NR 306: Maternal-Newborn Nursing Proctored Exam
Ultimate Study Bank with Detailed Rationales
Course Code: NR 212
Course Name: Fundamentals of Nursing and Clinical Mastery
Topic: Bladder Retraining, Safety Protocols, SBAR, Cultural Dietary Laws, and
Isolation Management
Academic Year: 2026/2027
1. A nurse is planning to implement bladder retraining for a client who has
urge urinary incontinence. Which of the following actions should the nurse
plan to take?
A) Assist the client to the toilet as soon as the urge to void is reported
B) Apply an adult diaper to the client during nighttime hours
C) Gradually lengthen the time between the client's scheduled voids
D) Restrict the client's total fluid intake to less than 1,000 mL daily
CORRECT ANSWER: C
RATIONALE: The core therapeutic mechanism of bladder retraining for
urge urinary incontinence is to systematically increase the bladder's functional
capacity and suppress involuntary detrusor muscle contractions by gradually
lengthening the intervals between scheduled voids. Assisting the client to the
toilet immediately upon experiencing an urge reinforces maladaptive urgency
patterns rather than conditioning the bladder. Adult diapers can promote skin
breakdown and dependency, while severe fluid restriction can cause concentrated
urine that irritates the detrusor muscle, worsening bladder spasms.
2. A charge nurse is teaching a group of newly licensed nurses how to prevent
errors during the administration of blood transfusions. Which of the following
actions should the nurse take?
A) Complete the administration of 1 unit of packed RBCs within six hours of
initiation
B) Infuse 500 mL of Lactated Ringer's when administering whole blood
C) Vigorously massage the blood bag to mix the cells prior to administration
D) Use a new blood administration tubing set for each blood bag infused
, CORRECT ANSWER: D
RATIONALE: To minimize the risk of bacterial proliferation and prevent
filter occlusion from microscopic fibrin clots, the nurse must utilize a new blood
administration tubing set for each discrete blood unit infused or adhere strictly
to the facility's 4-hour tubing change window. Transfusions must be fully
completed within a maximum of 4 hours from the time the blood leaves
refrigeration to prevent bacterial growth, making a 6-hour window dangerous.
Only 0.9% sodium chloride (normal saline) is compatible with blood products;
calcium-containing solutions like Lactated Ringer's will precipitate and cause
hemolysis. Vigorously massaging the bag is contraindicated as it can cause
mechanical trauma and lyse the red blood cells.
3. A nurse is preparing to administer three medications to a client who has an
NG tube: a levothyroxine tablet, an ibuprofen gel cap, and a delayed-release
omeprazole capsule. Which of the following actions should the nurse take?
A) Dissolve all three medications together in 30 mL of warm water and instill them
B) Crush the levothyroxine tablet into a powder and dissolve it in 30 mL of
warm sterile water
C) Pierce the ibuprofen gel cap and squeeze the liquid contents directly into the
tube
D) Open the delayed-release omeprazole capsule and crush the enteric-coated
granules into a fine powder
CORRECT ANSWER: B
RATIONALE: Standard protocol for nasogastric (NG) tube medication
administration requires the nurse to crush the solid levothyroxine tablet into a
fine powder and dissolve it independently in 30 mL of warm sterile water.
Medications must never be mixed together before administration due to
unpredictable chemical interactions. Gel caps cannot be effectively flushed through
an NG tube, and entering liquid contents manually yields inaccurate dosing,
meaning the nurse must request an alternative liquid formulation from the
provider. Enteric-coated or delayed-release granules (like omeprazole) must never
be crushed because breaking the protective outer layer destroys the medication's
acid-resistant properties and risks tube occlusion.
, 4. A nurse is teaching a client who has rheumatoid arthritis about chronic
pain management. Which of the following statements by the client indicates
an understanding of the teaching?
A) "I should stop participating in my bowling league completely."
B) "I should take a cool shower in the morning to relieve joint stiffness."
C) "I should decrease my intake of foods containing purine."
D) "I should use a warm paraffin dip for my hands and feet."
CORRECT ANSWER: D
RATIONALE: Warm paraffin wax baths supply soothing, uniform heat to
distal joints, reducing local stiffness and improving comfort and range of motion in
clients with rheumatoid arthritis. Complete physical immobilization or stopping
social activities like bowling accelerates joint contractures and muscle atrophy;
low-impact exercise should be maintained. Cool showers worsen morning joint
stiffness, which responds best to warm water application. Restricting purines is a
specific intervention for metabolic gouty arthritis, not autoimmune rheumatoid
arthritis.
5. A nurse is preparing to administer an immunization via IM injection into
an adult client's deltoid muscle. Which of the following actions should the
nurse take?
A) Select a 1-inch needle for the injection
B) Pinch the client's skin with the nondominant hand while inserting the needle
C) Aspirate and check for blood prior to injection of the vaccine
D) Limit the volume of fluid injected to 3 mL
CORRECT ANSWER: A
RATIONALE: For a standard intramuscular injection into the deltoid
muscle of an average-weight adult, a 1-inch needle is ideal to ensure the
medication penetrates past the subcutaneous tissue layer into the muscle belly. The
skin should be held taut or flattened using a Z-track technique rather than pinched.
Current CDC and clinical guidelines do not recommend aspiration prior to
immunizations because the deltoid lacks major accessible blood vessels, and
aspiration increases local tissue trauma. Fluid volumes injected into the deltoid
muscle must be strictly limited to a maximum of 1 to 2 mL, making 3 mL
excessively large for this site.
Ultimate Study Bank with Detailed Rationales
Course Code: NR 212
Course Name: Fundamentals of Nursing and Clinical Mastery
Topic: Bladder Retraining, Safety Protocols, SBAR, Cultural Dietary Laws, and
Isolation Management
Academic Year: 2026/2027
1. A nurse is planning to implement bladder retraining for a client who has
urge urinary incontinence. Which of the following actions should the nurse
plan to take?
A) Assist the client to the toilet as soon as the urge to void is reported
B) Apply an adult diaper to the client during nighttime hours
C) Gradually lengthen the time between the client's scheduled voids
D) Restrict the client's total fluid intake to less than 1,000 mL daily
CORRECT ANSWER: C
RATIONALE: The core therapeutic mechanism of bladder retraining for
urge urinary incontinence is to systematically increase the bladder's functional
capacity and suppress involuntary detrusor muscle contractions by gradually
lengthening the intervals between scheduled voids. Assisting the client to the
toilet immediately upon experiencing an urge reinforces maladaptive urgency
patterns rather than conditioning the bladder. Adult diapers can promote skin
breakdown and dependency, while severe fluid restriction can cause concentrated
urine that irritates the detrusor muscle, worsening bladder spasms.
2. A charge nurse is teaching a group of newly licensed nurses how to prevent
errors during the administration of blood transfusions. Which of the following
actions should the nurse take?
A) Complete the administration of 1 unit of packed RBCs within six hours of
initiation
B) Infuse 500 mL of Lactated Ringer's when administering whole blood
C) Vigorously massage the blood bag to mix the cells prior to administration
D) Use a new blood administration tubing set for each blood bag infused
, CORRECT ANSWER: D
RATIONALE: To minimize the risk of bacterial proliferation and prevent
filter occlusion from microscopic fibrin clots, the nurse must utilize a new blood
administration tubing set for each discrete blood unit infused or adhere strictly
to the facility's 4-hour tubing change window. Transfusions must be fully
completed within a maximum of 4 hours from the time the blood leaves
refrigeration to prevent bacterial growth, making a 6-hour window dangerous.
Only 0.9% sodium chloride (normal saline) is compatible with blood products;
calcium-containing solutions like Lactated Ringer's will precipitate and cause
hemolysis. Vigorously massaging the bag is contraindicated as it can cause
mechanical trauma and lyse the red blood cells.
3. A nurse is preparing to administer three medications to a client who has an
NG tube: a levothyroxine tablet, an ibuprofen gel cap, and a delayed-release
omeprazole capsule. Which of the following actions should the nurse take?
A) Dissolve all three medications together in 30 mL of warm water and instill them
B) Crush the levothyroxine tablet into a powder and dissolve it in 30 mL of
warm sterile water
C) Pierce the ibuprofen gel cap and squeeze the liquid contents directly into the
tube
D) Open the delayed-release omeprazole capsule and crush the enteric-coated
granules into a fine powder
CORRECT ANSWER: B
RATIONALE: Standard protocol for nasogastric (NG) tube medication
administration requires the nurse to crush the solid levothyroxine tablet into a
fine powder and dissolve it independently in 30 mL of warm sterile water.
Medications must never be mixed together before administration due to
unpredictable chemical interactions. Gel caps cannot be effectively flushed through
an NG tube, and entering liquid contents manually yields inaccurate dosing,
meaning the nurse must request an alternative liquid formulation from the
provider. Enteric-coated or delayed-release granules (like omeprazole) must never
be crushed because breaking the protective outer layer destroys the medication's
acid-resistant properties and risks tube occlusion.
, 4. A nurse is teaching a client who has rheumatoid arthritis about chronic
pain management. Which of the following statements by the client indicates
an understanding of the teaching?
A) "I should stop participating in my bowling league completely."
B) "I should take a cool shower in the morning to relieve joint stiffness."
C) "I should decrease my intake of foods containing purine."
D) "I should use a warm paraffin dip for my hands and feet."
CORRECT ANSWER: D
RATIONALE: Warm paraffin wax baths supply soothing, uniform heat to
distal joints, reducing local stiffness and improving comfort and range of motion in
clients with rheumatoid arthritis. Complete physical immobilization or stopping
social activities like bowling accelerates joint contractures and muscle atrophy;
low-impact exercise should be maintained. Cool showers worsen morning joint
stiffness, which responds best to warm water application. Restricting purines is a
specific intervention for metabolic gouty arthritis, not autoimmune rheumatoid
arthritis.
5. A nurse is preparing to administer an immunization via IM injection into
an adult client's deltoid muscle. Which of the following actions should the
nurse take?
A) Select a 1-inch needle for the injection
B) Pinch the client's skin with the nondominant hand while inserting the needle
C) Aspirate and check for blood prior to injection of the vaccine
D) Limit the volume of fluid injected to 3 mL
CORRECT ANSWER: A
RATIONALE: For a standard intramuscular injection into the deltoid
muscle of an average-weight adult, a 1-inch needle is ideal to ensure the
medication penetrates past the subcutaneous tissue layer into the muscle belly. The
skin should be held taut or flattened using a Z-track technique rather than pinched.
Current CDC and clinical guidelines do not recommend aspiration prior to
immunizations because the deltoid lacks major accessible blood vessels, and
aspiration increases local tissue trauma. Fluid volumes injected into the deltoid
muscle must be strictly limited to a maximum of 1 to 2 mL, making 3 mL
excessively large for this site.
