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NURS 236 Final questions with correct answers
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NURS 236 Final questions with correct answers
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NURS 236 FinalWhich of the following items of subjective client data would be documented in the medical record by the
nurse?
a. Client's face is pale
b. Cervical lymph nodes are palpable
c. Nursing assistant reports client refused lunch
d. Client feel nauseated - correct answer ✔✔d
The client reports nausea and constipation. Which of the following would be the priority nursing action?
a. Collect a stool sample
b. Complete an abdominal assessment
c. Administer an anti-nausea medication
d. Notify the physician - correct answer ✔✔b
A nurse concludes that the patient's elevated temperature, pulse and respirations are significant. Which
step of the nursing process is being used when the nurse comes to this conclusion?
a.Implementation
b.Assessment
c.Evaluation
d.Analysis - correct answer ✔✔d
The most effective method of evaluating a patient' s pain level is to:
a.Ask the patient where he or she feels the pain.
b.Select a tool to measure pain based on the patient's preference and cognitive level.
c.Observe the non verbal cues to pain level.
d.Determine if the pain medication ordered is actually relieving the patient's pain. - correct answer ✔✔b
,A registered nurse RN is precepting a new graduate nurse while she is administering the feeding via NGT
for patient with stroke and has difficulty swallowing. Which of the following new nurse actions reflect
the need of further education?
a.Warm the feeding formula to room temperature.
b.Aspirate the stomach contents to determine the amount of residual.
c.Elevate the head of the bed 15 degrees after feeding
d.Irrigate feeding tube with sterile water after feeding - correct answer ✔✔c
Which patient would benefit from a Nasogastric Tube?
a.A patient with Congestive Heart Failure
b.A patient who had a left leg amputation
c.A stroke victim who failed their swallow evaluation
d.A patient with a Platelet count of 50 - correct answer ✔✔c
You just inserted a Nasogastric tube. Which of the following is not a correct way to check correct
placement of the tube?
a. Administering a 100cc Water flush and assessing for patient coughing
b. Following the physician order for an X-ray to confirm placement
c. Checking pH of GI contents to be 5 or less
d. Obtaining a sample of GI contents through the tube by aspirating - correct answer ✔✔a
Which of the following accurately describes the greatest risk related to having a feeding tube?
A) Electrolyte imbalance
B) Fluid volume overload
C) Infection
D) Aspiration - correct answer ✔✔d
When irrigating a colostomy the nurse uses a cone that fits properly to prevent:
a.Introducing air into the colon
b. Leaking the solution around the stoma
, c.Administering the solution too rapidly
d.Introducing of bacteria from the stoma - correct answer ✔✔b
Which of the following would be a common nursing diagnosis for patient with a colostomy?
a. Disturbed body image
b. Constipation
c. Delayed growth and development
d. Excess fluid volume - correct answer ✔✔a
______ in stool is blood that his hidden in the specimen or cannot be seen on gross examination. Can be
detected with simple screening tests. - correct answer ✔✔occult blood
In what order should nurse perform a bowel assessment ?
a.Inspection, auscultation, percussion, palpation
b.Inspection, percussion, auscultation, palpation
c.Inspection, percussion, palpation, auscultation
d. Auscultation, inspection, percussion, palpation - correct answer ✔✔a
In the presence of the RN, a physician askes the LPN to remove the sutures from the incision before the
client is discharged. The initial response to the physician should be:
a.LPNs cannot remove the sutures; the RN will do it.
b.Please write the order and the sutures will be removed.
c.We will remove them right now.
d.The LPN will get the statures removal set for you because she is not allowed to remove statures. -
correct answer ✔✔b
•A new graduate Registered nurse RN has been assigned to work in the subacute nursing unit. The nurse
has the help of two UAPs to care for 15 clients. When delegating client care, what is the most important
concept for the nurse to keep in mind?
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