NR 223 Final Review Exam Test
Questions with Solved Solutions
Graded A+(2025-2026) Update.
Environmental safety - Answer meeting basic needs, reducing physical hazards and
transmission of pathogens, and controlling pollution.
Basic Needs: - Answer According to Maslow's hierarchy of needs, these basic needs must be
met before physical and psychological safety and security can be addressed:
Oxygen: not flammable but combustible.
Nutrition
Temperature: 65-75 F is the comfort zone.
Safety: - Answer freedom from psychological and physical injury and it is a basic human need.
In addition to taking measures to prevent injury of clients in a health care setting, nurses play: -
Answer a pivotal role in promoting safety in the client's home and community
Physical Hazards - Answer Motor vehicle accidents
Poison
Falls
Fire disasters
What is the leading cause of death for Americans of all ages? - Answer Unintentional injuries:
Motor vehicle accidents are the leading cause, followed by poisonings and falls
Factors Influencing Patient Safety - Answer Risks at developmental stages:
From infants to older adults
Individual risk factors:
Lifestyle, impaired mobility, sensory or communication impairment, lack of safety awareness
,A nurse is bathing a client who has a fever. Why should the nurse use tepid bath water for this
procedure? - Answer Increases heat loss. Heat is transferred from the warm surface of the skin
to the water that is in direct contact with the body, and evaporation of water promotes cooling.
Tepid water is slightly below body temperature, and a person with a fever has an elevated body
temperature (febrile).
A nurse must make a decision to give a client a full or partial bed bath. Which criterion is most
important for the basis of this decision? - Answer Immediate need of the client. A total client
assessment with an analysis of the data identifies the needs of the client and the appropriate
intervention to meet those needs.
A client has had a natural gastric tube to decompress the stomach for three days and is
scheduled for intestinal surgery in the morning. For which of the following is the client at the
highest risk? - Answer Altered oral mucous membranes. Not drinking anything by mouth and
having a tube through the nose and posterior pharynx can result in drying of the oral mucous
membranes and a coded, furrowed tongue.
A client is incontinent of urine and stool. For which client response should the nurse be most
concerned? - Answer Impaired skin integrity. Fecal material contains enzymes that erode the
skin, and urine is an acidic fluid that macerates the skin. As a result, altered skin integrity is a
serious concern.
A nurse is giving a client a bed bath. Which nursing action is most important? - Answer Ensure
that the bathwater is at least 110°F. The temperature of bathwater should be between 110°F
and 115°F to promote comfort, dilate blood vessels, and prevent chilling. A lower temperature
can cause chilling, and a higher temperature can cause skin trauma.
A nurse plans to give a client a back rub. Which product should the nurse use for this
intervention? - Answer Moisturizing lotion. Moisturizing lotion lubricates the skin and reduces
friction between the nurses hands and the clients back. Lotion facilitates smooth movement of
the hand across the client skin, which is relaxing and prevents trauma of the skin. The use of a
moisturizing lotion for a back rub does not require a primary health-care providers prescription.
A nurse changes the sheets and pillow case of a bed while the client sits in a chair. Of the
options presented, which is the most important nursing action when changing bed linens? -
Answer Checking the soiled bed linens for personal items. A nurse must take reasonable
precautions to ensure that her clients personal belongings, especially eyeglasses, dentures, and
prosthetic devices, are kept safe. Checking for personal belongings before placing soiled linen
into a linen hamper is a reasonable, prudent nursing action.
, Which condition identified by the nurse places the client at the highest risk for impaired self-
care when toileting? - Answer Fractured hip. Discomfort resulting from the proximity of the
fracture to the pelvic area and the limitations placed on the positioning of, or weight-bearing
on, affected leg influence a client's ability to use a bedpan or transfer to a commode.
A client asks the nurse, "Why do I have to use mouthwash if I brush my teeth?" Which rationale
about the use of all mouthwashes should the nurse include when responding to this question? -
Answer Reduces offensive mouth odors. And offensive odor to the breath (halitosis) can be
caused by inadequate oral hygiene, periodontal disease, or systemic disease. Rinsing the mouth
with mouthwash will flush the oral cavity of debris in microorganisms, which will reduce
halitosis if it is caused by a localized problem.
A nurse is assessing a client's heart rate by palpating the carotid artery. Which action should the
nurse implement when assessing a pulse at this site? - Answer Press gently when palpating
the site. The carotid artery should be palpated with a light touch to prevent interference to
blood flow to the brain and stimulation of the carotid sinus that can cause a reflex drop in the
heart rate.
A nurse is caring for a client receiving contact isolation. The nurse must take the clients rectal
temperature with a plastic thermometer. Which should the nurse do? - Answer Wear gloves
throughout the procedure. Gloves, personal protective pieces of equipment, are the best way
the nurse is protected from contracting or transmitting a pathogen.
An adult client's vital signs are: oral temperature 99°F, pulse 88 bpm with a regular rhythm,
respiration 16 breaths per minute and deep, and blood pressure 182/100 mm Hg. Which sign
should cause concern? - Answer Blood pressure. The blood pressure is more than the
expected systolic value of less than 120 mm Hg and a diastolic value of less than 80 mm Hg and,
of the options presented, should cause the most concern. A systolic blood pressure of 180 or
more and/or a diastolic pressure of 121 or more is in the blood pressure category of crisis.
When evaluating the vital signs of a group of clients, the nurse takes into consideration the
circadian rhythm of body temperature. At which time of day is body temperature usually at its
highest? - Answer 8 p.m. to 10 p.m. Diurnal variations (circadian rhythms) vary throughout the
day, with the highest body temperature usually occurring between 8 p.m. and midnight.
A nurse in the emergency department is engaging in an initial assessment of a client, which
assessment takes priority? - Answer Client assessment must always be conducted in the order
of priority of need in an emergency the ABC's of assessment or airway, breathing, and
Questions with Solved Solutions
Graded A+(2025-2026) Update.
Environmental safety - Answer meeting basic needs, reducing physical hazards and
transmission of pathogens, and controlling pollution.
Basic Needs: - Answer According to Maslow's hierarchy of needs, these basic needs must be
met before physical and psychological safety and security can be addressed:
Oxygen: not flammable but combustible.
Nutrition
Temperature: 65-75 F is the comfort zone.
Safety: - Answer freedom from psychological and physical injury and it is a basic human need.
In addition to taking measures to prevent injury of clients in a health care setting, nurses play: -
Answer a pivotal role in promoting safety in the client's home and community
Physical Hazards - Answer Motor vehicle accidents
Poison
Falls
Fire disasters
What is the leading cause of death for Americans of all ages? - Answer Unintentional injuries:
Motor vehicle accidents are the leading cause, followed by poisonings and falls
Factors Influencing Patient Safety - Answer Risks at developmental stages:
From infants to older adults
Individual risk factors:
Lifestyle, impaired mobility, sensory or communication impairment, lack of safety awareness
,A nurse is bathing a client who has a fever. Why should the nurse use tepid bath water for this
procedure? - Answer Increases heat loss. Heat is transferred from the warm surface of the skin
to the water that is in direct contact with the body, and evaporation of water promotes cooling.
Tepid water is slightly below body temperature, and a person with a fever has an elevated body
temperature (febrile).
A nurse must make a decision to give a client a full or partial bed bath. Which criterion is most
important for the basis of this decision? - Answer Immediate need of the client. A total client
assessment with an analysis of the data identifies the needs of the client and the appropriate
intervention to meet those needs.
A client has had a natural gastric tube to decompress the stomach for three days and is
scheduled for intestinal surgery in the morning. For which of the following is the client at the
highest risk? - Answer Altered oral mucous membranes. Not drinking anything by mouth and
having a tube through the nose and posterior pharynx can result in drying of the oral mucous
membranes and a coded, furrowed tongue.
A client is incontinent of urine and stool. For which client response should the nurse be most
concerned? - Answer Impaired skin integrity. Fecal material contains enzymes that erode the
skin, and urine is an acidic fluid that macerates the skin. As a result, altered skin integrity is a
serious concern.
A nurse is giving a client a bed bath. Which nursing action is most important? - Answer Ensure
that the bathwater is at least 110°F. The temperature of bathwater should be between 110°F
and 115°F to promote comfort, dilate blood vessels, and prevent chilling. A lower temperature
can cause chilling, and a higher temperature can cause skin trauma.
A nurse plans to give a client a back rub. Which product should the nurse use for this
intervention? - Answer Moisturizing lotion. Moisturizing lotion lubricates the skin and reduces
friction between the nurses hands and the clients back. Lotion facilitates smooth movement of
the hand across the client skin, which is relaxing and prevents trauma of the skin. The use of a
moisturizing lotion for a back rub does not require a primary health-care providers prescription.
A nurse changes the sheets and pillow case of a bed while the client sits in a chair. Of the
options presented, which is the most important nursing action when changing bed linens? -
Answer Checking the soiled bed linens for personal items. A nurse must take reasonable
precautions to ensure that her clients personal belongings, especially eyeglasses, dentures, and
prosthetic devices, are kept safe. Checking for personal belongings before placing soiled linen
into a linen hamper is a reasonable, prudent nursing action.
, Which condition identified by the nurse places the client at the highest risk for impaired self-
care when toileting? - Answer Fractured hip. Discomfort resulting from the proximity of the
fracture to the pelvic area and the limitations placed on the positioning of, or weight-bearing
on, affected leg influence a client's ability to use a bedpan or transfer to a commode.
A client asks the nurse, "Why do I have to use mouthwash if I brush my teeth?" Which rationale
about the use of all mouthwashes should the nurse include when responding to this question? -
Answer Reduces offensive mouth odors. And offensive odor to the breath (halitosis) can be
caused by inadequate oral hygiene, periodontal disease, or systemic disease. Rinsing the mouth
with mouthwash will flush the oral cavity of debris in microorganisms, which will reduce
halitosis if it is caused by a localized problem.
A nurse is assessing a client's heart rate by palpating the carotid artery. Which action should the
nurse implement when assessing a pulse at this site? - Answer Press gently when palpating
the site. The carotid artery should be palpated with a light touch to prevent interference to
blood flow to the brain and stimulation of the carotid sinus that can cause a reflex drop in the
heart rate.
A nurse is caring for a client receiving contact isolation. The nurse must take the clients rectal
temperature with a plastic thermometer. Which should the nurse do? - Answer Wear gloves
throughout the procedure. Gloves, personal protective pieces of equipment, are the best way
the nurse is protected from contracting or transmitting a pathogen.
An adult client's vital signs are: oral temperature 99°F, pulse 88 bpm with a regular rhythm,
respiration 16 breaths per minute and deep, and blood pressure 182/100 mm Hg. Which sign
should cause concern? - Answer Blood pressure. The blood pressure is more than the
expected systolic value of less than 120 mm Hg and a diastolic value of less than 80 mm Hg and,
of the options presented, should cause the most concern. A systolic blood pressure of 180 or
more and/or a diastolic pressure of 121 or more is in the blood pressure category of crisis.
When evaluating the vital signs of a group of clients, the nurse takes into consideration the
circadian rhythm of body temperature. At which time of day is body temperature usually at its
highest? - Answer 8 p.m. to 10 p.m. Diurnal variations (circadian rhythms) vary throughout the
day, with the highest body temperature usually occurring between 8 p.m. and midnight.
A nurse in the emergency department is engaging in an initial assessment of a client, which
assessment takes priority? - Answer Client assessment must always be conducted in the order
of priority of need in an emergency the ABC's of assessment or airway, breathing, and
