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NURS 113 Exam Questions And Accurate Answers
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NURS 113 Exam Questions And Accurate AnswersFour for the door - Answer The patient's bed should be locked in place, at the lowest
level, with the call light in reach, and both side rails UP
What is the correct order for abdominal assessment - Answer Inspection, auscultation,
percussion, palpation.
Auscultation follows inspection because percussion and palpation can alter the
frequency and intensity of bowel sounds.
How often does one hear normal bowel sounds in each quadrant of the abdomen?
Answer 5-35 times per minute
Which of the following is a significant component of carrying out an abdominal
assessment? Response Explaining each step of the assessment to the patient
If a patient is ticklish when you are palpating the abdomen, what would you do?
Response Place your hand over the patient's hand during palpation.
Moderate and deep palpation of the abdomen:
A. May cause tenderness
B. Should not detect masses
C. May locate the margins of the liver
D. All of the above - Answer D. All of the above
Which action would a nurse take to ensure the safety of an older adult patient who has
,received an enema? - Answer Provide assistance to the bathroom for expulsion of fluid
and stool
A nurse is going to administer an enema. The nurse should do which of the following to
best facilitate the insertion of the rectal tube? Answer Lubricate the first 6.5 to 7.5 cm
(2.5 to 3 inches) of the tip of the tube
The nurse is delegating to NAP the administration of an enema to an older adult patient.
The enema order states, "Enemas until clear." Which of the following statements by NAP
would necessitate follow-up by the nurse?
A. "I will have to get someone to assist me to turn her onto her side."
B. "Three or four enemas may be required to get a clear return."
C. "I will check the temperature of the water in the inside of my own wrist."
D. "The enema will tire her out, and I will wait until after she has ambulated." - ANS B
The nurse has delegated the administration of a routine enema to a 72-year-old patient
who has constipation. Which statement by NAP would the nurse need to clarify? - ANS
"I'll instill the solution and then check in on my other patients until I get the call signal."
Which of the following nursing actions would minimize the risk for infection for both
clients and staff while administering an enema to a dementia client? SELECT Perform
hand hygiene before putting on gloves.
1. The nurse has delegated to NAP the skill of assisting with a bedpan for a patient who
has demonstrated discomfort when ambulating to the bathroom. Which of the following
statements by the NAP requires follow-up by the nurse?
A. "Do you still need a stool sample for the lab?"
B. "If I can get someone to help, I'll walk her to the bathroom."
C. "The patient states that it is uncomfortable for her to move around. Has she had pain
medication recently?"
D. "The patient related to me that she has had hemorrhoids in the past." - Response B
The NAP is not qualified to make a judgment call regarding a determination of
appropriateness in ambulating a patient
,2. The patient has a nasogastric tube, an intravenous infusion line, and an indwelling
urinary catheter and needs to be placed on the bedpan. Which action would the nurse
take first for the safety of the patient? - Answer Get assistance to put the patient in the
bed pan
A bedpan is being provided for a dependent, confused patient. What can the nurse do to
best provide for the patient's safety?
A. Respond to the call light without delay.
B. Raise the side rails of the bed before exiting the room.
C. Slip one hand under the patient's sacrum to facilitate the patient lifting off the
bedpan.
D. Check on the patient every 5 minutes until the bedpan can be removed. -Answer B
The nurse is caring for a client who underwent knee surgery 24 hours ago. The nurse
must provide the client with a bedpan. Which of the following actions best promotes
comfort for this client while on the bedpan? - Answer Raise the head of the bed 30 to 60
degrees
After helping the patient with a bedpan, the nurse observes that the patient's stool is
streaked with bright-red blood. What is the first thing the nurse would do? - Answer Ask
if the patient has a history of hemorrhoids
What does the nurse do first when planning to change a patient's colostomy pouching
system? - Answer Putting on clean gloves
When pouching a patient's colostomy, which of the following actions minimizes the risk
of injury to the patient?
A. Measuring output when emptying the contents of the pouch
B. Maintaining the patient's bowel elimination function
C. Promoting the patient's autonomy with bowel elimination care
, D. Protecting the skin from irritation caused by fecal drainage - Answer D
When changing the pouching system, which routine step best minimizes irritation of the
skin surrounding the stoma?
A. Using adhesive remover
B. Emptying the ostomy bag only when full
C. Avoiding unnecessary changes of the pouching system
D. Putting on clean gloves - Answer C. Making no unnecessary changes of the pouching
system
Rationale: The greater the number of pouching system changes, the greater the risk of
irritating the tissue around the pouch.
Which first nursing action would most contribute to the patient's learning self-care of a
colostomy pouching system?
A. Providing the patient with handouts related to self-care of a colostomy
B. Allowing the patient to view an ostomy device
C. Identifying a family member who can participate in the ostomy appliance process
D. Giving the patient a handheld mirror to watch the nurse provide care - Answer D.
Giving the patient a handheld mirror to watch the nurse provide care
What is an instruction that the nurse might give to the nursing assistive personnel (NAP)
while caring for a patient with a newly established colostomy?
A. "Make sure that the skin around the stoma is patted dry before applying the new
pouch."
B. "Call me immediately if you have blood in the stool you see in the pouch."
C. "Using the guide on the stoma, cut the opening of the pouch about one-eighth of an
inch larger than the stoma."
D. "Remember to change your gloves after cleaning the stoma and the surrounding
skin." - Answer B. No part of pouching a colostomy can be done by a NAP
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