NR224 EXAM 2 UPDATED ACTUAL
Questions and CORRECT Answers
a. debridement - CORRECT ANSWER - What is the removal of devitalized tissue from a
wound called?
a. debridement
b. pressure reduction
c. negative pressure wound therapy
d. sanitization
b. oropharyngeal suctioning of a stable patient
d. permanent tracheostomy tube suctioning - CORRECT ANSWER - Which of the
following skills can the nurse delegate to nursing assistive personnel? Select all that apply.
a. nasotracheal suctioning
b. oropharyngeal suctioning of a stable patient
c. suctioning a new artificial airway
d. permanent tracheostomy tube suctioning
e. care of an endotracheal tube
4. verify functioning of suction device and pressure
6. increased supplemental oxygen
1. open kit and basin
3. lubricate catheter
2. apply gloves
5. connect suction tubing to suction catheter
8. suction airway
7. reapply oxygen - CORRECT ANSWER - Place the following in correct sequence for
suctioning a patient.
1. open kit and basin
,2. apply gloves
3. lubricate catheter
4. verify functioning of suction device and pressure
5. connect suction tubing to suction catheter
6. increased supplemental oxygen
7. reapply oxygen
8. suction airway
a. sharp pleuritic pain that worsens on inspiration
d. worsening dyspnea
e. absent lung sounds to auscultation on affected side - CORRECT ANSWER - A patient
was admitted following a motor vehicle accident with multiple fractured ribs. Respiratory
assessment includes signs/symptoms of secondary pneumothorax. Which are the most common
assessment findings associated with a pneumothorax? Select all that apply.
a. sharp pleuritic pain that worsens on inspiration
b. crackles over lung bases of affected lung
c. tracheal deviation toward the affected lung
d. worsening dyspnea
e. absent lung sounds to auscultation on affected side
B (Frequent change of position)
(Movement not only mobilizes secretions but helps strengthen respiratory muscles by impacting
the effectiveness of gas exchange processes.) - CORRECT ANSWER - The nurse is caring
for a patient who has decreased mobility. Which intervention is a simple and cost-effective
method for reducing the risks of pulmonary complication?
a. antibiotics
b. frequent change of position
c. oxygen humidification
d. chest physiotherapy
,B. Decrease or avoid caffeine
D. Avoid drinking alcohol - CORRECT ANSWER - A nurse in a provider's office is
evaluating a client who reports losing control of urine whenever she coughs, laughs, or sneezes.
THe client relates a history of three vaginal births, but no serious accidents or illnesses. Which of
the following interventions should the nurse suggest for helping to control or eliminate the
client's incontinence? Select all that apply.
A. limit total daily fluid intake
B. decrease or avoid caffeine
C. take calcium supplements
D. avoid drinking alcohol
E. use the Crede maneuver.
A. Check to see whether the catheter is patent. - CORRECT ANSWER - A client who has
an indwelling catheter reports a need to urinate. which of the following actions should the nurse
take?
a) check to see whether to catheter is patent
b) reassure the client that it is not possible for her to urinate
c) recatheterize the bladder with a larger-gauge catheter
d) collect a urine specimen for analysis
A. discard the first voiding. - CORRECT ANSWER - A nurse is caring for a client who
has a prescription for a 24-hr urine collection. Which of the following actions should the nurse
take?
A. discard the first voiding.
B. keep the urine in a single container at room temperature.
C. ask the client to urinate and pour the urine into a specimen container.
D. ask the client to urinate into the toilet, stop midstream, and finish urinating into the specimen
container.
A. frequent sexual intercourse
, D. location of the urethra in relation to the anus.
E. frequent catheterization - CORRECT ANSWER - A nurse is reviewing factors that
increase the risk of urinary tract infections with a client who has recurrent UTIs. Which of the
following factors should the nurse include? Select all that apply.
A. frequent sexual intercourse.
B. lowering of testosterone levels.
C. wiping from front to back.
D. location of urethra in relation to the anus.
E. frequent catheterization.
B. have the client record urination times.
C. gradually increase the urination intervals.
D. remind the client to hold urine until the next scheduled urination time. - CORRECT
ANSWER - A nurse is preparing to initiate a bladder-retraining program for a client who
has incontinence. Which for the following actions should the nurse take? Select all that apply.
A. Establish a schedule of urinating prior to meal times.
B. Have the client record urination times.
C. Gradually increase the urination intervals.
D. remind the client to hold urine until the next scheduled urination time.
E. provide a sterile container for urine.
A. restlessness
B. tachypnea
D. confusion
E. pallor - CORRECT ANSWER - A nurse is assessing a client who has an acute
respiratory infection that puts her at risk for hypoxemia. Which of the following findings are
early indications that should alert the nurse that the client is developing hypoxemia? Select all
that apply.
A. restlessness
B. tachypnea
Questions and CORRECT Answers
a. debridement - CORRECT ANSWER - What is the removal of devitalized tissue from a
wound called?
a. debridement
b. pressure reduction
c. negative pressure wound therapy
d. sanitization
b. oropharyngeal suctioning of a stable patient
d. permanent tracheostomy tube suctioning - CORRECT ANSWER - Which of the
following skills can the nurse delegate to nursing assistive personnel? Select all that apply.
a. nasotracheal suctioning
b. oropharyngeal suctioning of a stable patient
c. suctioning a new artificial airway
d. permanent tracheostomy tube suctioning
e. care of an endotracheal tube
4. verify functioning of suction device and pressure
6. increased supplemental oxygen
1. open kit and basin
3. lubricate catheter
2. apply gloves
5. connect suction tubing to suction catheter
8. suction airway
7. reapply oxygen - CORRECT ANSWER - Place the following in correct sequence for
suctioning a patient.
1. open kit and basin
,2. apply gloves
3. lubricate catheter
4. verify functioning of suction device and pressure
5. connect suction tubing to suction catheter
6. increased supplemental oxygen
7. reapply oxygen
8. suction airway
a. sharp pleuritic pain that worsens on inspiration
d. worsening dyspnea
e. absent lung sounds to auscultation on affected side - CORRECT ANSWER - A patient
was admitted following a motor vehicle accident with multiple fractured ribs. Respiratory
assessment includes signs/symptoms of secondary pneumothorax. Which are the most common
assessment findings associated with a pneumothorax? Select all that apply.
a. sharp pleuritic pain that worsens on inspiration
b. crackles over lung bases of affected lung
c. tracheal deviation toward the affected lung
d. worsening dyspnea
e. absent lung sounds to auscultation on affected side
B (Frequent change of position)
(Movement not only mobilizes secretions but helps strengthen respiratory muscles by impacting
the effectiveness of gas exchange processes.) - CORRECT ANSWER - The nurse is caring
for a patient who has decreased mobility. Which intervention is a simple and cost-effective
method for reducing the risks of pulmonary complication?
a. antibiotics
b. frequent change of position
c. oxygen humidification
d. chest physiotherapy
,B. Decrease or avoid caffeine
D. Avoid drinking alcohol - CORRECT ANSWER - A nurse in a provider's office is
evaluating a client who reports losing control of urine whenever she coughs, laughs, or sneezes.
THe client relates a history of three vaginal births, but no serious accidents or illnesses. Which of
the following interventions should the nurse suggest for helping to control or eliminate the
client's incontinence? Select all that apply.
A. limit total daily fluid intake
B. decrease or avoid caffeine
C. take calcium supplements
D. avoid drinking alcohol
E. use the Crede maneuver.
A. Check to see whether the catheter is patent. - CORRECT ANSWER - A client who has
an indwelling catheter reports a need to urinate. which of the following actions should the nurse
take?
a) check to see whether to catheter is patent
b) reassure the client that it is not possible for her to urinate
c) recatheterize the bladder with a larger-gauge catheter
d) collect a urine specimen for analysis
A. discard the first voiding. - CORRECT ANSWER - A nurse is caring for a client who
has a prescription for a 24-hr urine collection. Which of the following actions should the nurse
take?
A. discard the first voiding.
B. keep the urine in a single container at room temperature.
C. ask the client to urinate and pour the urine into a specimen container.
D. ask the client to urinate into the toilet, stop midstream, and finish urinating into the specimen
container.
A. frequent sexual intercourse
, D. location of the urethra in relation to the anus.
E. frequent catheterization - CORRECT ANSWER - A nurse is reviewing factors that
increase the risk of urinary tract infections with a client who has recurrent UTIs. Which of the
following factors should the nurse include? Select all that apply.
A. frequent sexual intercourse.
B. lowering of testosterone levels.
C. wiping from front to back.
D. location of urethra in relation to the anus.
E. frequent catheterization.
B. have the client record urination times.
C. gradually increase the urination intervals.
D. remind the client to hold urine until the next scheduled urination time. - CORRECT
ANSWER - A nurse is preparing to initiate a bladder-retraining program for a client who
has incontinence. Which for the following actions should the nurse take? Select all that apply.
A. Establish a schedule of urinating prior to meal times.
B. Have the client record urination times.
C. Gradually increase the urination intervals.
D. remind the client to hold urine until the next scheduled urination time.
E. provide a sterile container for urine.
A. restlessness
B. tachypnea
D. confusion
E. pallor - CORRECT ANSWER - A nurse is assessing a client who has an acute
respiratory infection that puts her at risk for hypoxemia. Which of the following findings are
early indications that should alert the nurse that the client is developing hypoxemia? Select all
that apply.
A. restlessness
B. tachypnea
