NUR 240 UPDATED FINAL EXAM QUESTIONS
AND CORRECT ANSWERS
You are assigned five patients on your nursing unit. Which patient is at most risk for pressure
ulcers?
A. A 72-year-old female weighing 82 lbs with stress incontinence and dementia.
B. A 90-year-old male with Congestive Heart Failure who has 3+ pitting edema in lower
extremities.
C. A 6 month old with the flu.
D. An ambulatory 88-year-old with dementia who is admitted with shingles. - CORRECT
ANSWERS A. A 72-year-old female weighing 82 lbs with stress incontinence and dementia.
Rationale: Since incontinence can lead to the moisture of the skin, it increases the risk of
pressure ulcers. It is important to check the patient's skin regularly for any sores and to make
sure the skin is always dry.
A nurse is caring for a patient with a variety of wounds. Which one will most likely heal by
primary intention?
a. cutting the skin by a kitchen knife
b. pressure ulcer
c. abrasion of the skin
d. excoriated perineal area - CORRECT ANSWERS Correct answer: a. cut in the skin by a
kitchen knife
Rationale: A cut in the skin by a sharp instrument with minimal tissue loss can heal by primary
intention when the wound edges are lightly pulled together (approximated).
,While performing a bed bath, the nurse should
A) raise the room temperature
B) completely remove linens
C) add soap to the water in the basin before beginning the bath
D) Complete the bathing for one side of the body at a time - CORRECT ANSWERS A) raise
the room temperature
Rationale: Raising the temperature of the room will keep the patient warm while various parts
of the body are washed and exposed.
A nurse has posted on social media about a client's situation. The nurse states, "I didn't violate
client privacy because I didn't use the client's name." What response by the nurse manager is
most appropriate?
A) "You may continue to post about the client, as long as you do not use the client's name."
B) "Any information that can identify a person is considered a breach of client privacy."
C) "All aspects of clinical practice are confidential and should not be discussed."
D) "the information posted on social media is inappropriate and should only be discussed with
family and friends of the client" - CORRECT ANSWERS B) "Any information that can
identify a person is considered a breach of client privacy."
Rationale : Any information that can identify a client is considered confidential. A medical
condition may identify a client who was cared for, especially if the location of the facility and
unit is disclosed in the post. No patient care should be discussed, even privately, with friends
and family without asking client's permission.
, A nurse is assessing a patients pressure ulcer due to friction and shear force. They see that the
wound has extended all of the way through the skin, but not through the muscle. Which stage
would the pressure ulcer be at?
A) stage 1
B)stage 2
C) stage 3
D) stage 4 - CORRECT ANSWERS C) Stage 3
Rationale: the dermal ulcer would be stage 3 because it has loss part of the skin (ruling out
stage 1) has gone further than the dermis (ruling out stage 2) and it has not gone through the
muscle (ruling out stage 4). This shows that the pressure ulcer has to be at stage 3.
The charge nurse observes a new staff nurse who is changing a dressing on a surgical wound.
After carefully washing her hands the nurse dons sterile gloves to remove the old dressing. After
removing the dirty dressing, the nurse removes the gloves and dons a new pair of sterile gloves
in preparation for cleaning and redressing the wound. The most appropriate action for the
charge nurse is to:
A . interrupt the procedure to inform the staff nurse that sterile gloves are not needed to
remove the old dressing.
B. congratulate the nurse on the use of good technique.
C. discuss dressing change technique with the nurse at a later date.
D. interrupt the procedure to inform the nurse of the need to wash her hands after removal of
the dirty dressing and gloves. - CORRECT ANSWERS D. interrupt the procedure to inform
the nurse of the need to wash her hands after removal of the dirty dressing and gloves.
Rationale: Non-sterile gloves are adequate for removing old dressings. However, the nurse
should wash her hands after removing the soiled dressing and before donning sterile gloves to
AND CORRECT ANSWERS
You are assigned five patients on your nursing unit. Which patient is at most risk for pressure
ulcers?
A. A 72-year-old female weighing 82 lbs with stress incontinence and dementia.
B. A 90-year-old male with Congestive Heart Failure who has 3+ pitting edema in lower
extremities.
C. A 6 month old with the flu.
D. An ambulatory 88-year-old with dementia who is admitted with shingles. - CORRECT
ANSWERS A. A 72-year-old female weighing 82 lbs with stress incontinence and dementia.
Rationale: Since incontinence can lead to the moisture of the skin, it increases the risk of
pressure ulcers. It is important to check the patient's skin regularly for any sores and to make
sure the skin is always dry.
A nurse is caring for a patient with a variety of wounds. Which one will most likely heal by
primary intention?
a. cutting the skin by a kitchen knife
b. pressure ulcer
c. abrasion of the skin
d. excoriated perineal area - CORRECT ANSWERS Correct answer: a. cut in the skin by a
kitchen knife
Rationale: A cut in the skin by a sharp instrument with minimal tissue loss can heal by primary
intention when the wound edges are lightly pulled together (approximated).
,While performing a bed bath, the nurse should
A) raise the room temperature
B) completely remove linens
C) add soap to the water in the basin before beginning the bath
D) Complete the bathing for one side of the body at a time - CORRECT ANSWERS A) raise
the room temperature
Rationale: Raising the temperature of the room will keep the patient warm while various parts
of the body are washed and exposed.
A nurse has posted on social media about a client's situation. The nurse states, "I didn't violate
client privacy because I didn't use the client's name." What response by the nurse manager is
most appropriate?
A) "You may continue to post about the client, as long as you do not use the client's name."
B) "Any information that can identify a person is considered a breach of client privacy."
C) "All aspects of clinical practice are confidential and should not be discussed."
D) "the information posted on social media is inappropriate and should only be discussed with
family and friends of the client" - CORRECT ANSWERS B) "Any information that can
identify a person is considered a breach of client privacy."
Rationale : Any information that can identify a client is considered confidential. A medical
condition may identify a client who was cared for, especially if the location of the facility and
unit is disclosed in the post. No patient care should be discussed, even privately, with friends
and family without asking client's permission.
, A nurse is assessing a patients pressure ulcer due to friction and shear force. They see that the
wound has extended all of the way through the skin, but not through the muscle. Which stage
would the pressure ulcer be at?
A) stage 1
B)stage 2
C) stage 3
D) stage 4 - CORRECT ANSWERS C) Stage 3
Rationale: the dermal ulcer would be stage 3 because it has loss part of the skin (ruling out
stage 1) has gone further than the dermis (ruling out stage 2) and it has not gone through the
muscle (ruling out stage 4). This shows that the pressure ulcer has to be at stage 3.
The charge nurse observes a new staff nurse who is changing a dressing on a surgical wound.
After carefully washing her hands the nurse dons sterile gloves to remove the old dressing. After
removing the dirty dressing, the nurse removes the gloves and dons a new pair of sterile gloves
in preparation for cleaning and redressing the wound. The most appropriate action for the
charge nurse is to:
A . interrupt the procedure to inform the staff nurse that sterile gloves are not needed to
remove the old dressing.
B. congratulate the nurse on the use of good technique.
C. discuss dressing change technique with the nurse at a later date.
D. interrupt the procedure to inform the nurse of the need to wash her hands after removal of
the dirty dressing and gloves. - CORRECT ANSWERS D. interrupt the procedure to inform
the nurse of the need to wash her hands after removal of the dirty dressing and gloves.
Rationale: Non-sterile gloves are adequate for removing old dressings. However, the nurse
should wash her hands after removing the soiled dressing and before donning sterile gloves to
