Virtual ATI Next Gen PN Comprehensive Predictor Exit
Assessment for NUR 265 Level 3 Forms A, B & C with Actual &
Retake Real Questions and Verified Solutions — Pass on First
Attempt
FUNDAMENTALS & BASIC CARE
Question 1: A nurse is preparing to administer an enema to an adult client. The
nurse should insert the rectal tube which distance?
• A) 1 inch (2.5 cm)
• B) 2 inches (5 cm)
• C) 4 inches (10 cm)
• D) 6 inches (15 cm)
Correct Answer: C
Rationale: For an adult, the rectal tube should be inserted 4 inches (10 cm).
Inserting too far can damage the bowel wall; not inserting far enough may cause
the solution to leak out or cause rectal discomfort.
Question 2: A nurse is performing a straight catheterization on a female client.
Which action indicates proper technique?
• A) Cleans the labia from the anal area upward
• B) Spreads the labia with the non-dominant hand and maintains this
position throughout
• C) Inserts the catheter 1 to 2 inches (2.5 to 5 cm) into the urethra
• D) Releases the labia before inserting the catheter
Correct Answer: B
,Rationale: The non-dominant hand spreads and maintains the labia in an open
position until urine flow is established. The dominant hand remains sterile.
Cleanse from top to bottom (pubis to anus). Insert catheter 2-3 inches (5-7.5 cm).
Question 3: A nurse is caring for a client with a sealed radiation implant for
brachytherapy. Which action by the nursing assistant requires immediate
intervention?
• A) The nursing assistant places the client in a semi-private room
• B) The nursing assistant places a "Caution: Radioactive Material" sign on
the door
• C) The nursing assistant wears a dosimeter badge while providing care
• D) The nursing assistant stands 3 feet away from the client's bed
Correct Answer: A
Rationale: Clients with sealed radiation implants must have a private room to
prevent radiation exposure to others. All other options are correct safety
measures.
Question 4: A nurse is preparing to suction a client's tracheostomy. Which action
demonstrates correct technique?
• A) Hyperoxygenates the client with 100% oxygen before suctioning
• B) Applies suction during insertion of the catheter
• C) Rotates the catheter while applying suction for 20 seconds
• D) Uses a new sterile catheter for each deep suctioning pass
Correct Answer: A
Rationale: Hyperoxygenation before suctioning prevents hypoxia. Suction is
applied only during withdrawal (not insertion). Suction time should be limited to
10-15 seconds maximum.
,Question 5: A nurse is caring for a client with a Sengstaken-Blakemore tube in
place for esophageal varices. Which action is most important for the nurse to
perform?
• A) Keep scissors at the bedside
• B) Deflate the gastric balloon every 4 hours
• C) Maintain the client in a supine position
• D) Encourage oral fluid intake
Correct Answer: A
Rationale: Scissors must be kept at the bedside at all times in case the tube
dislodges, so the balloons can be cut and the tube removed to prevent airway
obstruction.
Question 6: A nurse is providing teaching to a client about how to collect a clean-
catch midstream urine specimen. Which instruction should the nurse include?
• A) "Collect the first urine of the morning"
• B) "Start urinating into the toilet, then collect the specimen"
• C) "Collect urine after drinking 2 liters of fluid"
• D) "Wipe the perineum from back to front before collecting"
Correct Answer: B
Rationale: The client should void a small amount into the toilet first, then collect
the midstream urine. This technique flushes out contaminants from the urethra.
Question 7: A nurse is caring for a client who has an order for a 24-hour urine
collection. Which action should the nurse take?
• A) Discard the first voided specimen and start the collection
, • B) Include the first voided specimen in the collection
• C) Keep the collection container at room temperature
• D) Collect urine for exactly 12 hours
Correct Answer: A
Rationale: The client empties the bladder (discarding this specimen) and then
collects all urine for the next 24 hours. The final specimen is the first voided at the
end of the 24-hour period.
Question 8: A nurse is preparing to insert a nasogastric tube. Which measurement
is used to determine the length of tube to insert?
• A) Tip of nose to ear lobe to xiphoid process
• B) Corner of mouth to ear lobe to xiphoid process
• C) Tip of nose to ear lobe to umbilicus
• D) Corner of mouth to mastoid process to umbilicus
Correct Answer: A
Rationale: The standard measurement for NG tube insertion is from the tip of the
nose to the ear lobe to the xiphoid process (NEX measurement).
Question 9: A nurse is caring for a client receiving continuous enteral feedings.
The nurse should check gastric residual volume at which frequency?
• A) Every 1 hour
• B) Every 2 to 4 hours
• C) Every 8 hours
• D) Only at the start of each shift
Correct Answer: B
Assessment for NUR 265 Level 3 Forms A, B & C with Actual &
Retake Real Questions and Verified Solutions — Pass on First
Attempt
FUNDAMENTALS & BASIC CARE
Question 1: A nurse is preparing to administer an enema to an adult client. The
nurse should insert the rectal tube which distance?
• A) 1 inch (2.5 cm)
• B) 2 inches (5 cm)
• C) 4 inches (10 cm)
• D) 6 inches (15 cm)
Correct Answer: C
Rationale: For an adult, the rectal tube should be inserted 4 inches (10 cm).
Inserting too far can damage the bowel wall; not inserting far enough may cause
the solution to leak out or cause rectal discomfort.
Question 2: A nurse is performing a straight catheterization on a female client.
Which action indicates proper technique?
• A) Cleans the labia from the anal area upward
• B) Spreads the labia with the non-dominant hand and maintains this
position throughout
• C) Inserts the catheter 1 to 2 inches (2.5 to 5 cm) into the urethra
• D) Releases the labia before inserting the catheter
Correct Answer: B
,Rationale: The non-dominant hand spreads and maintains the labia in an open
position until urine flow is established. The dominant hand remains sterile.
Cleanse from top to bottom (pubis to anus). Insert catheter 2-3 inches (5-7.5 cm).
Question 3: A nurse is caring for a client with a sealed radiation implant for
brachytherapy. Which action by the nursing assistant requires immediate
intervention?
• A) The nursing assistant places the client in a semi-private room
• B) The nursing assistant places a "Caution: Radioactive Material" sign on
the door
• C) The nursing assistant wears a dosimeter badge while providing care
• D) The nursing assistant stands 3 feet away from the client's bed
Correct Answer: A
Rationale: Clients with sealed radiation implants must have a private room to
prevent radiation exposure to others. All other options are correct safety
measures.
Question 4: A nurse is preparing to suction a client's tracheostomy. Which action
demonstrates correct technique?
• A) Hyperoxygenates the client with 100% oxygen before suctioning
• B) Applies suction during insertion of the catheter
• C) Rotates the catheter while applying suction for 20 seconds
• D) Uses a new sterile catheter for each deep suctioning pass
Correct Answer: A
Rationale: Hyperoxygenation before suctioning prevents hypoxia. Suction is
applied only during withdrawal (not insertion). Suction time should be limited to
10-15 seconds maximum.
,Question 5: A nurse is caring for a client with a Sengstaken-Blakemore tube in
place for esophageal varices. Which action is most important for the nurse to
perform?
• A) Keep scissors at the bedside
• B) Deflate the gastric balloon every 4 hours
• C) Maintain the client in a supine position
• D) Encourage oral fluid intake
Correct Answer: A
Rationale: Scissors must be kept at the bedside at all times in case the tube
dislodges, so the balloons can be cut and the tube removed to prevent airway
obstruction.
Question 6: A nurse is providing teaching to a client about how to collect a clean-
catch midstream urine specimen. Which instruction should the nurse include?
• A) "Collect the first urine of the morning"
• B) "Start urinating into the toilet, then collect the specimen"
• C) "Collect urine after drinking 2 liters of fluid"
• D) "Wipe the perineum from back to front before collecting"
Correct Answer: B
Rationale: The client should void a small amount into the toilet first, then collect
the midstream urine. This technique flushes out contaminants from the urethra.
Question 7: A nurse is caring for a client who has an order for a 24-hour urine
collection. Which action should the nurse take?
• A) Discard the first voided specimen and start the collection
, • B) Include the first voided specimen in the collection
• C) Keep the collection container at room temperature
• D) Collect urine for exactly 12 hours
Correct Answer: A
Rationale: The client empties the bladder (discarding this specimen) and then
collects all urine for the next 24 hours. The final specimen is the first voided at the
end of the 24-hour period.
Question 8: A nurse is preparing to insert a nasogastric tube. Which measurement
is used to determine the length of tube to insert?
• A) Tip of nose to ear lobe to xiphoid process
• B) Corner of mouth to ear lobe to xiphoid process
• C) Tip of nose to ear lobe to umbilicus
• D) Corner of mouth to mastoid process to umbilicus
Correct Answer: A
Rationale: The standard measurement for NG tube insertion is from the tip of the
nose to the ear lobe to the xiphoid process (NEX measurement).
Question 9: A nurse is caring for a client receiving continuous enteral feedings.
The nurse should check gastric residual volume at which frequency?
• A) Every 1 hour
• B) Every 2 to 4 hours
• C) Every 8 hours
• D) Only at the start of each shift
Correct Answer: B
