Final Exam - Nur101 - Pa. College of Health Sciences (Questions And Answers) Graded A+
A postoperative patient has abdominal discomfort with the absence of bowel sounds.
Which is the most effective nursing action to help manage this abdominal
discomfort?
a. Encourage frequent ambulation
b. Administer PRN pain meds
c. Ensure adequate fluids by mouth
d. Provide sufficient fiber in the diet. Answer- a. Encourage frequent ambulation.
A patient has been on bed rest for two weeks. For which localized response to
immobility should the nurse assess the patient?
a. Orthostatic hypotension
b. Muscle atrophy
c. Osteoporosis
d. Atelectasis Answer- b. Muscle atrophy
A patient states, "I like to have a bowel movement every morning." Which additional
data collected by the nurse most supports a concern with perceived constipation?
a. Hard, dry stools are defecated daily
b. Laxatives are used excessively
c. Abdominal distention
d. Straining is required Answer- b. Laxatives are used excessively
The most important concept that nurses must consider to make accurate
assessments is that nonverbal behavior:
a. Is controlled by the conscious mind
b. Carries less weight than what the patient says
c. Does not have the same meaning for everyone
d. Is generally a poor reflection of what the patient is feeling. Answer- c. Does not
have the same meaning for everyone
A nurse is assisting a patient who has cognitive deficits with a bed bath. What is
most important for the nurse to do?
a. Have the patient feel each item of the bath products prior to starting
b. Encourage attention to each task of bathing
c. Arrange the basin within the center of the patient's visual field
,Final Exam - Nur101 - Pa. College of Health Sciences (Questions And Answers) Graded A+
d. Explain in detail everything that will be done during the bath before beginning
Answer- b. Encourage attention to each task of bathing
A nurse places a patient who had abdominal surgery in the semi-Fowler position.
What is the rationale for this nursing intervention?
a. Supports ventilation
b. Facilitates the passing of flatus
c. Encourages urinary elimination
d. Promotes drainage int he portable wound draining system Answer- a. Supports
ventilation
A newly admitted patient is exhibiting anxiety associated with being hospitalized.
What is most important for the nurse to do to help reduce the patient's anxiety?
a. Teach relaxation techniques
b. Validate the anxious feelings
c. Minimize environmental stimuli
d. Explain procedures to the patient. Answer- d. Explain procedures to the patiet
A nurse instills medicated drops into the ear of an adult. What should the nurse do to
ensure that the medication flows toward the eardrum?
a. Pull the pinna of the ear backward and downward
b. Insert the drops into the center of the auditory canal
c. Press the tragus of the ear several times after insertion
d. Roll the patient from the side-lying to the supine position Answer- c. Press the
tragus of the ear several times after insertion
A patient who is secretly smoking in bed falls asleep and the cigarette ignites the
patient's gown. What should the nurse do first after discovering the fire?
a. Close the door
b. Activate the fire alarm
c. Roll the patient from side to side
d. Smother the flames with a blanket. Answer- d. Smother the flames with a blanket
A nurse is assessing the skin of an older adult. Which response is of the greatest
concern?
a. Flat, brown-colored spots on the skin
b. Thin, translucent skin
c. Tenting of the skin
d. Dry, flaky skin Answer- C. Tenting of the skin
While reviewing both the client's problem list against the various identified nursing
diagnoses, what is the nurse doing?
a. Understanding abnormalities
b. Verifying clustered data
c. Consulting resources
d. Basing diagnoses on patterns Answer- b. Verifying clustered data
The nurse is performing a dressing change for a client and notices that there is a
new area of skin breakdown near the site of the dressing. On closer examination, it
,Final Exam - Nur101 - Pa. College of Health Sciences (Questions And Answers) Graded A+
appears to be caused from the tape used to secure the dressing. This would be an
example of which phase of the nursing process?
a. Assessment
b. Diagnoses
C. Implementation
D. Evaluation Answer- A. Assessment
When learning how to implement the nursing process into a plan of care for a client,
the student nurse realizes the part of the purpose of the nursing process is to:
a. Deliver care to a client in an organized way
b. Implement a plan that is close to the medical model
c. Identify client needs and deliver care to meet those needs
d. Make sure that standardized care is available to clients. Answer- b. Implement a
plan that is close to the medical model
A patient who has a wound infection after major surgery has only been taking in
about 50-75 percent of the ordered meals and states, "Nothing on the menu really
appeals to me." Which action by the nurse will be most effective in improving the
patient's oral intake?
a. Make a referral to the dietician
b. Tell the patient he has to eat what is on his meal tray
c. Have the doctor order supplements
d. Have family members bring in favorite foods from home. Answer- d. Have family
members bring in favorite foods from home
While changing a patient's dressing, the nurse notes thick yellow-green drainage on
the gauze. How should the nurse document this wounds drainage?
a. Purulent
b. Serous
c. Serosanguinous
d. Necrotic Answer- a. Purulent
How should the nurse position a client who is complaining of dyspnea?
a. A high fowler's position with two pillows behind the head
b. Orthopneic position across the over bed table
c. Semi-fowler's position on their right side
d. Supine on their left side Answer- b. Orthopneic position across the over bed table
Two days after surgery for an ileal conduit, the patient will not look at the stoma or
participate in care. The patient insists that no one but the ostomy nurse specialists
can care for the stoma. The nurse identifies a nursing diagnosis of:
a. Anxiety r/t effects of procedure on lifestyle
b. Disturbed body image r/t change in body function
c. Noncompliance r/t not participating in ostomy care
d. Imbalanced nutrition: less than body requirements r/t ileal conduit Answer- b.
Disturbed body image r/t change in body function
A patient sustained several wounds on the legs caused by a fall. On the day after the
injuries, the wounds appear red and edematous. The nurse identifies the sage of
healing of these wounds as long:
, Final Exam - Nur101 - Pa. College of Health Sciences (Questions And Answers) Graded A+
a. Inflammatory
b. Proliferate
c. Allergic reaction
d. Remodeling Answer- b. Proliferate
While assisting the client with a bath, the nurse encourages full range of motion in all
the client's joints. Which activity would be support range of motion in the hand and
arm?
a. Move the wash basin farther toward the foot of the bed so the client must reach
b. Have the client brush their hair and teeth
c. Move each of the patient's hand and arm joints through passive range of motion
d Have the client doing exercises with only the fingers Answer- b. Have the client
brush their hair and teeth
The newly admitted client has contractures of both lower extremities. What nursing
intervention should be included in the client's plan of care?
a. Weight-bearing activities
b. Passive range of motion exercises
c. Non-weight bearing exercises
d. Active range of motion Answer- b. Passive range of motion exercises
S1 is heard best at the:
a. 5th ICS left midclavicular line
b. 3rd ICS left midclavicular line
c. 2nd ICS right sternal border
d. 2nd ICS left sternal border Answer- a. 5th ICS left midclavicular line
A 22-year-old client with recent paraplegia lashes out and curses at the nurse about
the breakfast meal. The nurse's best response is:
a. "I know you are angry, but I cannot let you make me become the object of your
anger. I will send up the dietician."
b. "This is not about breakfast. Tell me what you are really angry about."
c. "This is not about breakfast. I'll shut the door and let you cool off."
d. "I hear a lot of anger in your voice. That is quite normal and healthy to hear. Is it a
new breakfast you want or something else?" Answer- d. "I hear a lot of anger in your
voice. That is quite normal and healthy to hear. Is it a new breakfast you want or
something else?"
What is primary prevention?
a. Remaining faithful to ethical principles, keeping commitments
b. Describes a nurse's role, according to the ANA Committee on Education
c. Helps to reduce the spread of disease
d. Prevent a disease from occurring, ex. diet, exercise, immunizations Answer- c.
Helps reduce the spread of the disease
What is tertiary prevention?
a. Educating the patient on prevention of possible diseases (ex: skin cancer)
b. Prevent a disease from ever occurring, ex: diet, exercise, immunizations
c. Detecting disease as early as possible, ex: BP screenings, mammograms, family
counseling
A postoperative patient has abdominal discomfort with the absence of bowel sounds.
Which is the most effective nursing action to help manage this abdominal
discomfort?
a. Encourage frequent ambulation
b. Administer PRN pain meds
c. Ensure adequate fluids by mouth
d. Provide sufficient fiber in the diet. Answer- a. Encourage frequent ambulation.
A patient has been on bed rest for two weeks. For which localized response to
immobility should the nurse assess the patient?
a. Orthostatic hypotension
b. Muscle atrophy
c. Osteoporosis
d. Atelectasis Answer- b. Muscle atrophy
A patient states, "I like to have a bowel movement every morning." Which additional
data collected by the nurse most supports a concern with perceived constipation?
a. Hard, dry stools are defecated daily
b. Laxatives are used excessively
c. Abdominal distention
d. Straining is required Answer- b. Laxatives are used excessively
The most important concept that nurses must consider to make accurate
assessments is that nonverbal behavior:
a. Is controlled by the conscious mind
b. Carries less weight than what the patient says
c. Does not have the same meaning for everyone
d. Is generally a poor reflection of what the patient is feeling. Answer- c. Does not
have the same meaning for everyone
A nurse is assisting a patient who has cognitive deficits with a bed bath. What is
most important for the nurse to do?
a. Have the patient feel each item of the bath products prior to starting
b. Encourage attention to each task of bathing
c. Arrange the basin within the center of the patient's visual field
,Final Exam - Nur101 - Pa. College of Health Sciences (Questions And Answers) Graded A+
d. Explain in detail everything that will be done during the bath before beginning
Answer- b. Encourage attention to each task of bathing
A nurse places a patient who had abdominal surgery in the semi-Fowler position.
What is the rationale for this nursing intervention?
a. Supports ventilation
b. Facilitates the passing of flatus
c. Encourages urinary elimination
d. Promotes drainage int he portable wound draining system Answer- a. Supports
ventilation
A newly admitted patient is exhibiting anxiety associated with being hospitalized.
What is most important for the nurse to do to help reduce the patient's anxiety?
a. Teach relaxation techniques
b. Validate the anxious feelings
c. Minimize environmental stimuli
d. Explain procedures to the patient. Answer- d. Explain procedures to the patiet
A nurse instills medicated drops into the ear of an adult. What should the nurse do to
ensure that the medication flows toward the eardrum?
a. Pull the pinna of the ear backward and downward
b. Insert the drops into the center of the auditory canal
c. Press the tragus of the ear several times after insertion
d. Roll the patient from the side-lying to the supine position Answer- c. Press the
tragus of the ear several times after insertion
A patient who is secretly smoking in bed falls asleep and the cigarette ignites the
patient's gown. What should the nurse do first after discovering the fire?
a. Close the door
b. Activate the fire alarm
c. Roll the patient from side to side
d. Smother the flames with a blanket. Answer- d. Smother the flames with a blanket
A nurse is assessing the skin of an older adult. Which response is of the greatest
concern?
a. Flat, brown-colored spots on the skin
b. Thin, translucent skin
c. Tenting of the skin
d. Dry, flaky skin Answer- C. Tenting of the skin
While reviewing both the client's problem list against the various identified nursing
diagnoses, what is the nurse doing?
a. Understanding abnormalities
b. Verifying clustered data
c. Consulting resources
d. Basing diagnoses on patterns Answer- b. Verifying clustered data
The nurse is performing a dressing change for a client and notices that there is a
new area of skin breakdown near the site of the dressing. On closer examination, it
,Final Exam - Nur101 - Pa. College of Health Sciences (Questions And Answers) Graded A+
appears to be caused from the tape used to secure the dressing. This would be an
example of which phase of the nursing process?
a. Assessment
b. Diagnoses
C. Implementation
D. Evaluation Answer- A. Assessment
When learning how to implement the nursing process into a plan of care for a client,
the student nurse realizes the part of the purpose of the nursing process is to:
a. Deliver care to a client in an organized way
b. Implement a plan that is close to the medical model
c. Identify client needs and deliver care to meet those needs
d. Make sure that standardized care is available to clients. Answer- b. Implement a
plan that is close to the medical model
A patient who has a wound infection after major surgery has only been taking in
about 50-75 percent of the ordered meals and states, "Nothing on the menu really
appeals to me." Which action by the nurse will be most effective in improving the
patient's oral intake?
a. Make a referral to the dietician
b. Tell the patient he has to eat what is on his meal tray
c. Have the doctor order supplements
d. Have family members bring in favorite foods from home. Answer- d. Have family
members bring in favorite foods from home
While changing a patient's dressing, the nurse notes thick yellow-green drainage on
the gauze. How should the nurse document this wounds drainage?
a. Purulent
b. Serous
c. Serosanguinous
d. Necrotic Answer- a. Purulent
How should the nurse position a client who is complaining of dyspnea?
a. A high fowler's position with two pillows behind the head
b. Orthopneic position across the over bed table
c. Semi-fowler's position on their right side
d. Supine on their left side Answer- b. Orthopneic position across the over bed table
Two days after surgery for an ileal conduit, the patient will not look at the stoma or
participate in care. The patient insists that no one but the ostomy nurse specialists
can care for the stoma. The nurse identifies a nursing diagnosis of:
a. Anxiety r/t effects of procedure on lifestyle
b. Disturbed body image r/t change in body function
c. Noncompliance r/t not participating in ostomy care
d. Imbalanced nutrition: less than body requirements r/t ileal conduit Answer- b.
Disturbed body image r/t change in body function
A patient sustained several wounds on the legs caused by a fall. On the day after the
injuries, the wounds appear red and edematous. The nurse identifies the sage of
healing of these wounds as long:
, Final Exam - Nur101 - Pa. College of Health Sciences (Questions And Answers) Graded A+
a. Inflammatory
b. Proliferate
c. Allergic reaction
d. Remodeling Answer- b. Proliferate
While assisting the client with a bath, the nurse encourages full range of motion in all
the client's joints. Which activity would be support range of motion in the hand and
arm?
a. Move the wash basin farther toward the foot of the bed so the client must reach
b. Have the client brush their hair and teeth
c. Move each of the patient's hand and arm joints through passive range of motion
d Have the client doing exercises with only the fingers Answer- b. Have the client
brush their hair and teeth
The newly admitted client has contractures of both lower extremities. What nursing
intervention should be included in the client's plan of care?
a. Weight-bearing activities
b. Passive range of motion exercises
c. Non-weight bearing exercises
d. Active range of motion Answer- b. Passive range of motion exercises
S1 is heard best at the:
a. 5th ICS left midclavicular line
b. 3rd ICS left midclavicular line
c. 2nd ICS right sternal border
d. 2nd ICS left sternal border Answer- a. 5th ICS left midclavicular line
A 22-year-old client with recent paraplegia lashes out and curses at the nurse about
the breakfast meal. The nurse's best response is:
a. "I know you are angry, but I cannot let you make me become the object of your
anger. I will send up the dietician."
b. "This is not about breakfast. Tell me what you are really angry about."
c. "This is not about breakfast. I'll shut the door and let you cool off."
d. "I hear a lot of anger in your voice. That is quite normal and healthy to hear. Is it a
new breakfast you want or something else?" Answer- d. "I hear a lot of anger in your
voice. That is quite normal and healthy to hear. Is it a new breakfast you want or
something else?"
What is primary prevention?
a. Remaining faithful to ethical principles, keeping commitments
b. Describes a nurse's role, according to the ANA Committee on Education
c. Helps to reduce the spread of disease
d. Prevent a disease from occurring, ex. diet, exercise, immunizations Answer- c.
Helps reduce the spread of the disease
What is tertiary prevention?
a. Educating the patient on prevention of possible diseases (ex: skin cancer)
b. Prevent a disease from ever occurring, ex: diet, exercise, immunizations
c. Detecting disease as early as possible, ex: BP screenings, mammograms, family
counseling
