Nursing 223 Final Exam Questions With Complete Solutions
- 4 - 90 degree angle of insertion : 1/2 inch length needle
inserted at 90 degree angle will ensure that the heparin is
inserted into the subcutaneous tissue.
•A nurse discourages a patient from straining excessively when
attempting to have a bowel movement.
•Which undesirable physiological response is the primary reason
why straining on defecation should be avoided? Correct
Answers Dysrhythmia, Straining on defecation requires the
person to hold the breath while bearing down (Valsalva
maneuver). This increases intrathoracic and intracranial
pressures, which can precipitate dysrhythmias, stroke, and
respiratory difficulties.
•A nurse in the ER is engaging in an initial assessment of a
patient. Which assessment takes priority? Correct Answers
Airway clearance. A clear airway is essential for life and is
therefore the priority.
•A nurse is caring for a patient who has a urinary retention
catheter.
•The primary health care provider orders a urine culture and
sensitivity.
•Which step ensures that the collected specimen is sterile?
Correct Answers •Swab the specimen port with an antiseptic
swab.
•Swabbing the specimen port with an antiseptic swab is
necessary to remove microorganisms from the port that may
contaminate the specimen.
,•Sterile gloves are not necessary to maintain sterility of the
specimen.
•A nurse is caring for a patient who is experiencing diarrhea.
•About which physiological response to diarrhea should the
nurse be most concerned? Correct Answers Dehydration
•A nurse is caring for a patient with an intestinal stoma. Which
intervention is most important? Correct Answers -. Selecting a
bag with an appropriate size stoma opening.
•The opening of the appliance must be large enough to encircle
the stoma to within ½ inch to protect the surrounding tissue from
the enzymes present in the intestinal discharge without
impinging on the stoma.
•A nurse should use a fracture bedpan for patients with which
conditions? Select all that apply. Correct Answers •Spinal cord
injury
Fractured hip
•A patient has a urinary retention catheter. Which is most
important when the nurse cares for this patient? Correct
Answers Ensuring that the catheter remains connected to the
collection bag. •Maintaining the connection of the catheter to the
collection bag prevents the introduction of microorganisms that
can cause an infection. This is a closed system and should
remain closed.
•A patient with flatulence is concerned about the production of
unpleasant odors. Which should the nurse encourage the patient
, to avoid? Select all that apply. Correct Answers asparagus,
onions, eggs (because they contain sulfur compounds)
•Which action is important for the nurse to teach patients about
the intake of bran to facilitate defecation? Correct Answers
•Drink at least 8 glasses of fluids each day.
1. A client in pain request the prescribed pain medication, which
is an opioid. Which nursing assessment is essential before
administering the opioid? Correct Answers - 2: Respirations
1. A home care nurse observes the spouse of a client inserting a
rectal Suppository into the client. Which behavior indicates that
the nurse must provide further teaching about the Suppository
administration? Correct Answers - 3 - insert the Suppository
while the client bears down : Bearing down increases intra-
abdominal pressure which impedes the insertion of the
Suppository. The client should be instructed to relax and breathe
deeply and slowly while the Suppository is inserted.
1. A nurse holds a bottle with the label next to the palm of her
hand when pouring liquid medication. Which is the rationale for
this action? Correct Answers - 1 - prevent soiling of the label
by spilled liquid : Liquid medication may drip down the side of
the bottle and soil the label, which may interfere with the ability
to read the label accurately.
1. A nurse instructs a client to close the eyes gently after
administration of eyedrops. Which rationale for this instruction
should the nurse explain to the client? Correct Answers 3 -
Disperses the medication over the eyeballs : Closing the eyes
- 4 - 90 degree angle of insertion : 1/2 inch length needle
inserted at 90 degree angle will ensure that the heparin is
inserted into the subcutaneous tissue.
•A nurse discourages a patient from straining excessively when
attempting to have a bowel movement.
•Which undesirable physiological response is the primary reason
why straining on defecation should be avoided? Correct
Answers Dysrhythmia, Straining on defecation requires the
person to hold the breath while bearing down (Valsalva
maneuver). This increases intrathoracic and intracranial
pressures, which can precipitate dysrhythmias, stroke, and
respiratory difficulties.
•A nurse in the ER is engaging in an initial assessment of a
patient. Which assessment takes priority? Correct Answers
Airway clearance. A clear airway is essential for life and is
therefore the priority.
•A nurse is caring for a patient who has a urinary retention
catheter.
•The primary health care provider orders a urine culture and
sensitivity.
•Which step ensures that the collected specimen is sterile?
Correct Answers •Swab the specimen port with an antiseptic
swab.
•Swabbing the specimen port with an antiseptic swab is
necessary to remove microorganisms from the port that may
contaminate the specimen.
,•Sterile gloves are not necessary to maintain sterility of the
specimen.
•A nurse is caring for a patient who is experiencing diarrhea.
•About which physiological response to diarrhea should the
nurse be most concerned? Correct Answers Dehydration
•A nurse is caring for a patient with an intestinal stoma. Which
intervention is most important? Correct Answers -. Selecting a
bag with an appropriate size stoma opening.
•The opening of the appliance must be large enough to encircle
the stoma to within ½ inch to protect the surrounding tissue from
the enzymes present in the intestinal discharge without
impinging on the stoma.
•A nurse should use a fracture bedpan for patients with which
conditions? Select all that apply. Correct Answers •Spinal cord
injury
Fractured hip
•A patient has a urinary retention catheter. Which is most
important when the nurse cares for this patient? Correct
Answers Ensuring that the catheter remains connected to the
collection bag. •Maintaining the connection of the catheter to the
collection bag prevents the introduction of microorganisms that
can cause an infection. This is a closed system and should
remain closed.
•A patient with flatulence is concerned about the production of
unpleasant odors. Which should the nurse encourage the patient
, to avoid? Select all that apply. Correct Answers asparagus,
onions, eggs (because they contain sulfur compounds)
•Which action is important for the nurse to teach patients about
the intake of bran to facilitate defecation? Correct Answers
•Drink at least 8 glasses of fluids each day.
1. A client in pain request the prescribed pain medication, which
is an opioid. Which nursing assessment is essential before
administering the opioid? Correct Answers - 2: Respirations
1. A home care nurse observes the spouse of a client inserting a
rectal Suppository into the client. Which behavior indicates that
the nurse must provide further teaching about the Suppository
administration? Correct Answers - 3 - insert the Suppository
while the client bears down : Bearing down increases intra-
abdominal pressure which impedes the insertion of the
Suppository. The client should be instructed to relax and breathe
deeply and slowly while the Suppository is inserted.
1. A nurse holds a bottle with the label next to the palm of her
hand when pouring liquid medication. Which is the rationale for
this action? Correct Answers - 1 - prevent soiling of the label
by spilled liquid : Liquid medication may drip down the side of
the bottle and soil the label, which may interfere with the ability
to read the label accurately.
1. A nurse instructs a client to close the eyes gently after
administration of eyedrops. Which rationale for this instruction
should the nurse explain to the client? Correct Answers 3 -
Disperses the medication over the eyeballs : Closing the eyes
