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NUR 3225L Adult Health Clinical check-offs, care plan Questions and Correct Answers (Ver, Exams of Nursing

NUR 3225L Adult Health Clinical check-offs, care plan Questions and Correct Answers (Verified Answers) with Rationales 2025

Typology: Exams

2024/2025

Available from 06/23/2025

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NUR 3225L Adult Health Clinical
check-offs, care plan Questions and
Correct Answers (Verified Answers)
with Rationales 2025
1. Which of the following is the most appropriate nursing intervention before
performing a sterile dressing change?
a. Clean the wound with sterile saline
b. Perform hand hygiene and don sterile gloves
c. Administer prescribed pain medication
d. Remove old dressing without gloves
Performing hand hygiene and donning sterile gloves maintains aseptic technique and
prevents infection.
2. What is the primary goal of a nursing care plan?
a. To increase hospital efficiency
b. To provide individualized patient-centered care
c. To assist physicians with treatment
d. To reduce nurse workload
Care plans are tools used to tailor nursing interventions to the unique needs of each
patient.
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NUR 3225L Adult Health Clinical

check-offs, care plan Questions and

Correct Answers (Verified Answers)

with Rationales 2025

  1. Which of the following is the most appropriate nursing intervention before performing a sterile dressing change? a. Clean the wound with sterile saline b. Perform hand hygiene and don sterile gloves c. Administer prescribed pain medication d. Remove old dressing without gloves Performing hand hygiene and donning sterile gloves maintains aseptic technique and prevents infection.
  2. What is the primary goal of a nursing care plan? a. To increase hospital efficiency b. To provide individualized patient-centered care c. To assist physicians with treatment d. To reduce nurse workload Care plans are tools used to tailor nursing interventions to the unique needs of each patient.
  1. During tracheostomy care, the nurse should first: a. Remove the old inner cannula b. Explain the procedure to the patient c. Suction the tracheostomy d. Clean the outer cannula Patient education helps reduce anxiety and ensures cooperation.
  2. Which of the following is a subjective assessment finding? a. Blood pressure 142/ b. Respiratory rate 20 c. “I feel dizzy” d. Warm, dry skin Subjective data is what the patient reports, not what is observed.
  3. A nursing diagnosis must always include: a. A medical diagnosis b. A problem, etiology, and signs/symptoms c. A doctor's order d. Only observable behaviors The standard nursing diagnosis format is the PES (Problem, Etiology, Symptoms) structure.

a. Weekly b. As the patient’s condition changes c. Every 48 hours d. Before physician rounds Care plans are living documents that evolve with the patient's condition.

  1. When evaluating the effectiveness of a care plan, the nurse should: a. Reassess the doctor’s plan b. Check if documentation is complete c. Determine if patient goals were met d. Review medication list Evaluating goals helps determine the success of interventions.
  2. Which lab value would be most important to check before administering furosemide? a. BUN b. Potassium c. Glucose d. Hemoglobin Furosemide can cause hypokalemia; potassium must be monitored closely.
  3. For a patient with oxygen saturation at 85%, what is the priority action?

a. Document the reading b. Recheck in 10 minutes c. Apply supplemental oxygen d. Elevate the legs Oxygen saturation <90% requires immediate intervention to prevent hypoxia.

  1. Which of the following best describes a nursing intervention? a. Starting an IV b. Turning the patient every 2 hours c. Ordering labs d. Diagnosing pneumonia Nursing interventions are actions taken independently to meet patient goals.
  2. The care plan for a post-op patient includes "Risk for infection." Which intervention is most appropriate? a. Administer all medications b. Maintain sterile technique during dressing changes c. Encourage patient to sleep d. Limit fluid intake Sterile technique helps prevent pathogens from entering wounds.
  3. Which action should the nurse take first when performing wound irrigation?

a. Inform family b. Report to charge nurse and document findings c. Order new dressings d. Massage the area Reporting and documentation are essential for legal and care continuity.

  1. Which finding would you expect to see in a care plan under "Outcomes"? a. Monitor vital signs b. Patient will ambulate 100 feet with assistance by end of shift c. Apply oxygen at 2L/min d. Assess pain scale Outcomes are measurable goals used to evaluate care.
  2. Which is the priority action if a patient has a blood glucose of 42 mg/dL? a. Notify the physician b. Give juice or glucose tabs c. Document the level d. Recheck in 30 minutes Immediate glucose replacement is critical to prevent loss of consciousness.
  3. Which is a long-term care plan goal? a. Patient verbalizes pain relief within 30 minutes b. Patient will remain free from pressure ulcers during hospital stay

c. Blood pressure is 120/80 this morning d. Administer meds as prescribed Long-term goals reflect ongoing outcomes to achieve during hospitalization.

  1. Which intervention supports the nursing diagnosis "Risk for Falls"? a. Provide soft diet b. Keep bed in lowest position with call light in reach c. Restrict visitors d. Apply sequential compression devices Environmental safety measures reduce fall risk.
  2. When preparing for clinical check-offs, what is the best way to ensure safety? a. Ask for help from classmates b. Read the textbook c. Practice skills in the lab using the checklist d. Observe other nurses Hands-on practice reinforces competency and confidence.
  3. Which assessment finding requires immediate action? a. Urine output 400 mL in 8 hours b. BP 134/

c. Administer oxygen as needed d. Chest x-ray ordered Nursing diagnoses focus on patient responses, not medical conditions.

  1. What is the first step when entering a patient’s room to perform a procedure? a. Check the patient’s vitals b. Introduce yourself and confirm identity c. Gather supplies d. Don gloves Identifying yourself and the patient ensures communication and safety.
  2. Which technique reduces infection during a Foley catheter insertion? a. Use clean gloves b. Apply lubricant to entire catheter c. Maintain strict sterile technique throughout d. Clamp the catheter for one hour post-insertion Sterile technique prevents contamination during invasive procedures.
  3. Which of the following is most appropriate for documenting wound assessment? a. “Looks okay.” b. “3 cm x 2 cm red wound with serous drainage and no odor.”

c. “Healing slowly.” d. “Bad wound.” Documentation must be objective, specific, and measurable.

  1. Which of the following is a clinical priority? a. Patient needs assistance with feeding b. Patient is anxious c. Patient is having difficulty breathing d. Patient is waiting for discharge papers Airway and breathing issues take top priority in patient care.
  2. What is a measurable outcome? a. Patient is feeling better b. Patient will ambulate 3 times a day by Friday c. Patient is happy d. Patient understands care plan Measurable outcomes are clear and quantifiable.
  3. When administering IV medications, what should be assessed first? a. The patient’s height b. IV patency and site condition c. The patient’s pain level d. Time of last dose
  1. What is the most accurate method to assess fluid balance? a. Asking about thirst b. Checking skin turgor c. Monitoring daily weight d. Observing for dry lips Weight changes reflect fluid gain or loss with high accuracy.
  2. Which action is required before administering blood? a. Ask patient if they’ve received blood before b. Check the blood for clots c. Verify with a second licensed nurse d. Start a second IV line Two licensed personnel must verify blood products for safety.
  3. If a patient develops hives during IV antibiotic administration, the nurse should: a. Administer diphenhydramine b. Increase IV rate c. Stop the infusion and notify the provider d. Flush with saline Stopping the infusion prevents worsening of an allergic reaction.
  1. Which of the following indicates an expected outcome of wound healing? a. Foul-smelling drainage b. Increased redness c. Granulation tissue formation d. Pain score of 9 Granulation tissue is a sign of healthy wound healing.
  2. What is the priority nursing action after removing a central line? a. Apply a cold compress b. Send tip for culture c. Apply pressure and an occlusive dressing d. Allow the site to air dry An occlusive dressing helps prevent air embolism after removal.
  3. The nursing student prepares to give a medication but realizes the dose seems too high. The student should: a. Give the medication and document b. Ask another student c. Recheck the MAR and verify with the instructor or nurse d. Call the pharmacy directly Always verify questionable orders before proceeding to ensure patient safety.
  1. What should be included in discharge teaching for a patient with a new colostomy? a. Eat only liquids for life b. How to perform proper stoma care c. Avoid showers d. Never touch the stoma Teaching stoma care promotes independence and infection prevention.
  2. Which is a correct entry for legal documentation? a. “Pt is acting weird.” b. “Patient states, ‘I feel dizzy’ at 1440.” c. “Seems upset.” d. “I think the wound looks worse.” Documentation must be objective, time-stamped, and use patient quotes when applicable.
  3. Which patient should the nurse assess first? a. BP 148/ b. Pink urine after Foley insertion c. Post-op patient reporting chest pain d. Patient requesting sleep aid Chest pain in a post-op patient may indicate a life-threatening complication like PE.
  1. What is the best indicator that a nursing intervention was effective? a. Nurse feels confident b. Patient meets the set outcome or goal c. Medication was given d. Documentation is complete Goal achievement reflects whether the intervention met its purpose.
  2. Before initiating enteral feeding through a PEG tube, the nurse must: a. Warm the formula b. Verify tube placement and residual volume c. Add medication to the formula d. Flush with cold water Tube placement and residual checks prevent aspiration and ensure safe feeding.