BSN 205 Hallmark Final EXAM 2024/2025
g g g g g g
Whichgofgthegfollowinggisgangexamplegofghealinggbygsecondarygintentio
n?
A. AgFullgthicknessgpressureginjury
B. Agsurgicalgincision
C. Agdoggbite
D. Agburn
E. Agskingtearg-gCORRECTg ANSWER
AgFullgthicknessgpressureginjury
Agdoggbiteg
Agburn
Togallowgagpressuregulcergongthegcoccyxgtoghealgingagpatientgwithg
urinarygincontinence.g-gCORRECTg ANSWER
Togdeterminegu
rinarygretention.
Agnursegisgexplaininggthegproceduregforginsertinggangindwellinggur
inarygcatheter.gWhichgofgthegfollowinggexplanationsgregardinggan
choringgofgthegcathetergwouldgbegmostgaccurate?
Angindwellinggcathetergtubegisgsecuredgtogagfemalegpatient'sgabdo
mengtogpreventgaccidentalgdislodgment.
Angindwellinggcathetergtubegisgsecuredgtogthegmalegpatient'sginnergt
highgwithgagstripgofgnonallergenicgtapegorgagcommercialgtubegholder
.
Itgisgimportantgtoganchorgthegcathetergtubinggtogminimizegthegriskgfor
gurethralgtraumagandgbladdergspasmsgfromgtractiongandgtogpreventg
accidentalgdislodgment.
,Whengsecuringgthegcathetergtubing,gslackgingthegcathetergshouldg
begavoidedgtogpreventgmovementgandgpossiblegtissueginjury.g-
gCORRECTg ANSWER
Itgisgimportantgtoganchorgthegcathetergtu
binggtogminimizegthegriskgforgurethralgtraumagandgbladdergspasm
sgfromgtractiongandgtogpreventgaccidentalgdislodgment.
Agnurseginsertinggangindwellinggurinarygcathetergingagfemalegpatientgad
vancesgthegcathetergandgobtainsgcleargyellowgurine.gWhatgisgthegnextga
ctiongthegnursegshouldgtake?
Inflategthegballoongwithgthegprefilledgsyringegofgsterilegwatergingthegballo
ongport.
Pullggentlygbackgongthegcathetergapproximatelyg1ginchgorguntilgresistan
cegisgmet.
Advancegcatheterganotherg1gtog2ginchesgandginflategballoon.
Askgpatientgtogbeargdowngasgifgtogvoid.g-
gCORRECTg ANSWERgAdvancegcatheterganotherg1gtog2ginchesgandgi
nflategballoon.
Thegnurseghasginsertedgagcatheterg7.5gcmg(3ginches)gingagfemalegpatie
ntgandgobtainsgnogurinegreturngevengthoughghergbladdergisgdistended.g
Whatgactiongshouldgthegnursegtakegatgthisgtime?
Removegthegcathetergandghaveganothergnursegattemptgtogcathete
rizegthegpatient.
Leavegthegcathetergingthegvaginagasgaglandmarkgandginsertganothergste
rilegcatheter.
Removegthegcathetergandgreinsertgintogthegurethra.gThegnursegmayg
straightengthegurethragbyginsertinggonegfingergofgagsterile-
glovedghandginsidegthegvaginagandgapplyingggentlegpressuregupwar
d.
,Inflategthegballoongandgreassessging1ghourgforgurinegreturngingtheg
bedsidegdrainagegbagg-gCORRECTg ANSWER
Leavegthegcat
hetergingthegvaginagasgaglandmarkgandginsertganothergsterilegcath
eter.
Thegnurseghasgagsterilegurinarygcathetergandgsterileggloves.gChoos
egthegremaininggequipmentgthegnursegwillgneedgtoginsertgagstraightg
urethralgcatheter:g(Selectgallgthatgapply.)
Sterilegcottongballs.
Antisepticgsolution.
Sterilegurinarygcollectiongbag.
Water-solubleglubricant.
Sterilegforceps.g-gCORRECTg ANSWER Sterilegcottongballs.
Antisepticgsolution.
Water-solubleglubricant.
Sterilegforceps.
Reasonsgforglackgofgurinegafterginsertinggagstraightgcatheterginclu
de:g(Selectgallgthatgapply.)
Thegcathetergisgoutsidegofgthegbladder.
Thegcathetergisginsertedgingthegvaginagrathergthangingthegurethragofga
gfemalegpatient.
Thegmalegpatient'sgprostategisgpreventinggurinegfromgexitinggthegbladde
r.
, Urethralgspasmsgaregpreventinggurinegfromgexitinggthegbody.
Thegpatient'sgbladdergisgdistended.g-gCORRECTg ANSWER
The
cathetergisgoutsidegofgthegbladder.
g
Thegcathetergisginsertedgingthegvaginagrathergthangingthegurethragofga
gfemalegpatient.
Agnursinggstudentgisgwatchinggagnursegcatheterizegagfemalegpatientgwit
hgangindwellinggcatheter.gWhichgofgthegfollowing,gifgitgoccurs,gindicatesg
agbreakgingsterilegtechnique?g(Selectgallgthatgapply.)
Thegnurseginsertsgthegurinarygcatheter,gandgwhengurinegdoesgnotgret
urn,gremovesgthegcathetergandgmakesgagsecondgattemptgtoglocategt
hegurethragwithgthegsamegcatheter.
Thegnurseglubricatesgthegcathetergandgplacesgitgbackgintogthegster
ilegtraygwhengitguncoilsgandgtouchesgthegbed.
Aftergthegnursegcleansgtheglabia,gtheglabiagbecomegslipperygandgclose
dgasgthegnursegattemptsgtogobtaingagcleargviewgofgthegurethra.
Thegnursegadvancesgthegcatheterganotherg2.5gtog5gcmg(1gtog2ginc
hes)gaftergurinegappears,greleasesgtheglabia,gandgholdsgongtogtheg
cathetergwithgthegnondominantghand.
Thegnursegusesgforcepsgandgagnewgcottongballgwhengcleansinggtheg
area,gwipinggalonggthegfarglabialgfold,gthegnearglabialgfold,gandgdirect
lygovergthegceg-gCORRECTg ANSWER
Thegnurseginsertsgth
egurinarygcatheter,gandgwhengurinegdoesgnotgreturn,gremovesgthegca
thetergandgmakesgagsecondgattemptgtoglocategthegurethragwithgthegs
amegcatheter.
g g g g g g
Whichgofgthegfollowinggisgangexamplegofghealinggbygsecondarygintentio
n?
A. AgFullgthicknessgpressureginjury
B. Agsurgicalgincision
C. Agdoggbite
D. Agburn
E. Agskingtearg-gCORRECTg ANSWER
AgFullgthicknessgpressureginjury
Agdoggbiteg
Agburn
Togallowgagpressuregulcergongthegcoccyxgtoghealgingagpatientgwithg
urinarygincontinence.g-gCORRECTg ANSWER
Togdeterminegu
rinarygretention.
Agnursegisgexplaininggthegproceduregforginsertinggangindwellinggur
inarygcatheter.gWhichgofgthegfollowinggexplanationsgregardinggan
choringgofgthegcathetergwouldgbegmostgaccurate?
Angindwellinggcathetergtubegisgsecuredgtogagfemalegpatient'sgabdo
mengtogpreventgaccidentalgdislodgment.
Angindwellinggcathetergtubegisgsecuredgtogthegmalegpatient'sginnergt
highgwithgagstripgofgnonallergenicgtapegorgagcommercialgtubegholder
.
Itgisgimportantgtoganchorgthegcathetergtubinggtogminimizegthegriskgfor
gurethralgtraumagandgbladdergspasmsgfromgtractiongandgtogpreventg
accidentalgdislodgment.
,Whengsecuringgthegcathetergtubing,gslackgingthegcathetergshouldg
begavoidedgtogpreventgmovementgandgpossiblegtissueginjury.g-
gCORRECTg ANSWER
Itgisgimportantgtoganchorgthegcathetergtu
binggtogminimizegthegriskgforgurethralgtraumagandgbladdergspasm
sgfromgtractiongandgtogpreventgaccidentalgdislodgment.
Agnurseginsertinggangindwellinggurinarygcathetergingagfemalegpatientgad
vancesgthegcathetergandgobtainsgcleargyellowgurine.gWhatgisgthegnextga
ctiongthegnursegshouldgtake?
Inflategthegballoongwithgthegprefilledgsyringegofgsterilegwatergingthegballo
ongport.
Pullggentlygbackgongthegcathetergapproximatelyg1ginchgorguntilgresistan
cegisgmet.
Advancegcatheterganotherg1gtog2ginchesgandginflategballoon.
Askgpatientgtogbeargdowngasgifgtogvoid.g-
gCORRECTg ANSWERgAdvancegcatheterganotherg1gtog2ginchesgandgi
nflategballoon.
Thegnurseghasginsertedgagcatheterg7.5gcmg(3ginches)gingagfemalegpatie
ntgandgobtainsgnogurinegreturngevengthoughghergbladdergisgdistended.g
Whatgactiongshouldgthegnursegtakegatgthisgtime?
Removegthegcathetergandghaveganothergnursegattemptgtogcathete
rizegthegpatient.
Leavegthegcathetergingthegvaginagasgaglandmarkgandginsertganothergste
rilegcatheter.
Removegthegcathetergandgreinsertgintogthegurethra.gThegnursegmayg
straightengthegurethragbyginsertinggonegfingergofgagsterile-
glovedghandginsidegthegvaginagandgapplyingggentlegpressuregupwar
d.
,Inflategthegballoongandgreassessging1ghourgforgurinegreturngingtheg
bedsidegdrainagegbagg-gCORRECTg ANSWER
Leavegthegcat
hetergingthegvaginagasgaglandmarkgandginsertganothergsterilegcath
eter.
Thegnurseghasgagsterilegurinarygcathetergandgsterileggloves.gChoos
egthegremaininggequipmentgthegnursegwillgneedgtoginsertgagstraightg
urethralgcatheter:g(Selectgallgthatgapply.)
Sterilegcottongballs.
Antisepticgsolution.
Sterilegurinarygcollectiongbag.
Water-solubleglubricant.
Sterilegforceps.g-gCORRECTg ANSWER Sterilegcottongballs.
Antisepticgsolution.
Water-solubleglubricant.
Sterilegforceps.
Reasonsgforglackgofgurinegafterginsertinggagstraightgcatheterginclu
de:g(Selectgallgthatgapply.)
Thegcathetergisgoutsidegofgthegbladder.
Thegcathetergisginsertedgingthegvaginagrathergthangingthegurethragofga
gfemalegpatient.
Thegmalegpatient'sgprostategisgpreventinggurinegfromgexitinggthegbladde
r.
, Urethralgspasmsgaregpreventinggurinegfromgexitinggthegbody.
Thegpatient'sgbladdergisgdistended.g-gCORRECTg ANSWER
The
cathetergisgoutsidegofgthegbladder.
g
Thegcathetergisginsertedgingthegvaginagrathergthangingthegurethragofga
gfemalegpatient.
Agnursinggstudentgisgwatchinggagnursegcatheterizegagfemalegpatientgwit
hgangindwellinggcatheter.gWhichgofgthegfollowing,gifgitgoccurs,gindicatesg
agbreakgingsterilegtechnique?g(Selectgallgthatgapply.)
Thegnurseginsertsgthegurinarygcatheter,gandgwhengurinegdoesgnotgret
urn,gremovesgthegcathetergandgmakesgagsecondgattemptgtoglocategt
hegurethragwithgthegsamegcatheter.
Thegnurseglubricatesgthegcathetergandgplacesgitgbackgintogthegster
ilegtraygwhengitguncoilsgandgtouchesgthegbed.
Aftergthegnursegcleansgtheglabia,gtheglabiagbecomegslipperygandgclose
dgasgthegnursegattemptsgtogobtaingagcleargviewgofgthegurethra.
Thegnursegadvancesgthegcatheterganotherg2.5gtog5gcmg(1gtog2ginc
hes)gaftergurinegappears,greleasesgtheglabia,gandgholdsgongtogtheg
cathetergwithgthegnondominantghand.
Thegnursegusesgforcepsgandgagnewgcottongballgwhengcleansinggtheg
area,gwipinggalonggthegfarglabialgfold,gthegnearglabialgfold,gandgdirect
lygovergthegceg-gCORRECTg ANSWER
Thegnurseginsertsgth
egurinarygcatheter,gandgwhengurinegdoesgnotgreturn,gremovesgthegca
thetergandgmakesgagsecondgattemptgtoglocategthegurethragwithgthegs
amegcatheter.
