NURS 236 Final Exam With
Complete Solution
Which of the following items of subjective client data would be documented
in the medical record by the nurse?
a. Client's face is pale
b. Cervical lymph nodes are palpable
c. Nursing assistant reports client refused lunch
d. Client feel nauseated - ANSWER d
The client reports nausea and constipation. Which of the following would be
the priority nursing action?
a. Collect a stool sample
b. Complete an abdominal assessment
c. Administer an anti-nausea medication
d. Notify the physician - ANSWER b
A nurse concludes that the patient's elevated temperature, pulse and
respirations are significant. Which step of the nursing process is being used
when the nurse comes to this conclusion?
a.Implementation
b.Assessment
,c.Evaluation
d.Analysis - ANSWER d
The most effective method of evaluating a patient' s pain level is to:
a.Ask the patient where he or she feels the pain.
b.Select a tool to measure pain based on the patient's preference and
cognitive level.
c.Observe the non verbal cues to pain level.
d.Determine if the pain medication ordered is actually relieving the patient's
pain. - ANSWER b
A registered nurse RN is precepting a new graduate nurse while she is
administering the feeding via NGT for patient with stroke and has difficulty
swallowing. Which of the following new nurse actions reflect the need of
further education?
a.Warm the feeding formula to room temperature.
b.Aspirate the stomach contents to determine the amount of residual.
c.Elevate the head of the bed 15 degrees after feeding
d.Irrigate feeding tube with sterile water after feeding - ANSWER c
Which patient would benefit from a Nasogastric Tube?
a.A patient with Congestive Heart Failure
b.A patient who had a left leg amputation
c.A stroke victim who failed their swallow evaluation
, d.A patient with a Platelet count of 50 - ANSWER c
You just inserted a Nasogastric tube. Which of the following is not a correct
way to check correct placement of the tube?
a. Administering a 100cc Water flush and assessing for patient coughing
b. Following the physician order for an X-ray to confirm placement
c. Checking pH of GI contents to be 5 or less
d. Obtaining a sample of GI contents through the tube by aspirating -
ANSWER a
Which of the following accurately describes the greatest risk related to
having a feeding tube?
A) Electrolyte imbalance
B) Fluid volume overload
C) Infection
D) Aspiration - ANSWER d
When irrigating a colostomy the nurse uses a cone that fits properly to
prevent:
a.Introducing air into the colon
b. Leaking the solution around the stoma
c.Administering the solution too rapidly
d.Introducing of bacteria from the stoma - ANSWER b
Which of the following would be a common nursing diagnosis for patient
Complete Solution
Which of the following items of subjective client data would be documented
in the medical record by the nurse?
a. Client's face is pale
b. Cervical lymph nodes are palpable
c. Nursing assistant reports client refused lunch
d. Client feel nauseated - ANSWER d
The client reports nausea and constipation. Which of the following would be
the priority nursing action?
a. Collect a stool sample
b. Complete an abdominal assessment
c. Administer an anti-nausea medication
d. Notify the physician - ANSWER b
A nurse concludes that the patient's elevated temperature, pulse and
respirations are significant. Which step of the nursing process is being used
when the nurse comes to this conclusion?
a.Implementation
b.Assessment
,c.Evaluation
d.Analysis - ANSWER d
The most effective method of evaluating a patient' s pain level is to:
a.Ask the patient where he or she feels the pain.
b.Select a tool to measure pain based on the patient's preference and
cognitive level.
c.Observe the non verbal cues to pain level.
d.Determine if the pain medication ordered is actually relieving the patient's
pain. - ANSWER b
A registered nurse RN is precepting a new graduate nurse while she is
administering the feeding via NGT for patient with stroke and has difficulty
swallowing. Which of the following new nurse actions reflect the need of
further education?
a.Warm the feeding formula to room temperature.
b.Aspirate the stomach contents to determine the amount of residual.
c.Elevate the head of the bed 15 degrees after feeding
d.Irrigate feeding tube with sterile water after feeding - ANSWER c
Which patient would benefit from a Nasogastric Tube?
a.A patient with Congestive Heart Failure
b.A patient who had a left leg amputation
c.A stroke victim who failed their swallow evaluation
, d.A patient with a Platelet count of 50 - ANSWER c
You just inserted a Nasogastric tube. Which of the following is not a correct
way to check correct placement of the tube?
a. Administering a 100cc Water flush and assessing for patient coughing
b. Following the physician order for an X-ray to confirm placement
c. Checking pH of GI contents to be 5 or less
d. Obtaining a sample of GI contents through the tube by aspirating -
ANSWER a
Which of the following accurately describes the greatest risk related to
having a feeding tube?
A) Electrolyte imbalance
B) Fluid volume overload
C) Infection
D) Aspiration - ANSWER d
When irrigating a colostomy the nurse uses a cone that fits properly to
prevent:
a.Introducing air into the colon
b. Leaking the solution around the stoma
c.Administering the solution too rapidly
d.Introducing of bacteria from the stoma - ANSWER b
Which of the following would be a common nursing diagnosis for patient
