking the medial aspect of the thigh. A consistent toileting routine is used
to re-establish voiding continence with an uninhibited bladder.
A nurse assesses clients on a medical-surgical unit. Which client is at greatest risk for pressure
ulcer development?
a. A 44-year-old prescribed IV antibiotics for pneumonia
b. A 26-year-old who is bedridden with a fractured leg
c. A 65-year-old with hemi-paralysis and incontinence
, d. A 78-year-old requiring assistance to ambulate with a walker - ANS ✔✔c Being immobile and
being incontinent are two significant risk factors for the development of pressure ulcers. The
client with pneumonia does not have specific risk factors. The young client who has a fractured
leg and the client who needs assistance with ambulation might be at moderate risk if they do
not move about much, but having two risk factors makes the 65-year-old the person at highest
risk.
A nurse cares for a client who has a deep wound that is being treated with a wet-to-damp
dressing. Which intervention should the nurse include in this clients plan of care?
a. Change the dressing every 6 hours.
b. Assess the wound bed once a day.
c. Change the dressing when it is saturated.
d. Contact the provider when the dressing leaks. - ANS ✔✔a Wet-to-damp dressings are
changed every 4 to 6 hours to provide maximum dbridement. The wound should be assessed
each time the dressing is changed. Dry gauze dressings should be changed when the outer layer
becomes saturated. Synthetic dressings can be left in place for extended periods of time but
need to be changed if the seal breaks and the exudate leaks.
A nurse assesses clients on a medical-surgical unit. Which client should the nurse evaluate for a
wound infection?
a. Client with blood cultures pending
b. Client who has thin, serous wound drainage
c. Client with a white blood cell count of 23,000/mm3
d. Client whose wound has decreased in size - ANS ✔✔c A client with an elevated white blood
cell count should be evaluated for sources of infection. Pending cultures, thin drainage, and a
decrease in wound size are not indications that the client may have an infection.
A nurse assesses a client who has a chronic wound. The client states, I do not clean the wound
and change the dressing every day because it costs too much for supplies. How should the
nurse respond?
a. You can use tap water instead of sterile saline to clean your wound.
ANSWERS 2026/2027
A student asks the nurse what is the best way to assess a clients pain. Which response by the
nurse is best?
a. Numeric pain scale
b. Behavioral assessment
c. Objective observation
d. Clients self-report - ANS ✔✔d. Many ways to measure pain are in use, including numeric pain
scales, behavioral assessments, and other objective observations. However, the most accurate
way to assess pain is to get a self-report from the client.
A new nurse reports to the precepting nurse that a client requested pain medication, and when
the nurse brought it, the client was sound asleep. The nurse states the client cannot possibly
sleep with the severe pain the client described. What response by the experienced nurse is
best?
a. Being able to sleep doesnt mean pain doesnt exist.
b. Have you ever experienced any type of pain?
c. The client should be assessed for drug addiction.
d. Youre right; I would put the medication back. - ANS ✔✔A. clients description is the most
accurate assessment of pain. The nurse should believe the client and provide pain relief.
Physiologic changes due to pain vary from client to client, and assessments of them should not
supersede the clients descriptions, especially if the pain is chronic in nature. Asking if the new
nurse has had pain is judgmental and flippant, and does not provide useful information. This
amount of information does not warrant an assessment for drug addiction. Putting the
medication back and ignoring the clients report of pain serves no useful purpose.
A faculty member explains to students the process by which pain is perceived by the client.
Which processes does the faculty member include in the discussion? (Select all that apply.)
a. Induction
b. Modulation
,c. Sensory perception
d. Transduction
e. Transmission - ANS ✔✔b, c, d, e The four processes involved in making pain a conscious
experience are modulation, sensory perception, transduction, and transmission.
A nursing student is studying pain sources. Which statements accurately describe different types
of pain? (Select all that apply.)
a. Neuropathic pain sometimes accompanies amputation.
b. Nociceptive pain originates from abnormal pain processing
.c. Deep somatic pain is pain arising from bone and connective tissues.
d. Somatic pain originates from skin and subcutaneous tissues.
e. Visceral pain is often diffuse and poorly localized. - ANS ✔✔a, c, d, e Neuropathic pain results
from abnormal pain processing and is seen in amputations and neuropathies. Somatic pain can
arise from superficial sources such as skin, or deep sources such as bone and connective tissues.
Visceral pain originates from organs or their linings and is often diffuse and poorly localized.
Nociceptive pain is normal pain processing and consists of somatic and visceral pain.
A nurse teaches a client about performing intermittent self-catheterization. The client states, I
am not sure if I will be able to afford these catheters. How should the nurse respond?
a. I will try to find out whether you qualify for money to purchase these necessary supplies.
b. Even though it is expensive, the cost of taking care of urinary tract infections would be even
higher.
c. Instead of purchasing new catheters, you can boil the catheters and reuse them up to 10
times each.
d. You can reuse the catheters at home. Clean technique, rather than sterile technique, is
acceptable. - ANS ✔✔d. At home, clean technique for intermittent self-catheterization is
sufficient to prevent cystitis and other urinary tract infections. The nurse would refer the client
to the social worker to explore financial concerns. The nurse should not threaten the client, nor
should the client be instructed to boil the catheters.
,A nurse is caring for a client who has a spinal cord injury at level T3. Which intervention should
the nurse implement to assist with bladder dysfunction?
a. Insert an indwelling urinary catheter.
b. Stroke the medial aspect of the thigh.
c. Use the Cred maneuver every 3 hours.
d. Apply a Texas catheter with a leg bag. - ANS ✔✔c. Two techniques are used to facilitate
voiding in a client with a flaccid bladder: the Valsalva maneuver and the Cred maneuver.
Indwelling urinary catheters generally are not used because of the increased incidence of
urinary tract infection. Stroking the medial aspect of the thigh facilitates voiding in clients with
upper motor neuron problems. If the spinal cord injury is above T12, the client is unaware of a
full bladder and does not void or is incontinent. Therefore, the client would not benefit from a
Texas catheter with a leg bag.
A nurse teaches a client who has a flaccid bladder. Which bladder training technique should the
nurse teach?
a. Stroking the medial aspect of the thigh
b. Valsalva maneuver
c. Self-catheterization
d. Frequent toileting - ANS ✔✔b With a flaccid bladder, the voiding reflex arc is not intact and
additional stimulation may be needed to initiate voiding, such as with the Valsalva and Cred
maneuvers. Intermittent catheterization may be used after the previous maneuvers are
attempted. In reflex bladder, the voiding arc is intact and voiding can be initiated by any
stimulus, such as stroking the medial aspect of the thigh. A consistent toileting routine is used
to re-establish voiding continence with an uninhibited bladder.
A nurse assesses clients on a medical-surgical unit. Which client is at greatest risk for pressure
ulcer development?
a. A 44-year-old prescribed IV antibiotics for pneumonia
b. A 26-year-old who is bedridden with a fractured leg
c. A 65-year-old with hemi-paralysis and incontinence
, d. A 78-year-old requiring assistance to ambulate with a walker - ANS ✔✔c Being immobile and
being incontinent are two significant risk factors for the development of pressure ulcers. The
client with pneumonia does not have specific risk factors. The young client who has a fractured
leg and the client who needs assistance with ambulation might be at moderate risk if they do
not move about much, but having two risk factors makes the 65-year-old the person at highest
risk.
A nurse cares for a client who has a deep wound that is being treated with a wet-to-damp
dressing. Which intervention should the nurse include in this clients plan of care?
a. Change the dressing every 6 hours.
b. Assess the wound bed once a day.
c. Change the dressing when it is saturated.
d. Contact the provider when the dressing leaks. - ANS ✔✔a Wet-to-damp dressings are
changed every 4 to 6 hours to provide maximum dbridement. The wound should be assessed
each time the dressing is changed. Dry gauze dressings should be changed when the outer layer
becomes saturated. Synthetic dressings can be left in place for extended periods of time but
need to be changed if the seal breaks and the exudate leaks.
A nurse assesses clients on a medical-surgical unit. Which client should the nurse evaluate for a
wound infection?
a. Client with blood cultures pending
b. Client who has thin, serous wound drainage
c. Client with a white blood cell count of 23,000/mm3
d. Client whose wound has decreased in size - ANS ✔✔c A client with an elevated white blood
cell count should be evaluated for sources of infection. Pending cultures, thin drainage, and a
decrease in wound size are not indications that the client may have an infection.
A nurse assesses a client who has a chronic wound. The client states, I do not clean the wound
and change the dressing every day because it costs too much for supplies. How should the
nurse respond?
a. You can use tap water instead of sterile saline to clean your wound.
