Review NUAS 130 SP 2026 Exam 3 T02 Mount Aloysius College

Explanation

Correct Answer: A) Assist the patient to cough, turn, and deep breathe every 2 hours

Assisting the patient to cough, turn, and deep breathe every 2 hours is the most effective preventive intervention for hospital-acquired pneumonia, particularly in elderly patients. Turning prevents pooling of secretions in dependent lung areas, deep breathing promotes full lung expansion and prevents atelectasis, and coughing mobilizes and clears secretions from the airways. Together, these actions reduce the risk of bacterial colonization and aspiration that lead to pneumonia in hospitalized patients.

Monitoring oxygen saturation and auscultating lung bases are important assessment activities but are detective rather than preventive measures. Decreasing fluid intake to 300 mL per shift would cause dangerous dehydration, thicken secretions, and impair mucociliary clearance — actually increasing pneumonia risk. Discontinuing humidification would dry the airways and thicken secretions, further impairing clearance and promoting infection rather than preventing it.

1. A nurse is preparing a bowel training program for a patient. Which actions will the nurse take? Select all that apply.

A) Maintain normal exercise within the patient's physical ability

B) Apply pressure with hands over the abdomen, and strain while pushing

C) Help the patient to the toilet at the designated time

D) Choose a time based on the patient's pattern to initiate defecation-control measures

E) Lean backward on the hips while sitting on the toilet

Explanation

Correct Answer: A, C, and D

A bowel training program aims to establish a predictable, consistent bowel routine. Maintaining normal exercise within the patient's physical ability promotes intestinal motility and supports regular bowel function. Helping the patient to the toilet at a designated time reinforces a consistent schedule and takes advantage of the gastrocolic reflex, typically strongest after meals. Choosing a time based on the patient's natural pattern of defecation personalizes the program for maximum effectiveness and patient compliance.

Applying pressure with hands over the abdomen while straining is not a recommended technique and can cause injury or increase intra-abdominal pressure inappropriately. Leaning backward on the hips is incorrect positioning — patients should lean slightly forward with feet flat on the floor or elevated on a footstool to adopt a more physiologically natural squatting-like position that facilitates bowel emptying.

1. A nurse is inserting a catheter into a female patient. When the nurse inserts the catheter, no urine is obtained. The nurse suspects the catheter is not in the urethra. What should the nurse do?

A) Fill the balloon with the recommended sterile water

B) Leave the catheter in the vagina as a landmark for insertion of a new, sterile catheter

C) Remove the catheter, wipe with alcohol, and reinsert after lubrication

D) Throw the catheter away and begin again

Explanation

Correct Answer: B) Leave the catheter in the vagina as a landmark for insertion of a new, sterile catheter

When a catheter is accidentally inserted into the vagina instead of the urethra, the correct technique is to leave the misplaced catheter in the vagina as a visual landmark. This clearly marks the incorrect opening so the nurse can identify the urethral meatus — which is located just anterior to the vaginal opening — and insert a new, sterile catheter into the correct location. Leaving the landmark catheter in place prevents the nurse from making the same error again.

Filling the balloon with sterile water would be dangerous and incorrect since the catheter is not properly placed in the bladder. Wiping the misplaced catheter with alcohol and reinserting it violates sterile technique and risks introducing infection. Simply throwing the catheter away and starting again without using the landmark technique increases the risk of repeated misplacement, especially in patients with challenging anatomy.

1. A nurse is preparing to catheterize a male client. What will the nurse consider a priority when performing this procedure on the client?

A) The catheter should be inserted to the bifurcation ("Y") port

B) Lubricate catheter after inserting into the meatus

C) Clean anatomy from dirty to clean

D) Insert the catheter until urine returns then inflate the balloon

Explanation

Correct Answer: D) Insert the catheter until urine returns then inflate the balloon

In male catheterization, the priority safety step is to advance the catheter fully until urine returns — confirming placement within the bladder — before inflating the balloon. Inflating the balloon prematurely, while the catheter tip is still within the urethra, can cause serious urethral trauma and injury. Urine return is the definitive confirmation that the catheter has passed through the urethra and into the bladder.

In male patients, the catheter should be inserted to the bifurcation to ensure it is fully in the bladder before balloon inflation, making option A partially relevant — but the critical priority remains confirming urine return first. Lubricating the catheter before insertion, not after entering the meatus, is correct technique to ease passage and reduce urethral trauma. Cleaning from dirty to clean is a general hygiene principle, but it does not represent the specific priority in catheter insertion technique.

1. The nurse is preparing to assess the posterior tibial artery. Which location will the nurse palpate to assess this pulse?

A) Lateral to the extensor tendon of the great toe

B) Over the lateral malleolus

C) Behind the knee

D) In the groove behind the medial malleolus

Explanation

Correct Answer: D) In the groove behind the medial malleolus

The posterior tibial pulse is palpated in the groove located just behind and slightly below the medial malleolus — the bony prominence on the inner ankle. This is where the posterior tibial artery runs as it courses down the lower leg and around the ankle toward the foot, making it accessible for assessment of peripheral vascular circulation in the lower extremity.

Lateral to the extensor tendon of the great toe describes the location of the dorsalis pedis pulse. Over the lateral malleolus is not a standard pulse assessment site. Behind the knee is where the popliteal pulse is assessed, which is a different peripheral pulse site entirely.

1. A graduate nurse is caring for a client ordered a fleet's enema. The graduate nurse understands that the client should be placed in which position for proper administration?

A) Sims

B) Supine

C) Dorsal recumbent

D) Prone

Explanation

Correct Answer: A) Sims

The Sims position — left lateral position with the upper knee flexed — is the standard and correct position for enema administration. This position takes advantage of gravity and the anatomy of the sigmoid colon, which curves toward the left side of the body, allowing the enema solution to flow naturally into the colon. The left lateral position also provides easier access for rectal tube insertion and promotes patient comfort during the procedure.

The supine position lies flat on the back and does not facilitate enema flow into the colon. Dorsal recumbent places the patient on their back with knees bent and is used for perineal and vaginal examinations, not enema administration. The prone position lies face down and would make rectal access very difficult while preventing proper solution distribution.

1. Which nutritional instruction is a priority for the nurse to advise a patient about with an ileostomy?

A) Chew food thoroughly

B) Keep fiber low

C) Eat large meals

D) Increase fluid intake

Explanation

Correct Answer: D) Increase fluid intake

Increasing fluid intake is the priority nutritional instruction for a patient with an ileostomy. Because the ileostomy bypasses the large intestine — where the majority of water reabsorption normally occurs — patients with ileostomies lose significantly more fluid and electrolytes through their stoma output. This places them at high risk for dehydration, which can lead to serious complications including electrolyte imbalances, kidney stones, and renal impairment. Maintaining adequate hydration is therefore the most critical dietary priority.

Chewing food thoroughly is beneficial to prevent stomal blockages but is not the top priority. Keeping fiber low may be recommended initially post-surgery or to reduce blockage risk, but it is not universally the priority instruction. Eating large meals is discouraged in ileostomy patients, as smaller, more frequent meals are better tolerated and produce more manageable stoma output.

1. The student nurse is caring for a client with a diagnosis of constipation. The student nurse knows which of the following factors may have contributed to constipation. Select all that apply.

A) Client is ambulating in hallway without assistance

B) Client is alert and oriented x 4

C) Client is prescribed pain medication around the clock

D) Decreased fluid intake

E) Decreased fiber intake

Explanation

Correct Answer: C, D, and E

Pain medications — particularly opioids prescribed around the clock — are a well-known cause of constipation, as they bind to opioid receptors in the gastrointestinal tract, slowing peristalsis and reducing intestinal motility. Decreased fluid intake leads to harder, drier stools that are more difficult to pass. Decreased fiber intake reduces stool bulk, which is necessary to stimulate normal peristaltic movement through the colon.

Ambulating in the hallway without assistance is a protective factor against constipation, as physical activity promotes intestinal motility — it would not contribute to constipation. Being alert and oriented x 4 is a normal neurological finding and has no relationship to bowel function or constipation risk.

1. A nurse is caring for a client diagnosed with pneumonia. Upon the morning assessment, the client's left lower leg is warm and tender and has a 3-cm area of erythema and swelling. Vital signs are stable. Which priority concern would the nurse establish?

A) Deep vein thrombosis (DVT)

B) Internal bleeding

C) Infection at the incisional site

D) Dehiscence of the wound

Explanation

Correct Answer: A) Deep vein thrombosis (DVT)

The classic triad of DVT — warmth, tenderness, and erythema with swelling in a lower extremity — is precisely what this patient is presenting with in the left lower leg. Patients with pneumonia are at elevated risk for DVT due to immobility, inflammatory states, and potential hypercoagulability. DVT is a priority concern because if the clot dislodges, it can travel to the pulmonary vasculature and cause a life-threatening pulmonary embolism.

Internal bleeding typically presents with systemic signs such as hypotension, tachycardia, and pallor — not localized leg warmth and erythema. Infection at an incisional site would require the presence of a surgical wound, which is not mentioned in this scenario. Dehiscence refers to wound separation and is also not applicable without a surgical incision being described.

1. A patient is experiencing oliguria. Which action should the nurse perform first?

A) Increase the patient's intravenous fluid rate

B) Encourage the patient to drink caffeinated beverages

C) Request an order for diuretics

D) Assess for bladder distention

Explanation

Correct Answer: D) Assess for bladder distention

The first action when a patient is experiencing oliguria is to assess for bladder distention. Oliguria — decreased urine output — can result from either inadequate urine production or an inability to void due to urinary retention. Palpating and percussing the bladder first allows the nurse to determine whether urine is being produced but retained, or whether true renal hypoperfusion or failure is present. This assessment guides all subsequent interventions and prevents inappropriate treatment.

Increasing IV fluids without first assessing could worsen fluid overload if the oliguria is due to retention rather than dehydration. Caffeinated beverages are a diuretic irritant and are not an appropriate clinical intervention. Requesting diuretics without a full assessment could be dangerous — if oliguria is due to prerenal causes such as dehydration, diuretics would worsen the condition significantly.

1. A nurse is caring for a male patient experiencing urinary retention. Which action should the nurse take first?

A) Insert a urinary catheter

B) Limit fluid intake

C) Assist to a standing position

D) Ask for a diuretic medication

Explanation

Correct Answer: C) Assist to a standing position

The first nursing action for a male patient with urinary retention should be to assist him to a standing position. Many men are unable to void while lying in bed due to psychological inhibition and the anatomical position of the male urinary tract. Standing mimics the natural voiding position for males, which can trigger the micturition reflex and allow spontaneous voiding, avoiding the need for more invasive interventions. This is a simple, non-invasive measure that should always be attempted first.

Inserting a urinary catheter is an invasive procedure that carries risks of infection and urethral injury and should only be used if non-invasive measures fail. Limiting fluid intake does not address the retention and could lead to dehydration. Diuretic medication increases urine production but does not resolve the underlying inability to void and could worsen discomfort by increasing bladder pressure.

1. The oncoming nurse has received the following information about four clients during shift report. What client has the highest priority?

A) A client who has a nasogastric tube to low intermittent suction

B) A client who has a pulse ox of 88% on room air and complaining of shortness of breath

C) A client who had surgery earlier in the day and has serosanguineous drainage

D) A client who had been confused for several days is now alert and oriented to person and place

Explanation

Correct Answer: B) A client who has a pulse ox of 88% on room air and complaining of shortness of breath

Airway and oxygenation always represent the highest priority using the ABC framework — airway, breathing, circulation. A pulse oximetry reading of 88% on room air indicates significant hypoxemia, which is a life-threatening emergency requiring immediate assessment and intervention. Combined with active complaints of shortness of breath, this patient is in acute respiratory distress and must be seen first.

A nasogastric tube on low intermittent suction is a routine management situation that does not indicate acute deterioration. Serosanguineous drainage following surgery is an expected and normal finding in the early postoperative period. A patient transitioning from confusion to alert and oriented is actually showing clinical improvement, not deterioration, and is a lower priority compared to the acutely hypoxic patient.

1. A post void residual (PVR) was 450mL on a client who is diagnosed with urinary retention. The registered nurse notified the physician and ordered an indwelling catheter insertion. The student nurse knows which of the following steps to initiate prior to insertion of the indwelling catheter.

A) Document color and amount

B) Position the client in a prone position

C) Determine whether the client is NPO

D) Apply clean gloves and perform perineal care

Explanation

Correct Answer: D) Apply clean gloves and perform perineal care

Before inserting an indwelling catheter, performing perineal care with clean gloves is an essential preparatory step. Cleansing the perineal area reduces the bacterial load around the urethral meatus, which significantly lowers the risk of introducing microorganisms into the bladder during catheter insertion and decreases the risk of catheter-associated urinary tract infections (CAUTIs). This is a standard pre-procedure step in safe catheterization practice.

Documenting color and amount applies after urine has been obtained, not before catheter insertion. Positioning the client in a prone position is incorrect — female patients should be in the dorsal recumbent position and male patients in the supine position for catheterization. Determining whether the client is NPO is relevant for surgical or procedural sedation, not for urinary catheter insertion.

1. A nurse is planning care for a group of patients. Which task will the nurse assign to the nursing assistive personnel (AP)?

A) Irrigating a catheter

B) Obtaining a midstream urine specimen

C) Inserting a straight catheter

D) Interpreting a bladder scan result

Explanation

Correct Answer: B) Obtaining a midstream urine specimen

Obtaining a midstream urine specimen is a non-invasive collection task that falls within the scope of practice of nursing assistive personnel. It does not require clinical judgment, sterile technique, or specialized nursing assessment — the AP simply instructs and assists the patient in collecting a clean-catch specimen following established protocol.

Irrigating a catheter requires clinical knowledge and sterile technique and is a nursing responsibility. Inserting a straight catheter is an invasive sterile procedure that requires nursing training and clinical judgment and cannot be delegated to AP staff. Interpreting a bladder scan result involves clinical assessment and decision-making, which is within the nurse's scope of practice, not the AP's.

1. An older adult's perineal skin is dry and thin with mild excoriation. When providing hygiene care after episodes of diarrhea, what should the nurse do?

A) Thoroughly scrub the skin with a washcloth and hypoallergenic soap

B) Tape an occlusive moisture barrier pad to the patient's skin

C) Apply a skin protective ointment after perineal care

D) Massage the skin with light kneading pressure

Explanation

Correct Answer: C) Apply a skin protective ointment after perineal care

In older adults, perineal skin is fragile, thin, and already excoriated — meaning it is at high risk for further breakdown from repeated exposure to stool and moisture. Applying a skin protective ointment — such as zinc oxide or a moisture barrier cream — after perineal hygiene creates a protective layer over the skin that shields it from the irritating effects of diarrheal stool and moisture, promotes healing of existing excoriation, and prevents further skin breakdown.

Thoroughly scrubbing the skin would cause further damage to already fragile and excoriated tissue — gentle patting is the appropriate technique. Taping an occlusive pad directly to compromised skin would cause pain, tearing, and worsening skin injury upon removal. Massaging with kneading pressure is inappropriate over excoriated or damaged skin and could deepA student nurse is providing care for a client with a diagnosis of pneumonia and is currently complaining of shortness of breath.

1. A student nurse is providing care for a client with a diagnosis of pneumonia and is currently complaining of shortness of breath. The client's pulse oximetry reading is 95% on 2L/minute via nasal cannula. What is the fraction of inspired oxygen (FiO2) being delivered to the client?

A) 28%

B) 36%

C) 32%

D) 24%

Explanation

Correct Answer: A) 28%

The standard formula for calculating FiO2 via nasal cannula is:

FiO2 = 21% + (4% × flow rate in L/min)

At 2L/min: 21% + (4% × 2) = 21% + 8% = 29%, which is closest to 28% among the answer choices.

This formula is based on the principle that room air provides 21% oxygen, and each additional liter per minute of supplemental oxygen delivered via nasal cannula raises the FiO2 by approximately 4%. This is a standard nursing calculation used to estimate oxygen concentration being delivered to a patient on low-flow oxygen therapy. The other options — 36%, 32%, and 24% — correspond to flow rates of approximately 4L/min, 3L/min, and 1L/min respectively, not 2L/min.

1. A nurse is preparing to administer oral medications to a client. What assessment is priority prior to administration?

A) Ability to speak

B) Ability to answer simple questions

C) Ability to perform activities of daily living

D) Ability to swallow

Explanation

Correct Answer: D) Ability to swallow

Before administering any oral medication, the priority assessment is the patient's ability to swallow safely. If a patient has dysphagia or an impaired swallowing reflex, administering oral medications poses a serious risk of aspiration — where medication enters the airway rather than the esophagus — which can lead to aspiration pneumonia or airway obstruction. Confirming the ability to swallow is a fundamental safety check that must occur before any oral medication is given.

Ability to speak, answer questions, and perform activities of daily living are all relevant assessments in general patient care, but none of them directly ensure the physical safety of administering an oral medication. A patient may be unable to speak clearly yet still swallow safely, or vice versa — making swallowing ability the specific and most critical priority here.

1. The nurse is reviewing the location of breath sounds. Which breath sounds would he expect to hear in the area noted below? (X mark located at the lower lateral chest/peripheral lung field)

A) Bronchial

B) Vesicular

C) Bronchovesicular

D) Adventitious

Explanation

Correct Answer: B) Vesicular

The X mark in the second image is positioned over the lower lateral chest wall, which overlies the peripheral lung tissue. Vesicular breath sounds are the normal expected finding over the peripheral lung fields. They are soft, low-pitched sounds with a longer inspiratory phase than expiratory phase, produced by air moving through the smaller airways and alveoli. These are the most commonly heard breath sounds during a routine respiratory assessment over most of the lung surface.

Bronchial breath sounds are high-pitched and loud and are only normally heard over the trachea — hearing them in peripheral lung fields would be abnormal and suggest consolidation. Bronchovesicular sounds are heard near the mainstem bronchi at the sternal border, not in the peripheral lung fields. Adventitious sounds are abnormal findings not expected in a healthy patient at any location.

1. Which assessment question should the nurse ask if stress incontinence is suspected?

A) "Do you think your bladder feels distended?"

B) "Do your symptoms increase with consumption of alcohol or caffeine?"

C) "Do you experience urine leakage when you cough or sneeze?"

D) "Do you empty your bladder completely when you void?"

Explanation

Correct Answer: C) "Do you experience urine leakage when you cough or sneeze?"

Stress incontinence is defined as the involuntary loss of urine triggered by activities that increase intra-abdominal pressure, such as coughing, sneezing, laughing, or physical exertion. Asking whether leakage occurs during these activities directly assesses the hallmark symptom of stress incontinence and helps differentiate it from other types of urinary incontinence.

Bladder distension is associated with urinary retention or overflow incontinence, not stress incontinence. Alcohol and caffeine worsening symptoms is more characteristic of urge incontinence, as these substances are bladder irritants that increase detrusor activity. Incomplete bladder emptying describes overflow incontinence or obstructive voiding patterns, not the pressure-triggered leakage of stress incontinence.

1. A nurse is caring for a male patient with an indwelling urinary catheter. Which nursing actions are appropriate? Select all that apply.

A) Assess the urinary meatus for signs of pressure injury

B) Secure the catheter to the patient's inner thigh or abdomen

C) Clean the urethral meatus with soap and water once a week

D) Position the drainage bag on the bed at the level of the bladder

E) Empty the drainage bag when it is half full

Explanation

Correct Answers: Assess the urinary meatus for signs of pressure injury, and Secure the catheter to the patient's inner thigh or abdomen

Regularly assessing the urinary meatus for signs of pressure injury is essential, as the catheter can cause irritation, erosion, or breakdown of the surrounding tissue with prolonged use. Securing the catheter to the inner thigh or abdomen in male patients prevents tension and movement at the insertion site, reducing the risk of urethral trauma and accidental dislodgement.

Cleaning the meatus only once a week is insufficient — perineal and meatal hygiene should be performed at least daily and after bowel movements to reduce infection risk. The drainage bag must always be positioned below the level of the bladder to prevent backflow of urine into the bladder, which increases infection risk — placing it at bladder level is incorrect. The drainage bag should be emptied when it is two-thirds to three-quarters full, not half full, to maintain an effective drainage system without unnecessary frequent interruptions.

1. The nurse is caring for a patient who is lying in bed experiencing dyspnea, despite receiving oxygen therapy. Which position would be most effective in decreasing dyspnea for the patient?

A) Sim's

B) Semi-Fowler's

C) Supine

D) High Fowler's

Explanation

Correct Answer: D) High Fowler's

High Fowler's position — with the head of the bed elevated at 90 degrees — is the most effective position for relieving dyspnea in a patient already on oxygen therapy. This upright position maximizes diaphragmatic excursion by allowing gravity to pull the abdominal contents downward, reducing pressure on the diaphragm and enabling full lung expansion. It significantly improves tidal volume, reduces the work of breathing, and enhances oxygenation.

Sim's position is a lateral position used for enema administration and rectal procedures, not for respiratory relief. Semi-Fowler's at 30-45 degrees provides some respiratory benefit but is less effective than High Fowler's for active dyspnea. The supine position is the worst choice for a dyspneic patient as it increases pressure on the diaphragm and reduces functional residual capacity, worsening breathlessness.

1. A nurse completes a focused assessment on a client diagnosed with respiratory failure and notes that the client has rhonchi in all lung fields with a decreasing pulse oximetry reading. The nurse prepares the client for nasotracheal suctioning. Which step is used when performing nasotracheal suctioning?

A) Apply suction while inserting and removing the catheter

B) Encourage the client to swallow as the suction catheter is inserted

C) Gently rotate the suction catheter as the catheter is removed

D) Regulate suction pressure between 40-80 mmHg

Explanation

Correct Answer: C) Gently rotate the suction catheter as the catheter is removed

During nasotracheal suctioning, the correct technique is to apply intermittent suction while gently rotating the catheter during withdrawal. The rotation ensures that the catheter tip contacts different areas of the airway mucosa, maximizing secretion removal while minimizing trauma to any single area of the airway wall.

Suction should never be applied while inserting the catheter — doing so removes oxygen from the airway during insertion and increases the risk of hypoxia and mucosal trauma. Encouraging the client to swallow applies to oropharyngeal suctioning technique, not nasotracheal. Safe suction pressure for nasotracheal suctioning in adults is 100-150 mmHg — 40-80 mmHg is too low to be effective for clearing secretions.

1. A fecal occult stool test is ordered for a patient. Which type of blood is the nurse checking for in this patient's stool?

A) Dark black blood

B) Bright red blood

C) Mucoid

D) Microscopic

Explanation

Correct Answer: D) Microscopic

A fecal occult blood test (FOBT) is specifically designed to detect microscopic amounts of blood in the stool that are not visible to the naked eye. The word "occult" means hidden — this test identifies blood that cannot be seen as dark black or bright red coloration in the stool. It is commonly used as a screening tool for colorectal cancer, polyps, and gastrointestinal bleeding where blood loss is too small to produce visible changes in stool appearance.

Dark black blood describes melena, which is visible and indicates upper GI bleeding — this does not require an occult test as it is already apparent. Bright red blood describes hematochezia, visible lower GI bleeding also detectable without a laboratory test. Mucoid refers to mucus in stool, not blood, and is unrelated to the fecal occult blood test.

1. The nurse is caring for patients with ostomies. In which ostomy location will the nurse expect very liquid stool to be present?

A) Sigmoid

B) Descending

C) Ascending

D) Transverse

Explanation

Correct Answer: C) Ascending

An ascending colostomy is located in the right side of the colon, very early in the large intestine. At this point, stool has just entered the colon from the small intestine and has had very little water reabsorbed, making the output very liquid and high in digestive enzymes. This is the most proximal colostomy location and therefore produces the most liquid, unformed output.

A sigmoid colostomy produces the most formed, solid stool as it is located at the very end of the colon where maximum water reabsorption has occurred. A descending colostomy produces semi-formed to formed stool. A transverse colostomy produces semi-liquid to mushy stool, less liquid than ascending but more liquid than descending or sigmoid locations.

1. A nurse is evaluating teaching for a client who has been newly diagnosed with diabetes and started on insulin. What action by the client would suggest that the teaching has been effective?

A) The nurse demonstrating the correct procedure for drawing medication from a vial

B) The client withdrawing insulin from the vial and injecting self correctly

C) The client discusses the importance of recapping the used needle

D) The client reads a handout that describes the different types of insulin that they are not prescribed

Explanation

Correct Answer: B) The client withdrawing insulin from the vial and injecting self correctly

Effective teaching is best demonstrated through the learner's ability to independently perform the skill correctly — this is behavioral demonstration, the highest level of learning evaluation. When the client can accurately withdraw insulin from the vial and self-administer the injection using proper technique, it confirms that the teaching has been understood and successfully applied in a practical, real-world context.

The nurse demonstrating the procedure reflects teaching, not the evaluation of client learning. Discussing the importance of recapping used needles is actually incorrect practice — needles should never be recapped due to the high risk of needlestick injury, so this would indicate a teaching failure rather than success. Reading a handout about insulin types not prescribed to the client is irrelevant and does not demonstrate practical understanding of their own care.

1. A student nurse is inspecting a client's abdomen with a colostomy and identifies that ostomy care needs to be completed. Choose the correct statements when considering assessment and care of an ostomy. Select all that apply.

A) Perform hand hygiene prior to performing ostomy care

B) The stoma should appear moist, shiny and beefy red

C) The peristomal area should appear red and swollen

D) Cut the skin barrier opening 0.15cm-0.3cm (1/18-1/8 inch) larger, allowing only the stoma to appear through the opening

E) Apply a moisturizer lotion to the peristomal area to prevent skin breakdown

Explanation

Correct Answers: A, B, and D

Hand hygiene before ostomy care is a fundamental infection control practice that must always be performed. A healthy, well-perfused stoma should appear moist, shiny, and beefy red — indicating adequate blood supply and tissue viability. Cutting the skin barrier opening slightly larger than the stoma (0.15-0.3cm) ensures the barrier fits snugly around the stoma without constricting it, protecting the peristomal skin from exposure to stool while allowing only the stoma to protrude through.

A red and swollen peristomal area is abnormal and indicates irritation, infection, or allergic reaction — it is not an expected or acceptable finding. Applying moisturizer lotion to the peristomal skin is incorrect because lotions create a barrier that prevents the adhesive skin barrier from adhering properly, leading to leakage and skin breakdown — skin barrier protective products specifically designed for ostomy care should be used instead.

1. An order is written for 240 mg of a medication in elixir form. The medication is available in 80 mg/tsp strength. The nurse prepares to administer how many milliliters?

A) 5 mL

B) 15 mL

C) 3 mL

D) 20 mL

Explanation

Correct Answer: B) 15 mL

Using the standard dosage calculation formula:

Dose ordered ÷ Dose available × Volume = Amount to administer

240 mg ÷ 80 mg × 1 tsp = 3 tsp

Since 1 teaspoon = 5 mL: 3 tsp × 5 mL = 15 mL

The nurse should administer 15 mL of the elixir to deliver the prescribed 240 mg dose. The other options — 5 mL (1 tsp = 80 mg), 3 mL, and 20 mL — do not correspond to the correct calculation for this order.

1. The following assessment data is collected by the nurse: respiratory rate = 16, pulse oximetry = 88%, respirations even and regular without use of accessory muscles, bilateral breath sounds clear on room air. Which intervention would be most appropriate?

A) Notify the healthcare provider

B) Document that all findings are within normal limits

C) Elevate the head of the bed and prepare to administer oxygen

D) Move the oximetry sensor to another area

Explanation

Correct Answer: C) Elevate the head of the bed and prepare to administer oxygen

While the respiratory rate of 16 and clear bilateral breath sounds are normal findings, a pulse oximetry reading of 88% indicates significant hypoxemia — normal SpO2 is 95-100%. This requires immediate nursing intervention. Elevating the head of the bed improves diaphragmatic excursion and lung expansion, and preparing to administer supplemental oxygen addresses the low oxygen saturation directly. The nurse should also notify the provider, but the immediate action is to intervene with positioning and oxygen.

Documenting all findings as within normal limits would be a serious error — an SpO2 of 88% is critically low and requires urgent action, not routine documentation. Moving the oximetry sensor is appropriate only if there is reason to suspect a faulty reading, but acting on the abnormal value first is the priority. The normal respiratory pattern does not negate the urgency of the low oxygen saturation reading.

1. A nurse teaches the patient about the prescribed buccal medication. Which statement by the patient indicates teaching by the nurse is successful?

A) "I should let the medication dissolve completely."

B) "I can only drink water, not juice, with this medication."

C) "I will place the medication in the same location."

D) "I better chew my medication first for faster distribution."

Explanation

Correct Answer: A) "I should let the medication dissolve completely."

Buccal medications are placed between the cheek and gum and must be allowed to dissolve completely in place to ensure proper absorption through the buccal mucosa directly into the bloodstream. This statement correctly reflects understanding of buccal medication administration technique.

Restricting fluids to only water is not a standard requirement for buccal medications. Placing the medication in the same location each time is actually discouraged — rotating sites helps prevent mucosal irritation and breakdown from repeated contact. Chewing a buccal medication is incorrect and counterproductive, as it destroys the medication's intended slow-dissolve mechanism and prevents proper buccal absorption.

1. The nurse is administering a subcutaneous injection to a client. Which of the following is not correct regarding the administration of subcutaneous (SQ) injections?

A) Insert the needle at a 45-degree angle

B) Choose insertion areas of the body over bony prominences

C) Pinch the skin in the area of insertion

D) Use a 23-25 gauge needle

Explanation

Correct Answer: B) Choose insertion areas of the body over bony prominences

Subcutaneous injection sites should be chosen over areas with adequate fatty tissue — such as the abdomen, outer upper arm, anterior thigh, or upper back. Sites over bony prominences lack sufficient subcutaneous tissue and are highly inappropriate for SQ injections, as the needle may strike bone, cause pain, or fail to deposit medication into the correct tissue layer.

Inserting the needle at a 45-degree angle is correct technique for SQ injections, though a 90-degree angle may be used in patients with more subcutaneous tissue. Pinching the skin lifts the subcutaneous tissue away from underlying muscle, ensuring correct tissue depth for injection. A 23-25 gauge needle is the appropriate size range for subcutaneous injections, as it is fine enough to minimize tissue trauma while delivering the medication effectively.

1. The nurse instructs a client how to use an incentive spirometer. The nurse understands that the primary expected outcome associated with the use of an incentive spirometer is:

A) Stimulation of sputum expectoration

B) Reduction of supplemental oxygen therapy

C) Increased inspiratory volume

D) Stimulation of the cough reflex

Explanation

Correct Answer: C) Increased inspiratory volume

The primary purpose of an incentive spirometer is to encourage slow, deep inhalations that maximize inspiratory volume. By providing visual feedback as the patient breathes in, the device motivates sustained maximal inspiration, which fully expands the alveoli, prevents atelectasis, and maintains adequate lung function — particularly important in postoperative patients or those with respiratory conditions who tend to breathe shallowly.

While deep breathing may secondarily help mobilize secretions and stimulate coughing, these are secondary effects — not the primary expected outcome. Reducing supplemental oxygen therapy may occur as lung function improves, but it is not the direct intended outcome of spirometer use. Stimulation of the cough reflex is a secondary benefit, not the primary therapeutic goal.

1. A nurse is caring for a patient with an indwelling urinary catheter. Which action is most important to prevent catheter-associated urinary infection (CAUTI)?

A) Keep the drainage bag below the level of the bladder at all times

B) Irrigate the catheter with tap water every shift

C) Change the catheter every 7 days to maintain sterility

D) Disconnecting and replacing the catheter drainage bag once per shift

Explanation

Correct Answer: A) Keep the drainage bag below the level of the bladder at all times

Maintaining the drainage bag below the level of the bladder at all times is the most important action to prevent CAUTI. If the bag is elevated above the bladder, urine can flow back into the bladder — this retrograde flow introduces bacteria from the bag into the sterile urinary tract, directly causing infection. Maintaining a closed, dependent drainage system is a cornerstone of CAUTI prevention bundles.

Irrigating the catheter with tap water introduces non-sterile fluid into a closed sterile system and is not a routine practice — irrigation is only performed with sterile solution when specifically ordered. Catheters are not changed on a routine 7-day schedule without clinical indication, as unnecessary catheter changes increase infection risk. Disconnecting and replacing the drainage bag breaks the closed drainage system, which is a major risk factor for introducing bacteria and causing CAUTI.

1. The patient has supplemental oxygen in place and requires suctioning to remove excess secretions from the airway. To promote maximum oxygenation, what is the next appropriate action by the nurse?

A) Replace the oxygen and allow rest in between suctioning passes

B) Complete a number of suctioning passes until the catheter comes back clear

C) Increase the amount of suction pressure to 200mmHg

D) Suction continuously for 30-second intervals

Explanation

Correct Answer: A) Replace the oxygen and allow rest in between suctioning passes

Suctioning removes not only secretions but also oxygen from the airway, creating a risk of hypoxia with each pass. To promote maximum oxygenation, the nurse must replace supplemental oxygen and allow the patient adequate rest between suctioning passes to recover their oxygen saturation before the next pass is performed. This is a fundamental principle of safe suctioning technique.

Completing multiple suctioning passes without rest periods compounds hypoxia with each successive pass, dangerously depleting the patient's oxygen levels. Increasing suction pressure to 200mmHg exceeds the safe range for adults (100-150mmHg) and causes unnecessary mucosal trauma and bleeding. Suctioning continuously for 30-second intervals is dangerous — each suction pass should be limited to 10-15 seconds to minimize hypoxia and airway trauma.

1. While performing a physical assessment, the student nurse tells the instructor that the client's bladder cannot be palpated. Which statement by the instructor is best?

A) "You need to try again; it takes practice but you will locate it."

B) "You must immediately notify the nurse assigned to the care of your client."

C) "You should document this abnormal finding on the client's chart."

D) "You will be able to palpate the client's bladder when it is distended by urine."

Explanation

Correct Answer: D) "You will be able to palpate the client's bladder when it is distended by urine."

A normal, empty or minimally filled bladder sits below the pubic symphysis and is not palpable on physical examination. This is a completely normal finding. The bladder only becomes palpable above the pubic bone when it is significantly distended with urine — typically containing at least 150-300mL or more. The instructor's best response is to educate the student that the inability to palpate the bladder is expected and normal when the bladder is not distended.

Telling the student to try again implies the bladder should be findable, which is incorrect when it is not distended. There is no need to notify the assigned nurse, as this is a normal assessment finding requiring no escalation. Documenting it as an abnormal finding would be inaccurate — a non-palpable bladder is the normal expected finding in a patient who does not have urinary retention.

1. A student nurse is assessing a client who is diagnosed with respiratory failure. The student nurse knows which of the following are signs and symptoms of inadequate oxygenation. Select all that apply.

A) Heart rate is 86 bpm

B) The client does not complain of shortness of breath

C) Lung sounds are clear bilaterally in all lobes

D) Cyanosis

E) Tachypnea

Explanation

Correct Answers: D) Cyanosis and E) Tachypnea

Cyanosis — a bluish discoloration of the skin, lips, or nail beds — is a visible sign of severe hypoxemia indicating that tissues are not receiving adequate oxygen. Tachypnea — an increased respiratory rate — is a compensatory response where the body attempts to take in more oxygen and expel more carbon dioxide in response to inadequate oxygenation.

A heart rate of 86 bpm is within the normal range and does not indicate inadequate oxygenation. The absence of shortness of breath complaints and clear bilateral lung sounds are normal, reassuring findings that suggest adequate respiratory function — they are not signs of inadequate oxygenation.

1. The physician orders Micronase 5 mg PO daily for type 2 diabetes. The pharmacy sends Micronase (glyburide) tablets 1.25 mg. How many tablets should the nurse administer?

Explanation

Correct Answer: 4 tablets

Using the standard dosage calculation formula:

Dose ordered ÷ Dose available = Number of tablets

5 mg ÷ 1.25 mg = 4 tablets

The nurse should administer 4 tablets of Micronase 1.25 mg to deliver the prescribed 5 mg dose. This is a straightforward dose calculation — since each tablet contains 1.25 mg and the ordered dose is 5 mg, dividing the ordered dose by the available tablet strength gives exactly 4 tablets.

1. Using the supply above, how much should the nurse administer to deliver the correct dose to the patient? Round to the nearest tenth and label your answer.

A) 1.5 mL

B) 2.5 mL

C) 3.75 mL

D) 5.0 mL

Explanation

Correct Answer: C) 3.75 mL

To calculate the volume to administer, the standard formula is used:

Volume = (Desired dose ÷ Dose on hand) × Volume on hand

Based on the supply label of 2 mg/mL, if the ordered dose is 7.5 mg:

(7.5 mg ÷ 2 mg) × 1 mL = 3.75 mL

This gives the correct volume of 3.75 mL to be administered. Rounding to the nearest tenth confirms the answer remains 3.75 mL, as it is already expressed to the tenth place.

Administering any volume above or below this calculated amount would result in either an underdose (reduced therapeutic effect) or an overdose (risk of toxicity), both of which compromise patient safety. Always verify the label concentration before drawing up any medication.

1. The nurse is caring for a patient who had a colostomy placed yesterday. The nurse should report which assessment finding immediately?

A) Stoma is flush with the skin.

B) Stoma is circular.

C) Stoma is purple.

D) Stoma is moist.

Explanation

Correct Answer: C) Stoma is purple.

A healthy, newly created stoma should appear beefy red or pink, indicating adequate blood supply and perfusion. A purple, dusky, or black stoma is an emergency finding that signals ischemia or necrosis — a severely compromised blood supply to the stoma tissue. This must be reported to the surgeon immediately, as it can progress to full necrotic tissue death if not addressed urgently.

A stoma that is flush with the skin (Option A) is a structural concern that may cause pouching difficulties but is not an immediate emergency. A circular shape (Option B) is a normal finding for a stoma. A moist stoma (Option D) is also expected and normal, as stomas should remain moist from mucous membrane tissue.

1. The student nurse is caring for a client with pneumonia and has a tracheostomy. The student nurse knows which of the following signs are indicated for suctioning? Select all that apply.

A) Gurgling sounds during respiration.

B) Pulse oximetry of 95% on tracheostomy mask.

C) Respiratory rate of 18 breaths per minute.

D) Decreased oxygenation saturation.

E) Clear lung sounds.

Explanation

Correct Answers: A) Gurgling sounds during respiration and D) Decreased oxygenation saturation.

Gurgling sounds during respiration indicate the presence of secretions in the airway that the patient cannot clear independently — suctioning is required to maintain a patent airway. Decreased oxygenation saturation signals that secretion buildup is compromising gas exchange, making suctioning necessary to restore adequate oxygenation.

1. A student nurse is preparing to assess the abdomen on a client. Which of the following correctly identifies the location of the transverse colon?

A) It runs vertically along the left side of the abdomen, descending from the splenic flexure to the sigmoid colon.

B) It runs horizontally across the upper abdomen, connecting the ascending colon on the right to the descending colon on the left.

C) It is located in the lower right quadrant, connecting the ileum to the ascending colon.

D) It is an S-shaped segment located in the lower left quadrant, connecting to the rectum.

Explanation

Correct Answer: B) It runs horizontally across the upper abdomen, connecting the ascending colon on the right to the descending colon on the left.

The transverse colon is the longest and most mobile segment of the large intestine. It stretches horizontally across the upper abdomen, spanning from the hepatic flexure (right colic flexure) on the right side to the splenic flexure (left colic flexure) on the left side. It lies just inferior to the stomach and is located primarily in the umbilical region.

1. To obtain a clean-voided urine specimen from a female patient, what should the nurse teach the patient to do?

A) Initiate the first part of the urine stream directly into the collection cup.

B) Drink fluids 5 minutes before collecting the urine specimen.

C) Cleanse the urethral meatus from the area of most contamination to least.

D) Hold the labia apart while voiding into the specimen cup.

Explanation

Correct Answer: D) Hold the labia apart while voiding into the specimen cup.

For a clean-catch midstream urine specimen in a female patient, holding the labia apart keeps the urethral meatus exposed and prevents contamination from surrounding skin and tissue during voiding. The correct sequence also includes cleansing from front to back (least to most contaminated), discarding the first stream, and collecting the midstream portion.

1. The physician orders Lasix 20 mg every day. The nurse notices that the route is missing. What is the next action the nurse should take?

A) Rely on your past experience with the physician to determine the route.

B) Contact the hospital pharmacy to clarify the order.

C) Call the prescribing physician to clarify the order.

D) Ask another nurse to interpret the medication order.

Explanation

Correct Answer: C) Call the prescribing physician to clarify the order.

When a medication order is incomplete or unclear, the nurse's responsibility is to contact the prescribing physician directly to clarify before administering the medication. Lasix (furosemide) can be given orally or intravenously, and the route significantly impacts dosing, onset, and patient safety — making clarification essential.

1. A nurse is providing care to a patient with an indwelling catheter. Which practice indicates the nurse is following guidelines for avoiding catheter-associated urinary tract infection (CAUTI)?

A) Drapes the urinary drainage tubing with no dependent loops.

B) Washes the drainage tube toward the meatus with soap and water.

C) Places the urinary drainage bag gently on the floor below the patient.

D) Allows the spigot to touch the receptacle when emptying the drainage bag.

Explanation

Correct Answer: A) Drapes the urinary drainage tubing with no dependent loops.

Keeping drainage tubing free of dependent loops prevents urine from pooling and flowing back toward the bladder, which reduces the risk of bacterial contamination and CAUTI. The drainage bag must always remain below the level of the bladder and tubing should be secured to allow free flow of urine.

1. A client diagnosed with congestive heart failure (CHF) is ordered strict I&O. Calculate the client's 24-hour intake and output in milliliters, then identify a positive, excess, or negative, deficit result.

Explanation

Correct Answer: 995 mL excess

INTAKE CALCULATION: All liquid items are converted to mL (1 oz = 30 mL)

• Breakfast: 8oz tea (240) + 8oz gelatin (240) + 8oz milk (240) = 720 mL
• 10 am: 250 mL emesis = subtracted from intake
• 11:30 am: 4oz ice = half volume = 60 mL
• Lunch: 8oz broth (240) + 4oz water (120) = 360 mL
• Dinner: 4oz lemonade (120) + 8oz broth (240) = 360 mL

Total Intake: 720 + 60 + 360 + 360 = 1,500 mL − 250 mL emesis = 1,250 mL

OUTPUT CALCULATION:

• 11:30 am urine: 500 mL
• 3:00 pm urine: 400 mL + 100 mL emesis = 500 mL
• 7:00 pm urine: 450 mL

Total Output: 500 + 500 + 450 = 1,450 mL

Wait — Intake (1,250) < Output (1,450) = 200 mL deficit

This CHF patient is showing a 200 mL deficit, which should be documented and reported as fluid output is exceeding intake.

1. A client has a prescription for regular insulin (Novolin R). The prescription states: Administer Novolin R insulin before meals and at bedtime based on the client's glucose monitoring results.

• Blood glucose 71–150: no insulin
• 151–200: 3 units
• 201–250: 5 units
• 251–300: 7 units
• 301–350: 9 units
• 351–400: 11 units and call MD

The client's blood glucose at 11:30 am is 350. How many units of Novolin R insulin should the nurse administer?

Explanation

Correct Answer: 9 units

A blood glucose of 350 falls within the 301–350 range, which corresponds to 9 units of Novolin R insulin per the sliding scale. The nurse should administer 9 units before the meal. Note that 350 does NOT fall in the 351–400 range, so calling the MD is not yet required. Accurate range identification is critical to prevent hypoglycemia or hyperglycemia.

1. The physician orders 1000 mL of 0.9% NSS to be infused over 11 hours. How many mL per hour should the nurse set the IV pump to deliver the IV fluid as directed by the physician?

Explanation

Correct Answer: 90.9 mL/hr, rounded to 91 mL/hr

Using the IV flow rate formula:

mL/hr = Total volume ÷ Total hours 1000 mL ÷ 11 hours = 90.9 mL/hr

IV pumps are typically programmed to the nearest whole number, making the correct setting 91 mL/hr. Setting the pump above or below this rate would result in the infusion completing too early or too late, which affects fluid balance and therapeutic outcomes.

1. A registered nurse is teaching a newly licensed nurse about heart sounds. Which of the following sound is heard when the mitral and tricuspid valves close?

A) Gallop

B) Murmur

C) S1

D) S2

Explanation

Correct Answer: C) S1

S1 is the first heart sound, produced by the closure of the mitral (bicuspid) and tricuspid valves at the beginning of ventricular systole. It is heard as the "lub" in the classic "lub-dub" heart sound and is best auscultated at the apex of the heart.

1. A nurse is caring for a client with a fecal impaction. Which of the following would be a priority nursing intervention to perform prior to removing stool digitally?

A) Obtain baseline vital signs.

B) Have the client sign an informed consent.

C) Administer a cleansing enema.

D) Ask the client to cough and deep breath prior to the procedure.

Explanation

Correct Answer: A) Obtain baseline vital signs.

Obtaining baseline vital signs is the priority intervention before digital removal of a fecal impaction because the procedure stimulates the vagus nerve, which can trigger a vasovagal response — causing bradycardia, hypotension, and even syncope. Having a baseline allows the nurse to immediately detect any dangerous changes during or after the procedure.

1. A patient asks about treatment for stress urinary incontinence. Which is the nurse's best response?

A) Avoid voiding frequently.

B) Wear an adult diaper.

C) Drink cranberry juice.

D) Perform pelvic floor exercises.

Explanation

Correct Answer: D) Perform pelvic floor exercises.

Pelvic floor exercises (Kegel exercises) are the first-line, evidence-based treatment for stress urinary incontinence. They strengthen the pubococcygeus muscles that support the bladder and urethra, reducing involuntary urine leakage triggered by increased abdominal pressure such as coughing, sneezing, or laughing.

1. A new graduate nurse is taking care of a client who has been prescribed a new medication having a side effect of decreased peristalsis. The graduate nurse is concerned about what potential problem for the client?

A) Fluid Volume Deficit

B) Constipation

C) Fluid Volume Overload

D) Diarrhea

Explanation

Correct Answer: B) Constipation

Peristalsis is the coordinated wave-like muscular contractions that move contents through the gastrointestinal tract. When peristalsis is decreased, intestinal motility slows, causing stool to remain in the colon longer. This leads to increased water reabsorption from the stool, resulting in hard, dry, difficult-to-pass stool — constipation.