NURS 226 Final Exam Questions With Complete Solutions
A 22-year-old new mother is breastfeeding. You ask her if she is
taking the correct quantities of nutrients. Which statement
reflects that she understands the dietary guidelines?
A. "I am not concerned with what I am eating."
B. "I am taking vitamin doses based on TV."
C. "I am taking a daily MVI."
D. "I am making eating choices according to the recommended
dietary allowances and intakes." Correct Answer D. "I am
making eating choices according to the recommended dietary
allowances and intakes."
A client is admitted to the hospital with an acute respiratory
problem resulting from lung disease. The nurse makes a
diagnosis of Ineffective Breathing Pattern related to inability to
maintain adequate rate and depth of respirations. Which nursing
intervention should be listed first on the care plan?
a. Determine airway adequacy hourly and as needed.
b. Administer oxygen as needed.
c. Monitor arterial blood gas values.
d. Place the client in a high Fowler's position. Correct Answer
a. Determine airway adequacy hourly and as needed.
A client is receiving an enteral feeding at 65 mL/hr. The gastric
residual volume in 4 hours was 125 mL. What is the priority
nursing intervention?
A. Assess bowel sounds.
,B. Raise the head of the bed to at least 45 degrees.
C. Continue the feedings; this is normal gastric residual for this
feeding.
D. Hold the feeding until you talk to the primary care provider.
Correct Answer C. Continue the feedings; this is normal gastric
residual for this
A client who is receiving parenteral nutrition (PN) through a
cen- tral venous catheter (CVC) has an air embolus. What
should be the nurse's priority action?
A. Have the patient turn on the left side and perform a Valsalva
maneuver.
B. Clamp the intravenous (IV) tubing to prevent more air from
entering the line.
C. Have the patient take a deep breath and hold it.
D. Notify the health care provider immediately. Correct
Answer A. Have the patient turn on the left side and perform a
Valsalva maneuver.
A nurse enters the hospital room of a patient who had a total
knee replacement the day before. Which of the following pose
potential safety risks? (Select all that apply.)
A. A current safety inspection sticker is on the IV fluids pump.
B. A walker is positioned near the patient's bedside.
C. The hospital bed is in the high position.
D. There is no gait belt at the bedside.
E. The overbed table with the patient's glasses is positioned
against the wall opposite the end of the bed. Correct Answer
C, D, and E
,A nurse is administering ophthalmic ointment to a patient. Place
the following steps in correct order for the administration of the
ointment.
A. Clean eye, washing from inner to outer canthus.
B. Assess patient's level of consciousness and ability to follow
instructions.
C. Apply thin ribbon of ointment evenly along inner edge of
lower eyelid on conjunctiva.
D. Have patient close eye and rub lightly in a circular motion
with
a cotton ball.
E. Ask patient to look at ceiling, and explain the steps to patient.
Correct Answer B, A, E, C, D
A nurse is assess the pain level of a client who has come to the
emergency department reporting severe abdominal pain. The
nurse asks the client whether he has nausea and has been
vomiting. The nurse is assessing which of the following?
a. Presence of associated symptoms
b. Location of the pain
c. Pain quality
d. Aggravating and relieving factors Correct Answer a.
Presence of associated symptoms
A nurse is assessing a client who has an acute respiratory
infection that places her at risk for hypoxemia. Which of the
following findings are early indicators that should alert the nurse
that the patient is developing hypoxemia? Select all that apply
, a. Restlessness
b. Tachypnea
c. Bradycardia
d. Confusion
e. Pallor Correct Answer a, b, d, and e
A nurse is assessing a client who is in respiratory distress. The
nurse should recognize that which of the following can cause a
low pulse oximetry reading? (select all that apply)
a. Nail polish
b. Inadequate peripheral circulation
c. Hyperthermia
d. Increased hemoglobin level
e. Edema Correct Answer a, b, and e
A nurse is assessing a client who is postoperative following a
colon resection. Which of the following findings indicates that
the client is ready to transition from NPO to oral intake?
a. Client report of hunger
b. Urinary output exceeding 30 mL/hr
c. Decrease in incisional pain
d. Passage of flatus Correct Answer d. Passage of flatus
A nurse is caring for a client who has Alzheimer's Disease and
falls frequently. Which of the following actions should the nurse
take first to keep the client safe?
a. Keep the call light near the client.
A 22-year-old new mother is breastfeeding. You ask her if she is
taking the correct quantities of nutrients. Which statement
reflects that she understands the dietary guidelines?
A. "I am not concerned with what I am eating."
B. "I am taking vitamin doses based on TV."
C. "I am taking a daily MVI."
D. "I am making eating choices according to the recommended
dietary allowances and intakes." Correct Answer D. "I am
making eating choices according to the recommended dietary
allowances and intakes."
A client is admitted to the hospital with an acute respiratory
problem resulting from lung disease. The nurse makes a
diagnosis of Ineffective Breathing Pattern related to inability to
maintain adequate rate and depth of respirations. Which nursing
intervention should be listed first on the care plan?
a. Determine airway adequacy hourly and as needed.
b. Administer oxygen as needed.
c. Monitor arterial blood gas values.
d. Place the client in a high Fowler's position. Correct Answer
a. Determine airway adequacy hourly and as needed.
A client is receiving an enteral feeding at 65 mL/hr. The gastric
residual volume in 4 hours was 125 mL. What is the priority
nursing intervention?
A. Assess bowel sounds.
,B. Raise the head of the bed to at least 45 degrees.
C. Continue the feedings; this is normal gastric residual for this
feeding.
D. Hold the feeding until you talk to the primary care provider.
Correct Answer C. Continue the feedings; this is normal gastric
residual for this
A client who is receiving parenteral nutrition (PN) through a
cen- tral venous catheter (CVC) has an air embolus. What
should be the nurse's priority action?
A. Have the patient turn on the left side and perform a Valsalva
maneuver.
B. Clamp the intravenous (IV) tubing to prevent more air from
entering the line.
C. Have the patient take a deep breath and hold it.
D. Notify the health care provider immediately. Correct
Answer A. Have the patient turn on the left side and perform a
Valsalva maneuver.
A nurse enters the hospital room of a patient who had a total
knee replacement the day before. Which of the following pose
potential safety risks? (Select all that apply.)
A. A current safety inspection sticker is on the IV fluids pump.
B. A walker is positioned near the patient's bedside.
C. The hospital bed is in the high position.
D. There is no gait belt at the bedside.
E. The overbed table with the patient's glasses is positioned
against the wall opposite the end of the bed. Correct Answer
C, D, and E
,A nurse is administering ophthalmic ointment to a patient. Place
the following steps in correct order for the administration of the
ointment.
A. Clean eye, washing from inner to outer canthus.
B. Assess patient's level of consciousness and ability to follow
instructions.
C. Apply thin ribbon of ointment evenly along inner edge of
lower eyelid on conjunctiva.
D. Have patient close eye and rub lightly in a circular motion
with
a cotton ball.
E. Ask patient to look at ceiling, and explain the steps to patient.
Correct Answer B, A, E, C, D
A nurse is assess the pain level of a client who has come to the
emergency department reporting severe abdominal pain. The
nurse asks the client whether he has nausea and has been
vomiting. The nurse is assessing which of the following?
a. Presence of associated symptoms
b. Location of the pain
c. Pain quality
d. Aggravating and relieving factors Correct Answer a.
Presence of associated symptoms
A nurse is assessing a client who has an acute respiratory
infection that places her at risk for hypoxemia. Which of the
following findings are early indicators that should alert the nurse
that the patient is developing hypoxemia? Select all that apply
, a. Restlessness
b. Tachypnea
c. Bradycardia
d. Confusion
e. Pallor Correct Answer a, b, d, and e
A nurse is assessing a client who is in respiratory distress. The
nurse should recognize that which of the following can cause a
low pulse oximetry reading? (select all that apply)
a. Nail polish
b. Inadequate peripheral circulation
c. Hyperthermia
d. Increased hemoglobin level
e. Edema Correct Answer a, b, and e
A nurse is assessing a client who is postoperative following a
colon resection. Which of the following findings indicates that
the client is ready to transition from NPO to oral intake?
a. Client report of hunger
b. Urinary output exceeding 30 mL/hr
c. Decrease in incisional pain
d. Passage of flatus Correct Answer d. Passage of flatus
A nurse is caring for a client who has Alzheimer's Disease and
falls frequently. Which of the following actions should the nurse
take first to keep the client safe?
a. Keep the call light near the client.
