# NR 224 Fundamentals of Nursing Final
Examination
## Comprehensive Practice Questions with
Rationales
---
**Question 1**
A nurse is preparing to insert a nasogastric tube for a client who is alert and oriented. Which of the
following actions should the nurse take first?
A. Measure the length of the tube from the client's nose to the xiphoid process
B. Place the client in a high Fowler's position
C. Apply topical anesthetic to the nares
D. Assess the client's gag reflex
💫RATIONALE✔️✔️: The nurse should first place the client in high Fowler's position to facilitate passage of
the tube and reduce the risk of aspiration.
💫ANSWER✔️✔️: B. Place the client in a high Fowler's position
---
**Question 2**
A client has an order for 500 mL of lactated Ringer's solution to be infused over 4 hours. The drop factor
is 20 gtt/mL. What is the drip rate in drops per minute?
,A. 21 gtt/min
B. 31 gtt/min
C. 42 gtt/min
D. 62 gtt/min
💫RATIONALE✔️✔️: 500 mL/4 hours = 125 mL/hour; 125 mL/hour × 20 gtt/mL = 2500 gtt/hour; 2500/60
minutes = 41.6 gtt/min (round to 42 gtt/min).
💫ANSWER✔️✔️: C. 42 gtt/min
---
**Question 3**
A nurse is providing care to a client who is on fall precautions. Which of the following interventions
should the nurse include in the plan of care?
A. Keep all four side rails up at all times
B. Place the bed in the lowest position
C. Apply wrist restraints during the night
D. Keep the room completely dark for sleep
💫RATIONALE✔️✔️: Placing the bed in the lowest position reduces the risk of injury if the client attempts
to get out of bed independently.
💫ANSWER✔️✔️: B. Place the bed in the lowest position
---
,**Question 4**
A client is 1 day post-operative and has not had a bowel movement. Which of the following nursing
interventions should the nurse implement first?
A. Administer a stool softener
B. Assess the client's usual bowel pattern
C. Encourage increased fluid intake
D. Provide privacy for the client
💫RATIONALE✔️✔️: Assessing the client's usual bowel pattern provides baseline data to determine if the
current situation is abnormal for the client.
💫ANSWER✔️✔️: B. Assess the client's usual bowel pattern
---
**Question 5**
A nurse is preparing to administer an enema to a client. Which of the following actions is correct?
A. Position the client in the dorsal recumbent position
B. Insert the rectal tube 3-4 inches into the rectum
C. Administer the solution at room temperature
D. Hold the enema bag 12 inches above the anus
💫RATIONALE✔️✔️: The enema bag should be held 12-18 inches above the anus to allow for proper flow
by gravity.
💫ANSWER✔️✔️: D. Hold the enema bag 12 inches above the anus
, ---
**Question 6**
A client is receiving continuous tube feeding through a nasogastric tube. Which of the following actions
should the nurse take to prevent aspiration?
A. Elevate the head of the bed to 30 degrees
B. Check residual volume every 8 hours
C. Flush the tube with 50 mL of water every 4 hours
D. Administer the feeding at room temperature
💫RATIONALE✔️✔️: Elevating the head of the bed to 30 degrees or more reduces the risk of aspiration
during tube feeding.
💫ANSWER✔️✔️: A. Elevate the head of the bed to 30 degrees
---
**Question 7**
A client is complaining of pain at the site of a peripheral IV. The nurse notes redness, warmth, and a
palpable cord along the vein. Which of the following complications is most likely?
A. Infiltration
B. Phlebitis
C. Extravasation
D. Infection
Examination
## Comprehensive Practice Questions with
Rationales
---
**Question 1**
A nurse is preparing to insert a nasogastric tube for a client who is alert and oriented. Which of the
following actions should the nurse take first?
A. Measure the length of the tube from the client's nose to the xiphoid process
B. Place the client in a high Fowler's position
C. Apply topical anesthetic to the nares
D. Assess the client's gag reflex
💫RATIONALE✔️✔️: The nurse should first place the client in high Fowler's position to facilitate passage of
the tube and reduce the risk of aspiration.
💫ANSWER✔️✔️: B. Place the client in a high Fowler's position
---
**Question 2**
A client has an order for 500 mL of lactated Ringer's solution to be infused over 4 hours. The drop factor
is 20 gtt/mL. What is the drip rate in drops per minute?
,A. 21 gtt/min
B. 31 gtt/min
C. 42 gtt/min
D. 62 gtt/min
💫RATIONALE✔️✔️: 500 mL/4 hours = 125 mL/hour; 125 mL/hour × 20 gtt/mL = 2500 gtt/hour; 2500/60
minutes = 41.6 gtt/min (round to 42 gtt/min).
💫ANSWER✔️✔️: C. 42 gtt/min
---
**Question 3**
A nurse is providing care to a client who is on fall precautions. Which of the following interventions
should the nurse include in the plan of care?
A. Keep all four side rails up at all times
B. Place the bed in the lowest position
C. Apply wrist restraints during the night
D. Keep the room completely dark for sleep
💫RATIONALE✔️✔️: Placing the bed in the lowest position reduces the risk of injury if the client attempts
to get out of bed independently.
💫ANSWER✔️✔️: B. Place the bed in the lowest position
---
,**Question 4**
A client is 1 day post-operative and has not had a bowel movement. Which of the following nursing
interventions should the nurse implement first?
A. Administer a stool softener
B. Assess the client's usual bowel pattern
C. Encourage increased fluid intake
D. Provide privacy for the client
💫RATIONALE✔️✔️: Assessing the client's usual bowel pattern provides baseline data to determine if the
current situation is abnormal for the client.
💫ANSWER✔️✔️: B. Assess the client's usual bowel pattern
---
**Question 5**
A nurse is preparing to administer an enema to a client. Which of the following actions is correct?
A. Position the client in the dorsal recumbent position
B. Insert the rectal tube 3-4 inches into the rectum
C. Administer the solution at room temperature
D. Hold the enema bag 12 inches above the anus
💫RATIONALE✔️✔️: The enema bag should be held 12-18 inches above the anus to allow for proper flow
by gravity.
💫ANSWER✔️✔️: D. Hold the enema bag 12 inches above the anus
, ---
**Question 6**
A client is receiving continuous tube feeding through a nasogastric tube. Which of the following actions
should the nurse take to prevent aspiration?
A. Elevate the head of the bed to 30 degrees
B. Check residual volume every 8 hours
C. Flush the tube with 50 mL of water every 4 hours
D. Administer the feeding at room temperature
💫RATIONALE✔️✔️: Elevating the head of the bed to 30 degrees or more reduces the risk of aspiration
during tube feeding.
💫ANSWER✔️✔️: A. Elevate the head of the bed to 30 degrees
---
**Question 7**
A client is complaining of pain at the site of a peripheral IV. The nurse notes redness, warmth, and a
palpable cord along the vein. Which of the following complications is most likely?
A. Infiltration
B. Phlebitis
C. Extravasation
D. Infection
