NU 136 UPDATED EXAM SCRIPT QUESTIONS AND
ANSWERS GRADED A+
✔✔Example of surgical asepsis - ✔✔-administering injections
-administering IV therapy
-changing wound dressings
-performing urinary catherization
✔✔Nursing actions to promote patient safety - ✔✔-keep the bed in the low position if
not giving direct care
-lock the bed wheels to prevent the bed from rolling when the patient attempts to get in
or out
-answer call lights quickly so that the patient learns to trust you and does not feel the
need to get up without you
✔✔Major risk factors for a pressure injury - ✔✔-immobility
-inactivity
-moisture
-malnutrition
-advanced age
-altered sensory perception
-lowered mental awareness
-friction and shear
✔✔contributing risk factors for a pressure injury - ✔✔-dehydration
-obesity
-edema
✔✔stage 1 pressure injury - ✔✔-An area of intact skin that is red, deep pink, or mottled
skin
-does not blanch with fingertip pressure
✔✔stage 2 pressure injury - ✔✔-partial thickness skin loss with exposed dermis
-may appear as ruptured blister
✔✔stage 3 pressure injury - ✔✔-full thickness loss
-looks like deep crater extend to fascia
-subtaneous tissue damaged/necrotic fat visible
-undermining/tunneling may be present
✔✔stage 4 pressure injury - ✔✔-full-thickness skin loss with extensive tissue necrosis
or damage to muscle or bone
-the injury may appear black, necrotic tissue(eschar)
✔✔unstageable pressure injury - ✔✔-loss full thickness
,-base injury covered in eschar ( tan, brown, black) in wound bed
✔✔When should you not take an oral temperature? - ✔✔When the patient has:
-smoked
-chewed gum
-consumed hot/cold beverages.
✔✔How long should you wait to take an oral temp is the patient consumed a hot or cold
beverage, smoked or recently chewed gum? - ✔✔wait 15 to 30 minutes
✔✔Rectal temperatures should not be used for - ✔✔-cardiac patients
-patients who have had rectal surgery
✔✔What should you do if the pedal pulses are weak or unequal? - ✔✔check pulse with
a Doppler stethoscope
✔✔Dyspnea - ✔✔-difficult or labored breathing
-also known as shortness of breath
-accompanied by flared nostrils, anxious appearance
-"I can't get enough air"
✔✔Kussmaul respirations - ✔✔-increased rate, very deep, labored breathing (usually
associated with diabetic acidosis and renal failure)
-400+ blood sugar
✔✔Cheyne-Stokes respiration - ✔✔-consist of a pattern of dyspnea followed by a short
period of apnea (respirations are faster and deeper, then slower, and are followed by a
period of no breathing)
-seen in patients with heart or kidney failure
✔✔Patient Interview: If the patient is confused, who should you talk to? - ✔✔a family
member
✔✔Palpation - ✔✔-an examination technique in which the examiner's pads of fingers
are used to feel pain, tenderness, swelling, growth, skin temperature, edema
-1/2 - 3/4 in
✔✔percussion - ✔✔-used primarily over the chest and abdomen to determine the size,
location and density
-performed by a doctor
✔✔The best time to collect a sputum specimen is - ✔✔-just after the patient awakens
-after a nebulizer treatment
, ✔✔What is the best nursing intervention if the sputum is too thick? - ✔✔increase fluids -
fluids make the sputum thinner
✔✔How to collect a midstream urine specimen? - ✔✔1. void a small amount of urine
into the toilet
2. catch the middle portion of urine by moving the container into the stream
3. collect about 1 oz of urine
4. set the container on the sink
5. finish voiding into the toilet
✔✔Midstream clean catch - ✔✔Most common procedure for collecting any type of urine
specimen that is relatively free from external contamination
✔✔24 hr urine specimen - ✔✔Voids:
-1st time (discard)
-2nd time and so forth is kept for 24 hrs
-post a sign
-keep urine on ice
✔✔How to prevent recurrent cystitis (UTI) - ✔✔-avoid citrus fruits and juices
-always wipe the rectal area from front to back after a bowel movement
-emptying bladder after intercourse and drinking two glasses of water to flush out
microorganisms that may have entered the bladder
✔✔hyperactive bowel - ✔✔-increase in peristalsis
-usually results in diarrhea
-may be self-limiting
✔✔gastritis - ✔✔-Inflammation of the stomach lining
-hyperactive bowel sounds
-S&S- Hematemesis; indigestion; epigastric pain
-Irritants such as aspirin; poisons; alcohol; tobacco
✔✔constipation - ✔✔-Hard, slow stools that are difficult to eliminate; often a result of too
little fiber in the diet
-hypoactive bowel sounds
✔✔normal bowel sounds - ✔✔-high-pitched, gurgling, cascading sounds, occurring
irregularly anywhere from 5 to 30 times per minute.
✔✔ileostomy - ✔✔bowel diversion which processes liquid fecal content from the small
intestine to be eliminated via the stomach
✔✔colostomy - ✔✔-a surgical operation that creates an opening from the colon to the
surface of the body to function as an anus
ANSWERS GRADED A+
✔✔Example of surgical asepsis - ✔✔-administering injections
-administering IV therapy
-changing wound dressings
-performing urinary catherization
✔✔Nursing actions to promote patient safety - ✔✔-keep the bed in the low position if
not giving direct care
-lock the bed wheels to prevent the bed from rolling when the patient attempts to get in
or out
-answer call lights quickly so that the patient learns to trust you and does not feel the
need to get up without you
✔✔Major risk factors for a pressure injury - ✔✔-immobility
-inactivity
-moisture
-malnutrition
-advanced age
-altered sensory perception
-lowered mental awareness
-friction and shear
✔✔contributing risk factors for a pressure injury - ✔✔-dehydration
-obesity
-edema
✔✔stage 1 pressure injury - ✔✔-An area of intact skin that is red, deep pink, or mottled
skin
-does not blanch with fingertip pressure
✔✔stage 2 pressure injury - ✔✔-partial thickness skin loss with exposed dermis
-may appear as ruptured blister
✔✔stage 3 pressure injury - ✔✔-full thickness loss
-looks like deep crater extend to fascia
-subtaneous tissue damaged/necrotic fat visible
-undermining/tunneling may be present
✔✔stage 4 pressure injury - ✔✔-full-thickness skin loss with extensive tissue necrosis
or damage to muscle or bone
-the injury may appear black, necrotic tissue(eschar)
✔✔unstageable pressure injury - ✔✔-loss full thickness
,-base injury covered in eschar ( tan, brown, black) in wound bed
✔✔When should you not take an oral temperature? - ✔✔When the patient has:
-smoked
-chewed gum
-consumed hot/cold beverages.
✔✔How long should you wait to take an oral temp is the patient consumed a hot or cold
beverage, smoked or recently chewed gum? - ✔✔wait 15 to 30 minutes
✔✔Rectal temperatures should not be used for - ✔✔-cardiac patients
-patients who have had rectal surgery
✔✔What should you do if the pedal pulses are weak or unequal? - ✔✔check pulse with
a Doppler stethoscope
✔✔Dyspnea - ✔✔-difficult or labored breathing
-also known as shortness of breath
-accompanied by flared nostrils, anxious appearance
-"I can't get enough air"
✔✔Kussmaul respirations - ✔✔-increased rate, very deep, labored breathing (usually
associated with diabetic acidosis and renal failure)
-400+ blood sugar
✔✔Cheyne-Stokes respiration - ✔✔-consist of a pattern of dyspnea followed by a short
period of apnea (respirations are faster and deeper, then slower, and are followed by a
period of no breathing)
-seen in patients with heart or kidney failure
✔✔Patient Interview: If the patient is confused, who should you talk to? - ✔✔a family
member
✔✔Palpation - ✔✔-an examination technique in which the examiner's pads of fingers
are used to feel pain, tenderness, swelling, growth, skin temperature, edema
-1/2 - 3/4 in
✔✔percussion - ✔✔-used primarily over the chest and abdomen to determine the size,
location and density
-performed by a doctor
✔✔The best time to collect a sputum specimen is - ✔✔-just after the patient awakens
-after a nebulizer treatment
, ✔✔What is the best nursing intervention if the sputum is too thick? - ✔✔increase fluids -
fluids make the sputum thinner
✔✔How to collect a midstream urine specimen? - ✔✔1. void a small amount of urine
into the toilet
2. catch the middle portion of urine by moving the container into the stream
3. collect about 1 oz of urine
4. set the container on the sink
5. finish voiding into the toilet
✔✔Midstream clean catch - ✔✔Most common procedure for collecting any type of urine
specimen that is relatively free from external contamination
✔✔24 hr urine specimen - ✔✔Voids:
-1st time (discard)
-2nd time and so forth is kept for 24 hrs
-post a sign
-keep urine on ice
✔✔How to prevent recurrent cystitis (UTI) - ✔✔-avoid citrus fruits and juices
-always wipe the rectal area from front to back after a bowel movement
-emptying bladder after intercourse and drinking two glasses of water to flush out
microorganisms that may have entered the bladder
✔✔hyperactive bowel - ✔✔-increase in peristalsis
-usually results in diarrhea
-may be self-limiting
✔✔gastritis - ✔✔-Inflammation of the stomach lining
-hyperactive bowel sounds
-S&S- Hematemesis; indigestion; epigastric pain
-Irritants such as aspirin; poisons; alcohol; tobacco
✔✔constipation - ✔✔-Hard, slow stools that are difficult to eliminate; often a result of too
little fiber in the diet
-hypoactive bowel sounds
✔✔normal bowel sounds - ✔✔-high-pitched, gurgling, cascading sounds, occurring
irregularly anywhere from 5 to 30 times per minute.
✔✔ileostomy - ✔✔bowel diversion which processes liquid fecal content from the small
intestine to be eliminated via the stomach
✔✔colostomy - ✔✔-a surgical operation that creates an opening from the colon to the
surface of the body to function as an anus
