NURS 204 Exam 2– Comprehensive Nursing Review and Study
Guide|2025-2026 Questions and Correct Answers Update| Graded
A+
What indications are there for applying restraints as last resort?
harm self or others
A nurse is caring for a 25-year-old client who is quadriplegic. Which
treatment would be a priority to decrease the risk of joint contracture
and promote joint mobility?
A. Active ROM
B. Passive ROM
C. Turning every 2 hours
D. Applying a trochanter roll
B. Passive ROM
Area where they are unable to move (all 4 extremities), do PROM in
arms, shoulders, elbows, wrists, and fingers, hips, knees, ankles, toes.
Quadriplegic does NOT mean they are unable to do some movements
A client is admitted to the hospital with COPD. He is receiving
supplemental oxygen via nasal cannula. Which position will best
assist his breathing?
A. Fowler's
B. Sims'
C. Lateral
D. Supine
E. Prone
A. Fowler's
Will help breathing the best
High, Semi, and Low Fowler's do exist
pg. 1
,A teenage client was hospitalized 3 weeks ago after MVA in which he
crushed his pelvis. He remains on bedrest. His parents tell the nurse, "
Our son is just staring off into space and won't talk to us. He doesn't
want to listen to his music or watch television. That is so unlike him."
What is the nurse's best response?
A. "I will inform the doctor and see whether we can get your son
started on an antidepressant medication."
B. "He is at a critical time in his life; teens are often moody, and being
in the hospital with an injury will only make that worse."
C. "Your son had a major injury, and his immobility might be causing
him to feel isolated and depressed."
D. "He is bored because he has been in the hospital for 3 weeks; I'll
try to find something new for him to do."
C. "Your son had a major injury, and his immobility might be causing
him to feel isolated and depressed."
A = incorrect, RN is making dx that patient is depressed
B = making assumption "moody"
C= MIGHT, major injury = takes adjustment
D = dont' want to make assumption
An older client suffered left-sided paralysis from a stroke. Which are
the best actions for this client? Select all that apply.
A. Monitor for constipation
B. Encourage an even gait when walking in place
C. Assess the extremities for swelling and muscle atrophy
D. Encourage taking deep breaths frequently to hyper-inflate the
lungs.
E. Encourage the client to hold onto the wall while ambulating
A. Monitor for constipation
pg. 2
,*not moving around which assists peristalsis
C. Assess the extremities for swelling and muscle atrophy
*not moving, use it or lose it
D. Encourage taking deep breaths frequently to hyper-inflate the
lungs.
**prevents pneumonia, keeps air circulating through lungs
B = unrealistic expectation, gait is uneven after stroke
E = need more of an assistive device than just wall, which will run
out, is there a handrail? not enough info
A client is being transferred from the bed to a stretch for surgery using
a transfer board. What should be the nurse's first action?
A. Lower the stretched below the level of the bed.
B. Explain the procedure to the client.
C. Place the client in the prone position.
D. Place the bed in the lowest position.
B. Explain the procedure to the client.
**Always explain procedure first for anything
A = want transfer to be LEVEL
C = Never put patient face down
D = bad for RN ergonomics
What are the stages of wound healing?
1. inflammatory
2. proliferative
3. maturation/remodelling
What is the inflammatory stage of wound healing?
begins with injury, lasts 3-6 days
pg. 3
, control bleeding (vasoconstriction, blood vessel retraction, fibrin
accumulation, clot formation)
deliver O2, WBC, and nutrients
macrophages, phagocytosis
What is the proliferative stage of wound healing?
lasts the next 3-24 days
replace lost tissue w/ connective or granulated tissue and collagen
contract wound's edges to reduce area that requires healing
resurfacing of new epithelial cells
What is the maturation or remodeling stage of wound healing?
occurs on/about day 21
strengthening of collagen scar and restoration of more normal
appearance
can take > 1 year to complete depending on original wound extent
What are the phases of healing process?
1. primary intention
2. secondary intention
3. tertiary intention
What occurs during primary intention?
-little/no tissue loss
-edges approximated (eg w/in surgical incision)
-heals rapidly
-low risk of infection
-no/minimal scarring
pg. 4
Guide|2025-2026 Questions and Correct Answers Update| Graded
A+
What indications are there for applying restraints as last resort?
harm self or others
A nurse is caring for a 25-year-old client who is quadriplegic. Which
treatment would be a priority to decrease the risk of joint contracture
and promote joint mobility?
A. Active ROM
B. Passive ROM
C. Turning every 2 hours
D. Applying a trochanter roll
B. Passive ROM
Area where they are unable to move (all 4 extremities), do PROM in
arms, shoulders, elbows, wrists, and fingers, hips, knees, ankles, toes.
Quadriplegic does NOT mean they are unable to do some movements
A client is admitted to the hospital with COPD. He is receiving
supplemental oxygen via nasal cannula. Which position will best
assist his breathing?
A. Fowler's
B. Sims'
C. Lateral
D. Supine
E. Prone
A. Fowler's
Will help breathing the best
High, Semi, and Low Fowler's do exist
pg. 1
,A teenage client was hospitalized 3 weeks ago after MVA in which he
crushed his pelvis. He remains on bedrest. His parents tell the nurse, "
Our son is just staring off into space and won't talk to us. He doesn't
want to listen to his music or watch television. That is so unlike him."
What is the nurse's best response?
A. "I will inform the doctor and see whether we can get your son
started on an antidepressant medication."
B. "He is at a critical time in his life; teens are often moody, and being
in the hospital with an injury will only make that worse."
C. "Your son had a major injury, and his immobility might be causing
him to feel isolated and depressed."
D. "He is bored because he has been in the hospital for 3 weeks; I'll
try to find something new for him to do."
C. "Your son had a major injury, and his immobility might be causing
him to feel isolated and depressed."
A = incorrect, RN is making dx that patient is depressed
B = making assumption "moody"
C= MIGHT, major injury = takes adjustment
D = dont' want to make assumption
An older client suffered left-sided paralysis from a stroke. Which are
the best actions for this client? Select all that apply.
A. Monitor for constipation
B. Encourage an even gait when walking in place
C. Assess the extremities for swelling and muscle atrophy
D. Encourage taking deep breaths frequently to hyper-inflate the
lungs.
E. Encourage the client to hold onto the wall while ambulating
A. Monitor for constipation
pg. 2
,*not moving around which assists peristalsis
C. Assess the extremities for swelling and muscle atrophy
*not moving, use it or lose it
D. Encourage taking deep breaths frequently to hyper-inflate the
lungs.
**prevents pneumonia, keeps air circulating through lungs
B = unrealistic expectation, gait is uneven after stroke
E = need more of an assistive device than just wall, which will run
out, is there a handrail? not enough info
A client is being transferred from the bed to a stretch for surgery using
a transfer board. What should be the nurse's first action?
A. Lower the stretched below the level of the bed.
B. Explain the procedure to the client.
C. Place the client in the prone position.
D. Place the bed in the lowest position.
B. Explain the procedure to the client.
**Always explain procedure first for anything
A = want transfer to be LEVEL
C = Never put patient face down
D = bad for RN ergonomics
What are the stages of wound healing?
1. inflammatory
2. proliferative
3. maturation/remodelling
What is the inflammatory stage of wound healing?
begins with injury, lasts 3-6 days
pg. 3
, control bleeding (vasoconstriction, blood vessel retraction, fibrin
accumulation, clot formation)
deliver O2, WBC, and nutrients
macrophages, phagocytosis
What is the proliferative stage of wound healing?
lasts the next 3-24 days
replace lost tissue w/ connective or granulated tissue and collagen
contract wound's edges to reduce area that requires healing
resurfacing of new epithelial cells
What is the maturation or remodeling stage of wound healing?
occurs on/about day 21
strengthening of collagen scar and restoration of more normal
appearance
can take > 1 year to complete depending on original wound extent
What are the phases of healing process?
1. primary intention
2. secondary intention
3. tertiary intention
What occurs during primary intention?
-little/no tissue loss
-edges approximated (eg w/in surgical incision)
-heals rapidly
-low risk of infection
-no/minimal scarring
pg. 4
