NRSG 2220 Exam 3 Questions With Complete Solutions
A 40-year-old female client reports dull pain in the left breast.
Before examining the client's breasts, using the wedge method,
the nurse places the client in which position? Correct Answers
Dorsal recumbent with the arm of the side being examined
above the head
A client has been prescribed a small-volume enema for
constipation following surgery and asks the nurse how such a
small amount of fluid can lead to a bowel movement. What is
the nurse's best response? Correct Answers "This enema pulls
fluid from the intestine to stimulate defecation."
A client has had a nasogastric tube inserted in preparation for
tube feedings. When developing the client's plan of care, the
nurse would anticipate checking the placement of the tube at
which time? Correct Answers Before administering a
medication through the tube
A client is receiving a continuous tube feeding. Which
accurately describes an aspect of this procedure? Correct
Answers A feeding pump is used for a continuous feeding.
A client with dysphagia prepares to eat dinner. How does the
nurse best help this client? Correct Answers Ensure the head of
the bed is high-Fowler
A health care provider prescribes oxygen for a client at 4 liters
per minute via a nasal cannula after an initial pulse oximeter
reading of 88% on room air. Which is the priority client
,assessment that the nurse should make prior to administering the
oxygen? Correct Answers respiratory rate and effort
A nurse aspirates a small amount of fluid from a client's
nasogastric tube. The nurse determines that the tube is in the
intestines based on the aspirate being which color? Correct
Answers Straw-colored
A nurse caring for a patient who reports frequent constipation
learns the patient uses phosphate and sodium citrate enemas
several times weekly. What education would the nurse provide?
Correct Answers These enemas should be avoided with kidney
failure
A nurse delivers a tray of food to an older client and sets it on
the overbed table. The client shows no interest in the food,
however. Which actions should the nurse take? Select all that
apply. Correct Answers Ask why the client does not want to eat
anything on the tray
Assess the client for signs of depression
Consult a dietician if the problem persists
A nurse enters a client's room to perform a tube feeding. Which
nursing action should be performed first? Correct Answers
Aspirate stomach contents and check pH.
A nurse has just inserted a nasogastric tube in a client. Which
method is most reliable for verifying the correct placement of
the tube? Correct Answers Radiographic confirmation of
position
,A nurse has just received a client's laboratory results and is
reviewing them. Which finding should the nurse recognize as an
indication of malnutrition or malabsorption? Correct Answers
Serum albumin 2.8 g/dL (28 g/L)
A nurse in the emergency department is caring for a client who
had eaten shellfish and is now wheezing. The nurse explains to
the patient that the health care provider has prescribed a
bronchodilator, which will have what action? Correct Answers
Opening narrowed airways and relieving wheezing
A nurse is administering a large-volume cleansing enema to a
patient prior to surgery. When the enema solution is introduced,
the patient reports severe cramping. What nursing intervention
would the nurse perform next? Correct Answers Lowering the
solution container and checking the temperature and flow rate
A nurse is administering a small-volume enema to a client to
relieve fecal impaction. After initiating this action, the client
reports nausea and lightheadedness. The nurse also notes a
decrease in the client's heart rate. What should the nurse do
first? Correct Answers Stop the procedure and monitor client's
heart rate.
A nurse is assessing a patient with COPD who is experiencing
dyspnea. What action will the nurse take first? Correct Answers
Place patient in Fowler position --> elevate head of bed
A nurse is assisting a client with the use of a bedpan. The nurse
understands that which statement about bedpans is true? Correct
, Answers The largest part of a regular bedpan should be placed
under the client's buttocks.
A nurse is assisting a client with the use of a urinal. The nurse
recognizes that which statement about the use of a urinal is true?
Correct Answers Unless contraindicated, nurses should
encourage clients to stand to use a urinal.
A nurse is caring for a client receiving oxygen at 2 liters per
minute via nasal cannula. During the morning assessment, the
nurse notes reddened areas at the top of the ears and neck. What
actions should the nurse take? Select all that apply. Correct
Answers Request a consult by a skin care team to determine
further actions
Apply padding to the tubing that goes over the ears and loosen
neck tubing
Loosen the nasal cannula tubing to ensure the tubing is not too
tight
A nurse is caring for a client who has been prescribed a clear
liquid diet. Which liquid can be included in the client's diet?
Correct Answers Cranberry juice
A nurse is caring for a client who has spontaneous respirations
and needs to have oxygen administered at a FiO2 of 100%.
Which oxygen delivery system should the nurse use? Correct
Answers Nonrebreather mask
A nurse is caring for a patient admitted for acute asthma
exacerbation. The patient reports extreme dyspnea, stating,
"Turn up the oxygen, I'm not getting enough air." Which actions
A 40-year-old female client reports dull pain in the left breast.
Before examining the client's breasts, using the wedge method,
the nurse places the client in which position? Correct Answers
Dorsal recumbent with the arm of the side being examined
above the head
A client has been prescribed a small-volume enema for
constipation following surgery and asks the nurse how such a
small amount of fluid can lead to a bowel movement. What is
the nurse's best response? Correct Answers "This enema pulls
fluid from the intestine to stimulate defecation."
A client has had a nasogastric tube inserted in preparation for
tube feedings. When developing the client's plan of care, the
nurse would anticipate checking the placement of the tube at
which time? Correct Answers Before administering a
medication through the tube
A client is receiving a continuous tube feeding. Which
accurately describes an aspect of this procedure? Correct
Answers A feeding pump is used for a continuous feeding.
A client with dysphagia prepares to eat dinner. How does the
nurse best help this client? Correct Answers Ensure the head of
the bed is high-Fowler
A health care provider prescribes oxygen for a client at 4 liters
per minute via a nasal cannula after an initial pulse oximeter
reading of 88% on room air. Which is the priority client
,assessment that the nurse should make prior to administering the
oxygen? Correct Answers respiratory rate and effort
A nurse aspirates a small amount of fluid from a client's
nasogastric tube. The nurse determines that the tube is in the
intestines based on the aspirate being which color? Correct
Answers Straw-colored
A nurse caring for a patient who reports frequent constipation
learns the patient uses phosphate and sodium citrate enemas
several times weekly. What education would the nurse provide?
Correct Answers These enemas should be avoided with kidney
failure
A nurse delivers a tray of food to an older client and sets it on
the overbed table. The client shows no interest in the food,
however. Which actions should the nurse take? Select all that
apply. Correct Answers Ask why the client does not want to eat
anything on the tray
Assess the client for signs of depression
Consult a dietician if the problem persists
A nurse enters a client's room to perform a tube feeding. Which
nursing action should be performed first? Correct Answers
Aspirate stomach contents and check pH.
A nurse has just inserted a nasogastric tube in a client. Which
method is most reliable for verifying the correct placement of
the tube? Correct Answers Radiographic confirmation of
position
,A nurse has just received a client's laboratory results and is
reviewing them. Which finding should the nurse recognize as an
indication of malnutrition or malabsorption? Correct Answers
Serum albumin 2.8 g/dL (28 g/L)
A nurse in the emergency department is caring for a client who
had eaten shellfish and is now wheezing. The nurse explains to
the patient that the health care provider has prescribed a
bronchodilator, which will have what action? Correct Answers
Opening narrowed airways and relieving wheezing
A nurse is administering a large-volume cleansing enema to a
patient prior to surgery. When the enema solution is introduced,
the patient reports severe cramping. What nursing intervention
would the nurse perform next? Correct Answers Lowering the
solution container and checking the temperature and flow rate
A nurse is administering a small-volume enema to a client to
relieve fecal impaction. After initiating this action, the client
reports nausea and lightheadedness. The nurse also notes a
decrease in the client's heart rate. What should the nurse do
first? Correct Answers Stop the procedure and monitor client's
heart rate.
A nurse is assessing a patient with COPD who is experiencing
dyspnea. What action will the nurse take first? Correct Answers
Place patient in Fowler position --> elevate head of bed
A nurse is assisting a client with the use of a bedpan. The nurse
understands that which statement about bedpans is true? Correct
, Answers The largest part of a regular bedpan should be placed
under the client's buttocks.
A nurse is assisting a client with the use of a urinal. The nurse
recognizes that which statement about the use of a urinal is true?
Correct Answers Unless contraindicated, nurses should
encourage clients to stand to use a urinal.
A nurse is caring for a client receiving oxygen at 2 liters per
minute via nasal cannula. During the morning assessment, the
nurse notes reddened areas at the top of the ears and neck. What
actions should the nurse take? Select all that apply. Correct
Answers Request a consult by a skin care team to determine
further actions
Apply padding to the tubing that goes over the ears and loosen
neck tubing
Loosen the nasal cannula tubing to ensure the tubing is not too
tight
A nurse is caring for a client who has been prescribed a clear
liquid diet. Which liquid can be included in the client's diet?
Correct Answers Cranberry juice
A nurse is caring for a client who has spontaneous respirations
and needs to have oxygen administered at a FiO2 of 100%.
Which oxygen delivery system should the nurse use? Correct
Answers Nonrebreather mask
A nurse is caring for a patient admitted for acute asthma
exacerbation. The patient reports extreme dyspnea, stating,
"Turn up the oxygen, I'm not getting enough air." Which actions
