Four for the door
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
Inspection, auscultation, percussion, palpation.
Auscultation follows inspection because percussion an...
NURS 113 EXAM QUESTIONS AND
ANSWERS TOP-RATED
Four for the door
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
Inspection, auscultation, percussion, palpation.
Auscultation follows inspection because percussion and palpation can alter the
frequency and intensity of bowel sounds.
How often should normal bowel sounds be heard in each quadrant of the abdomen
5-35 times per minute
Which of the following is an important part of performing an abdominal
assessment?
Explaining each step of the assessment to the patient
What should you do if a patient is ticklish when you are palpating the abdomen?
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
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?
Provide assistance to the bathroom for expulsion of fluid and stool
A nurse is preparing to administer an enema. How can the nurse best facilitate the
insertion of the rectal tube?
Lubricate the first 6.5 to 7.5 cm (2.5 to 3 inches) of the tip of the tube
A nurse is delegating to NAP the administration of an emma for an older adult
patient. The enema order reads, "Enemas until clear." Which statement made by
NAP requires the nurse to follow up?
A. "I'll need help to turn her onto her side."
B. "It may take three or four enemas to achieve a clear return."
C. "I'll test the water temperature in the inside of my own wrist."
D. "The enema will wear her out, so I'll wait until after she ambulates."
B
The nurse has delegated administration of a standard enema for a 72-year-old
patient with constipation. Which statement made by nursing assistive personnel
(NAP) requires the nurse to follow-up?
"I'll instill the solution and then check in on my other patients until I get the call
signal."
Which action would the nurse take to reduce the risk of infection among patients
and staff when administering an enema to an older adult patient with dementia?
Perform hand hygiene before donning gloves.
1. The nurse has delegated to nursing assistive personnel (NAP) the skill of
assisting with a bedpan for a patient who has had discomfort when walking to the
bathroom. Which statement made by the NAP requires the nurse's follow-up?
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 reports that moving is uncomfortable for her. Has she had pain
medication recently?"
D. "The patient told me that she's had problems with hemorrhoids in the past."
B. The NAP is not qualified to determine whether it is appropriate to ambulate a
patient
,2. A patient with a nasogastric tube, an intravenous infusion line, and an indwelling
urinary catheter needs to be placed on the bedpan. Which action would the nurse
take first to ensure the patient's safety?
Obtain help to place the patient in the bed pan
A dependent, confused patient is being given a bedpan. How can the nurse best
ensure the patient's safety?
A. Respond promptly to the call light.
B. Raise the side rails on the bed before leaving the room.
C. Slide one hand under the patient's sacrum to help the patient lift off the bedpan.
D. Check in on the patient every 5 minutes until the bedpan can be removed.
B
The nurse is assisting with a bedpan for a patient who had knee surgery 24 hours
ago. What is the best way for the nurse to maximize comfort while the patient uses
the bedpan?
Elevate the head of the bed to between 30 and 60 degrees
After assisting with a bedpan, the nurse notes the patient's stool is streaked with
bright-red blood. What would the nurse do first?
Ask if the patient has a history of hemorrhoids
What is the nurse's initial action when preparing to change a patient's colostomy
pouching system?
Applying clean gloves
When pouching a patient's colostomy, which action reduces the patient's risk for
injury?
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
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. Wearing clean gloves
C. Avoiding unnecessary changes of the pouching system
Rationale: Each pouching system change increases the risk of irritating the
surrounding skin tissue.
Which initial nursing action would best help the patient learn self-care of a
colostomy pouching system?
A. Giving the patient handouts on self care of a colostomy
B. Allowing the patient to examine 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
D. Giving the patient a handheld mirror to watch the nurse provide care
Which instruction might the nurse give to nursing assistive personnel (NAP)
regarding the care of a patient with a newly established colostomy?
A. "Be sure to pat-dry the skin surrounding the stoma before applying the new
pouch."
B. "Alert me immediately if you see any blood in the fecal matter in the pouch."
C. "Using the stoma guide, cut the pouch opening about one-eighth of an inch
bigger than the stoma."
D. "Remember to change your gloves after cleaning the stoma and the surrounding
skin."
B. No part of pouching a colostomy can be done by a NAP
What is included in the preparation for an assessment of the female genitalia?
A. Having the patient empty the bladder
B. Explaining the exam thoroughly if it is the patient's first exam
C. Laying the head of the table flat
D. Both A and B
D. Both A and B
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