RNSH 1105- Theory Exam 2|Advanced Nursing Clinical Assessment, Hygiene
Management, Skin Integrity, Oral Care, Foot Care, Catheterization, Neurogenic
Bladder, Urinary Tract Infection Prevention, Postoperative Care, Bed Bath
Techniques, Patient Positioning, Infection Control, Critical Thinking, Clinical
Judgment, Patient Safety, Comfort Promotion, Delegation, Assistive Personnel
Coordination, Cultural Competence, Patient Education, Pain Management,
Nausea Management, Aspiration Prevention, Mobility Assessment, Cognitive
Assessment, Peripheral Vascular Disease, Diabetes Management, Evidence-
Based Practice, QSEN Competencies, Advocacy, Health Promotion, Chronic
Illness Care, Interprofessional Collaboration Exam Questions Verified and
Provided with Complete A+ Graded Rationales Latest Updated 2026
Mr. Gabriel Epstein is a 68-year-old Israeli male admitted to the cardiac unit after undergoing open-
heart surgery for a coronary artery bypass graft (CABG) caused by blocked vessels in his heart. His
procedure was invasive; his breastbone was cut, and the chest opened to expose the heart. After the
surgery he is groggy and weak. He is a bachelor and has no family to visit him at the hospital.
Ruth is the nursing student assigned to Mr. Epstein. Her priority nursing goals for him are to maintain
comfort, safety, and hygiene to prevent infection.
1. Ruth enters Mr. Epstein's room to perform a skin assessment. She will check for which of the
following components of the skin? (Select all that apply.)
A. Color
B. Texture
C. Temperature
D. Turgor
E. Symmetry
Answer: A, B, C, D
Rationale: A skin assessment includes assessing the color, texture, temperature, turgor, thickness, and
hydration of the skin.
Mr. Gabriel Epstein is a 68-year-old Israeli male admitted to the cardiac unit after undergoing open-
heart surgery for a coronary artery bypass graft (CABG) caused by blocked vessels in his heart. His
,procedure was invasive; his breastbone was cut, and the chest opened to expose the heart. After the
surgery he is groggy and weak. He is a bachelor and has no family to visit him at the hospital.
Ruth is the nursing student assigned to Mr. Epstein. Her priority nursing goals for him are to maintain
comfort, safety, and hygiene to prevent infection.
2. Mr. Epstein is too groggy to brush his own teeth. Ruth knows that it is important to keep his mouth
clean to prevent infection. When performing oral care for Mr. Epstein, Ruth notices that his tongue is
red and swollen. Which oral condition does he have?
A. Halitosis
B. Glossitis
C. Alopecia
D. Cerumen
Answer: B
Rationale: Glossitis is the condition of an inflamed tongue.
Mr. Gabriel Epstein is a 68-year-old Israeli male admitted to the cardiac unit after undergoing open-
heart surgery for a coronary artery bypass graft (CABG) caused by blocked vessels in his heart. His
procedure was invasive; his breastbone was cut, and the chest opened to expose the heart. After the
surgery he is groggy and weak. He is a bachelor and has no family to visit him at the hospital.
Ruth is the nursing student assigned to Mr. Epstein. Her priority nursing goals for him are to maintain
comfort, safety, and hygiene to prevent infection.
3. Ruth prepares to give Mr. Epstein a bed bath since he is not able to bathe independently. Which of
the following are guidelines that she should follow while giving him a bed bath? (Select all that apply.)
A. Maintain safety.
B. Provide privacy.
C. Maintain warmth.
D. Promote independence.
E. Hydrate skin.
Answer: A, B, C, D
,Rationale: Guidelines for giving a bed bath are to maintain safety, provide privacy, maintain warmth,
promote independence, and anticipate needs.
Mr. Ryan Kelter is a 33-year-old Caucasian who lives in an acute rehabilitation center. He was injured in
a motorcycle accident that caused a spinal cord injury (SCI). As a result of the SCI, he has neurogenic
bladder that prevents him from fully emptying his bladder. Because of this, he needs to be straight
catheterized several times a day.
Beth is the student nurse assigned to Mr. Kelter. She understands the importance of keeping him on his
bladder schedule to prevent a urinary tract infection (UTI).
1. Beth enters Mr. Kelter's room after lunch to perform straight catheterization. List in order the steps
Beth takes to perform straight catheterization on Mr. Kelter.
A. Lubricate the catheter.
B. Clean penis with dominant hand.
C. Apply sterile gloves.
D. Advance catheter into penis.
E. Apply fenestrated drape.
F. Hold penis with nondominant hand.
G. Ask patient to bear down.
H. Coil catheter in dominant hand.
Answer: C, E, A, F, B, H, G, D
Rationale: The steps of straight catheterization are to position the patient, apply sterile gloves, apply the
fenestrated drape, lubricate the catheter, hold the penis with the nondominant hand, clean the penis
with the dominant hand, coil the catheter in the dominant hand, ask the patient to bear down, and
advance the catheter into the penis.
Mr. Ryan Kelter is a 33-year-old Caucasian who lives in an acute rehabilitation center. He was injured in
a motorcycle accident that caused a spinal cord injury (SCI). As a result of the SCI, he has neurogenic
bladder that prevents him from fully emptying his bladder. Because of this, he needs to be straight
catheterized several times a day.
, Beth is the student nurse assigned to Mr. Kelter. She understands the importance of keeping him on his
bladder schedule to prevent a urinary tract infection (UTI).
2. Beth should advance the catheter ________ to _______ inches or until urine flows out of it.
Answer: 7 to 9
Rationale: In an adult male the catheter should be advanced 7 to 9 inches (17-22.5 cm) or until urine
flows out of it.
Mr. Ryan Kelter is a 33-year-old Caucasian who lives in an acute rehabilitation center. He was injured in
a motorcycle accident that caused a spinal cord injury (SCI). As a result of the SCI, he has neurogenic
bladder that prevents him from fully emptying his bladder. Because of this, he needs to be straight
catheterized several times a day.
Beth is the student nurse assigned to Mr. Kelter. She understands the importance of keeping him on his
bladder schedule to prevent a urinary tract infection (UTI).
3. As Beth inserts the catheter into Mr. Kelter's penis, she feels resistance. She should use more force to
guide the catheter through his urethra.
A. True
B. False
Answer: B
Rationale: When resistance is felt while inserting a catheter, withdraw the catheter and do not force it. If
there is resistance to the catheter insertion, have the patient take slow, deep breaths while slowly
inserting the catheter. When urine appears, advance the catheter another 2.5 to 5 cm (1 to 2 inches).
What is the proper position to use for an unresponsive patient during oral care to prevent aspiration?
(Select all that apply.)
1. Prone position
2. Modified left lateral recumbent position
3. Semi-Fowler's position with head to side
4. Trendelenburg position
Management, Skin Integrity, Oral Care, Foot Care, Catheterization, Neurogenic
Bladder, Urinary Tract Infection Prevention, Postoperative Care, Bed Bath
Techniques, Patient Positioning, Infection Control, Critical Thinking, Clinical
Judgment, Patient Safety, Comfort Promotion, Delegation, Assistive Personnel
Coordination, Cultural Competence, Patient Education, Pain Management,
Nausea Management, Aspiration Prevention, Mobility Assessment, Cognitive
Assessment, Peripheral Vascular Disease, Diabetes Management, Evidence-
Based Practice, QSEN Competencies, Advocacy, Health Promotion, Chronic
Illness Care, Interprofessional Collaboration Exam Questions Verified and
Provided with Complete A+ Graded Rationales Latest Updated 2026
Mr. Gabriel Epstein is a 68-year-old Israeli male admitted to the cardiac unit after undergoing open-
heart surgery for a coronary artery bypass graft (CABG) caused by blocked vessels in his heart. His
procedure was invasive; his breastbone was cut, and the chest opened to expose the heart. After the
surgery he is groggy and weak. He is a bachelor and has no family to visit him at the hospital.
Ruth is the nursing student assigned to Mr. Epstein. Her priority nursing goals for him are to maintain
comfort, safety, and hygiene to prevent infection.
1. Ruth enters Mr. Epstein's room to perform a skin assessment. She will check for which of the
following components of the skin? (Select all that apply.)
A. Color
B. Texture
C. Temperature
D. Turgor
E. Symmetry
Answer: A, B, C, D
Rationale: A skin assessment includes assessing the color, texture, temperature, turgor, thickness, and
hydration of the skin.
Mr. Gabriel Epstein is a 68-year-old Israeli male admitted to the cardiac unit after undergoing open-
heart surgery for a coronary artery bypass graft (CABG) caused by blocked vessels in his heart. His
,procedure was invasive; his breastbone was cut, and the chest opened to expose the heart. After the
surgery he is groggy and weak. He is a bachelor and has no family to visit him at the hospital.
Ruth is the nursing student assigned to Mr. Epstein. Her priority nursing goals for him are to maintain
comfort, safety, and hygiene to prevent infection.
2. Mr. Epstein is too groggy to brush his own teeth. Ruth knows that it is important to keep his mouth
clean to prevent infection. When performing oral care for Mr. Epstein, Ruth notices that his tongue is
red and swollen. Which oral condition does he have?
A. Halitosis
B. Glossitis
C. Alopecia
D. Cerumen
Answer: B
Rationale: Glossitis is the condition of an inflamed tongue.
Mr. Gabriel Epstein is a 68-year-old Israeli male admitted to the cardiac unit after undergoing open-
heart surgery for a coronary artery bypass graft (CABG) caused by blocked vessels in his heart. His
procedure was invasive; his breastbone was cut, and the chest opened to expose the heart. After the
surgery he is groggy and weak. He is a bachelor and has no family to visit him at the hospital.
Ruth is the nursing student assigned to Mr. Epstein. Her priority nursing goals for him are to maintain
comfort, safety, and hygiene to prevent infection.
3. Ruth prepares to give Mr. Epstein a bed bath since he is not able to bathe independently. Which of
the following are guidelines that she should follow while giving him a bed bath? (Select all that apply.)
A. Maintain safety.
B. Provide privacy.
C. Maintain warmth.
D. Promote independence.
E. Hydrate skin.
Answer: A, B, C, D
,Rationale: Guidelines for giving a bed bath are to maintain safety, provide privacy, maintain warmth,
promote independence, and anticipate needs.
Mr. Ryan Kelter is a 33-year-old Caucasian who lives in an acute rehabilitation center. He was injured in
a motorcycle accident that caused a spinal cord injury (SCI). As a result of the SCI, he has neurogenic
bladder that prevents him from fully emptying his bladder. Because of this, he needs to be straight
catheterized several times a day.
Beth is the student nurse assigned to Mr. Kelter. She understands the importance of keeping him on his
bladder schedule to prevent a urinary tract infection (UTI).
1. Beth enters Mr. Kelter's room after lunch to perform straight catheterization. List in order the steps
Beth takes to perform straight catheterization on Mr. Kelter.
A. Lubricate the catheter.
B. Clean penis with dominant hand.
C. Apply sterile gloves.
D. Advance catheter into penis.
E. Apply fenestrated drape.
F. Hold penis with nondominant hand.
G. Ask patient to bear down.
H. Coil catheter in dominant hand.
Answer: C, E, A, F, B, H, G, D
Rationale: The steps of straight catheterization are to position the patient, apply sterile gloves, apply the
fenestrated drape, lubricate the catheter, hold the penis with the nondominant hand, clean the penis
with the dominant hand, coil the catheter in the dominant hand, ask the patient to bear down, and
advance the catheter into the penis.
Mr. Ryan Kelter is a 33-year-old Caucasian who lives in an acute rehabilitation center. He was injured in
a motorcycle accident that caused a spinal cord injury (SCI). As a result of the SCI, he has neurogenic
bladder that prevents him from fully emptying his bladder. Because of this, he needs to be straight
catheterized several times a day.
, Beth is the student nurse assigned to Mr. Kelter. She understands the importance of keeping him on his
bladder schedule to prevent a urinary tract infection (UTI).
2. Beth should advance the catheter ________ to _______ inches or until urine flows out of it.
Answer: 7 to 9
Rationale: In an adult male the catheter should be advanced 7 to 9 inches (17-22.5 cm) or until urine
flows out of it.
Mr. Ryan Kelter is a 33-year-old Caucasian who lives in an acute rehabilitation center. He was injured in
a motorcycle accident that caused a spinal cord injury (SCI). As a result of the SCI, he has neurogenic
bladder that prevents him from fully emptying his bladder. Because of this, he needs to be straight
catheterized several times a day.
Beth is the student nurse assigned to Mr. Kelter. She understands the importance of keeping him on his
bladder schedule to prevent a urinary tract infection (UTI).
3. As Beth inserts the catheter into Mr. Kelter's penis, she feels resistance. She should use more force to
guide the catheter through his urethra.
A. True
B. False
Answer: B
Rationale: When resistance is felt while inserting a catheter, withdraw the catheter and do not force it. If
there is resistance to the catheter insertion, have the patient take slow, deep breaths while slowly
inserting the catheter. When urine appears, advance the catheter another 2.5 to 5 cm (1 to 2 inches).
What is the proper position to use for an unresponsive patient during oral care to prevent aspiration?
(Select all that apply.)
1. Prone position
2. Modified left lateral recumbent position
3. Semi-Fowler's position with head to side
4. Trendelenburg position
