NURS 102 FINAL EXAM QUESTIONS AND CORRECT ANSWERS

NURS 102 FINAL EXAM QUESTIONS
AND CORRECT ANSWERS
TheA2nurseA2reviewsA2theA2electronicA2healthA2recordA2forA2clientA2infoA2&A2documentsA2c
areA2inA2theA2nursingA2progressA2notes.A2ClientA2careA2implementedA2perA2standingA2orde
rs.A2

WhichA2actionA2wouldA2theA2nurseA2takeA2forA2aA2clientA2whoseA2rightA2radialA2pulseA2isA2
weakA2&A2thready?
A2SelectA2allA2thatA2apply.A2One,A2some,A2orA2allA2responsesA2mayA2beA2correct.A2-A2Ans---
A2AssessA2allA2peripheralA2pulses
-A2AssessA2&A2compareA2bothA2radialA2pulses
-A2AskA2aA2secondA2nurseA2toA2assessA2theA2client'sA2pulses
-
A2AssessA2forA2edemaA2orA2otherA2issuesA2thatA2mayA2beA2restrictingA2peripheralA2bloodA2f
low
-A2ObserveA2forA2pallor/A2skinA2temperatureA2differencesA2distalA2toA2theA2weakA2pulse

AA2clientA2whoA2isA2positiveA2forA2humanA2immunodeficiencyA2virusA2(HIV)A2isA2admittedA2
toA2aA2surgicalA2unitA2afterA2anA2orthopedicA2procedure.A2SelectA2theA22A2possibleA2routes
A2ofA2HIVA2transmission?A2-A2Ans---A2BloodA2
-A2Semen

HIV:A2-A2Ans--
IsA2theA2virusA2thatA2causesA2acquiredA2immunodeficiencyA2syndromeA2(AIDS)A2isA2trans
mittedA2throughA2infectedA2blood,A2semen,A2&A2bloodyA2bodilyA2fluids.A2HIVA2isA2notA2spre
adA2casually.A2AlthoughA2HIVA2mayA2beA2foundA2inA2otherA2bodilyA2secretions,A2includingA
2feces,A2urine,A2sweat,A2tears,A2saliva,A2sputum,A2&A2emesis,A2theA2amountA2ofA2virusA2isA
2likelyA2notA2sufficientA2enoughA2toA2beA2transmitted.


WhichA2findingA2wouldA2theA2nurseA2identifyA2asA2normalA2forA2aA2newborn?
A2(SelectA2allA2thatA2apply):A2-A2Ans---A2Baby'sA2weightA2isA26lbsA2(2700g)
-A2HandsA2&A2feetA2appearA2cyanosedA2
-A2HeadA2circumferenceA2ofA233cmA2(13A2inches)

WhichA2interventionA2wouldA2theA2nurseA2performA2whileA2caringA2forA2anA2activelyA2dying
A2client?A2(SelectA2allA2thatA2apply):A2-A2Ans---
A2EnsureA2theA2nurseA2talksA2toA2&A2notA2aboutA2theA2client.
-A2ProvideA2clientA2&A2familyA2reassurance.
-A2TryA2toA2setA2aA2comfortableA2environmentA2inA2theA2room.
-A2PerformA2symptomA2managementA2forA2theA2client.
-A2EncourageA2familyA2toA2talkA2toA2theA2client.

,WhenA2findingA2notedA2duringA2assessmentA2wouldA2leadA2theA2nurseA2toA2determineA2th
atA2aA2clientA2isA2atA2anA2increasedA2riskA2forA2infection?A2(SelectA2allA2thatA2apply):A2-
A2Ans---A2SurgicalA2incision
-A2UrinaryA2catheter
-A2IntravenousA2access
-A2AntibioticA2therapy

AfterA2reviewingA2theA2nurses'A2notesA2&A2labA2results,A2theA2nurseA2preparesA2toA2notifyA2
theA2physician.

ChooseA2theA2mostA2likelyA2optionsA2forA2theA2infoA2missingA2fromA2theA2statementsA2byA2
selectingA2fromA2theA2listsA2ofA2optionsA2provided.

TheA2nurseA2anticipatesA2theA2physicianA2orderA2_________A2toA2_________.A2Effectiven
essA2ofA2careA2isA2evidencedA2byA2____________.A2-A2Ans--anA2intermittentA2catheter
relieveA2urinaryA2retention
postvoidA2bladderA2scanA2ofA235A2mL

(CaseA2Study):

ClickA2toA2highlightA2theA2findingsA2thatA2wouldA2requireA2follow-upA2fromA2theA2nurse:

AdmittedA2Michelle,A264-year-
oldA2clientA2fromA2theA2EmergencyA2DepartmentA2whoA2developedA2ClostridiumA2difficileA2
(C.A2difficileA2orA2C.A2diff)A2afterA2treatmentA2withA2antibioticsA2forA2aA2severeA2infection.A2
TheA2clientA2isA2experiencingA2explosiveA2foul-
smellingA2diarrhea.A2Alert,A2orientedA2toA2person,A2place,A2&A2time.A2SkinA2warmA2withA2te
ntedA2skinA2turgor.A2HeratA2tonesA2irregularA2withA2noA2murmurs.A2LungA2soundsA2clearA2
bilaterallyA2toA2auscultation.A2AbdomenA2withA2tendernessA2&A2hyperactiveA2bowelA2soun
ds.A2Sates,A2"I'mA2soA2thirstyA2allA2theA2time."A2UrinatingA2smallA2amountsA2ofA2darkA2amb
erA2urine.A2StatesA2thatA2hasA2soreA2onA2ankleA2thatA2won'tA2heal.A2VitalA2signs:A2TA299.2A2
(degreesA2Fahrenheit),A2PA294A2BPM,A2RA220A2breathsA2perA2minute,A2BPA2144/84A2mmH
g,A2&A2O2A2SatA2onA2roomA2airA296%.A2-A2Ans---A2TentedA2skinA2turgor
-A2"I'mA2soA2thirstyA2allA2theA2time."
-A2UrinatingA2smallA2amountsA2ofA2darkA2amberA2urine.
-A2StatesA2thatA2hasA2soreA2onA2ankleA2thatA2won'tA2heal.

(CaseA2Study-A2Michelle):
IndicateA2whetherA2theseA2findingsA2fromA2thisA2client'sA2assessmentA2areA2generallyA2as
sociatedA2withA2hypertension,A2diabetes,A2orA2C.A2diff.A2-A2Ans--
IntakeA2&A2OutputA2resultsA2=A2C.A2diff
Foul-smellingA2diarrheaA2=A2C.A2diff
HasA2ankleA2soreA2thatA2won'tA2healA2=A2Diabetes
BloodA2pressureA2readingA2=A2Hypertension
HyperactiveA2bowelA2soundsA2=A2C.A2diff

,(CaseA2StudyA2-A2Michelle):
TheA2clientA2isA2atA2forA2experiencingA2_________A2&A2_________.A2-A2Ans--
fallsA2&A2dehydration

(CaseA2StudyA2-A2Michelle):

WhichA2actionsA2wouldA2theA2nurseA2includeA2inA2theA2planA2ofA2careA2atA2thisA2time?
A2(SelectA2allA2thatA2apply):A2-A2Ans---A2ContinueA2withA2contactA2precautions
-A2OfferA2bland,A2low-residueA2foods
-A2InstituteA2fallA2precautions
-A2MonitorA2forA2sepsis
-A2NotifyA2theA2physician

HESIA2UrinaryA2Patterns:

TheA2clientA2reports,A2priorA2toA2stroke,A2gettingA2upA2fiveA2orA2sixA2timesA2toA2urinateA2nig
htlyA2butA2controlledA2theA2urgeA2longA2enoughA2toA2makeA2itA2toA2theA2bathroom.A2HowA2s
houldA2theA2nurseA2describeA2theA2urinaryA2patternA2thatA2theA2clientA2isA2describing?A2-
A2Ans--Nocturia


Nocturia:A2-A2Ans--
RefersA2toA2voidingA2frequentlyA2atA2night.A2TheA2incidenceA2ofA2nocturiaA2increasesA2gre
atlyA2inA2theA2olderA2maleA2clientA2whoA2hasA2anA2enlargedA2prostate.A2ItA2mayA2alsoA2indi
cateA2anA2inabilityA2toA2concentrateA2urineA2bcA2ofA2poorA2bloodA2flowA2toA2theA2kidneys.

SinceA2theA2clientA2nowA2voidsA2spontaneouslyA2withoutA2recognizingA2theA2needA2toA2voi
d,A2howA2shouldA2theA2nurseA2documentA2theA2client'sA2currentA2urinaryA2patternA2inA2theA
2medA2chart?A2-A2Ans--IncontinenceA2


*IncontinenceA2isA2theA2involuntaryA2lossA2ofA2urine.

ToA2helpA2manageA2theA2client'sA2incontinence,A2theA2nurseA2initiatesA2aA2bladderA2trainin
gA2program.A2WhichA2instructionA2shouldA2theA2nurseA2provideA2toA2theA2unlicensedA2assi
stiveA2personnelA2(UAP)A2whoA2willA2beA2helpingA2careA2forA2theA2client?A2-A2Ans--
RemindA2theA2clientA2toA2voidA2everyA22A2hoursA2whileA2awakeA2&A2toA2callA2forA2assistanc
eA2toA2theA2bathroom.A2

*AA2toiletingA2scheduleA2isA2anA2effectiveA2meansA2toA2retrainA2theA2bladder.A2BladderA2tra
iningA2shouldA2startA2withA2voidingA2everyA22A2hoursA2inA2theA2daytimeA2&A2everyA24A2hour
sA2atA2nightA2&A2thenA2beA2adaptedA2toA2theA2individualA2needs.A2TheA2callA2bellA2shouldA2
beA2nearA2theA2clientA2soA2thatA2heA2canA2ringA2theA2bellA2forA2assistanceA2toA2preventA2th
eA2riskA2ofA2falling.

AfterA2severalA2weeks,A2theA2bladderA2trainingA2programA2isA2unsuccessfulA2inA2stoppingA
2theA2client'sA2incontinence.A2TheA2clientA2appearsA2withdrawnA2&A2statesA2thatA2theyA2are
A2frustratedA2atA2theA2numberA2ofA2episodesA2thatA2continueA2toA2occur.A2WhichA2intervent

, ionsA2shouldA2theA2nurseA2includeA2inA2theA2client'sA2planA2ofA2care?
A2(SelectA2allA2thatA2apply):A2-A2Ans---A2ReportA2signsA2ofA2insomniaA2dueA2toA2anxiety
-A2DiscussA2possibleA2copingA2strategies

FollowingA2anA2episodeA2ofA2incontinence,A2theA2nurseA2washesA2theA2client'sA2perinealA2
areaA2withA2mildA2soapA2andA2waterA2andA2appliesA2aA2water-
repellentA2ointmentA2toA2theA2skin.A2TheA2client'sA2spouseA2isA2presentA2andA2theA2nurseA2
usesA2thisA2opportunityA2toA2educateA2themA2aboutA2properA2skinA2careA2toA2preventA2bre
akdown.A2WhichA2statementA2byA2theA2client'sA2spouseA2indicatesA2thatA2teachingA2provid
edA2wasA2effective?A2-A2Ans--
WashA2theA2areaA2withA2mildA2soapA2&A2waterA2followedA2byA2ointment.A2

*TheseA2water-
repellentA2ointmentsA2helpA2protectA2theA2skinA2fromA2acidicA2effectsA2ofA2urine.

TheA2nursingA2staffA2continuesA2withA2bladder-
training,A2butA2theA2client'sA2incontinenceA2showsA2aA2littleA2improvement.A2SinceA2bladde
rA2trainingA2hasA2notA2beenA2successful,A2theA2nurseA2obtainsA2aA2prescriptionA2toA2applyA
2anA2externalA2maleA2catheter.A2WhichA2interventionA2isA2MOSTA2importantA2forA2theA2nur
seA2toA2includeA2inA2theA2client'sA2planA2ofA2care?A2-A2Ans--
AssessA2forA2signsA2ofA2skinA2breakdown.A2

*CathetersA2canA2causeA2skinA2breakdownA2&A2leadA2toA2externalA2infections.A2ItA2isA2imp
ortantA2toA2useA2goodA2handA2hygiene,A2&A2replaceA2catheterA2daily.

TheA2clientA2isA2admittedA2toA2theA2acuteA2careA2facilityA2forA2minorA2surgery.A2Preoperativ
eA2prescriptionsA2includeA2theA2insertionA2ofA2anA2indwellingA2urinaryA2catheter.A2AA2stude
ntA2nurseA2isA2assignedA2toA2careA2forA2theA2client.A2TheA2nursingA2instructorA2asksA2theA2
studentA2nurseA2toA2prepareA2toA2insertA2theA2indwellingA2catheterA2underA2supervision.A2
WhatA2isA2theA2firstA2stepA2inA2theA2properA2placementA2ofA2anA2indwellingA2urinaryA2cathe
terA2forA2aA2maleA2client?A2-A2Ans--WashA2perinealA2areaA2withA2soapA2&A2water

TheA2nurseA2reviewsA2factorsA2thatA2mayA2impactA2catheterA2insertionA2withA2theA2student
A2nurse.A2WhichA2physiologicA2changeA2thatA2commonlyA2occursA2inA2adultA2malesA2mayA
2affectA2insertionA2ofA2theA2catheter?A2-A2Ans--ProstateA2glandA2enlargement.


*TheA2prostateA2glandA2oftenA2beginsA2toA2enlargeA2afterA2aA2maleA2clientA2reachesA2theA2
ageA2ofA240,A2makingA2urethralA2catheterizationA2moreA2difficultA2ifA2theA2glandA2compress
esA2theA2urethra.

TheA2studentA2obtainsA2aA216A2FrenchA2FoleyA2CatheterA2fromA2theA2supplyA2room.A2TheA
2studentA2nurseA2explainsA2theA2procedureA2toA2theA2client,A2whoA2givesA2permissionA2toA2
begin.A2AfterA2cleansingA2theA2urinaryA2meatus,A2theA2studentA2nurseA2maintainsA2sterileA
2techniqueA2whileA2insertingA2theA2catheterA2intoA2theA2urethraA2aboutA24A2inches.A2WhileA
2inflatingA2theA2balloon,A2theA2clientA2criesA2outA2inA2obviousA2pain.A2