NR224 Exam 3 Actual Exam Style V1 | NR
224 Fundamentals - Skills | Chamberlain
1. A nurse is assessing a client’s IV site and notes coolness, pallor, and swelling. Which of the
following conditions should the nurse suspect?
A. Infiltration
B. Phlebitis
C. Extravasation
D. Hematoma
Answer: A
Rationale: Infiltration occurs when non-vesicant IV fluid leaks into the surrounding tissue,
causing the skin to feel cool and appear swollen. The nurse must stop the infusion and
remove the catheter immediately to prevent further tissue damage. Elevating the affected
limb can help facilitate the reabsorption of the fluid.
2. When staging a pressure injury, the nurse observes full-thickness skin loss where adipose
tissue is visible, but bone and muscle are not. Which stage is this?
A. Stage 1
B. Stage 3
C. Stage 2
,D. Stage 4
Answer: B
Rationale: A Stage 3 pressure injury involves full-thickness loss of skin with visible
subcutaneous fat. It is distinguished from Stage 4 because it does not yet expose bone,
tendon, or muscle. Proper documentation includes measuring the wound size and
assessing for any undermining.
3. A nurse is preparing to verify the placement of a newly inserted nasogastric (NG) tube.
Which method is the gold standard for verification?
A. Aspiration of gastric contents
B. Radiographic X-ray
C. Auscultation of air bolus
D. Testing the pH of aspirate
Answer: B
Rationale: Radiographic imaging is the only definitive method to confirm the tip of the NG
tube is in the stomach before starting feedings. While pH testing is a helpful bedside tool, it
is not as reliable as an X-ray. Auscultation is no longer recommended as a primary method
of verification due to safety concerns.
4. A nurse is performing sterile wound care. Which action would result in a break in the
sterile technique?
A. Keeping sterile objects within the field of vision
, B. Opening a sterile package away from the body
C. Reaching over the sterile field to pick up a gauze
D. Maintaining a 1-inch border around the sterile field
Answer: C
Rationale: Reaching over a sterile field contaminates it because microorganisms can drop
from the nurse’s sleeves or skin onto the field. The nurse should always work from the
sides or front without crossing over the sterile area. Any item that falls outside the 1-inch
border is also considered unsterile.
5. A nurse is caring for a client with Clostridioides difficile (C. diff). Which hand hygiene
practice is required?
A. Using alcohol-based hand sanitizer
B. Using chlorhexidine wipes
C. Washing hands with soap and water
D. Wearing double gloves at all times
Answer: C
Rationale: C. diff spores are resistant to alcohol-based sanitizers, so mechanical friction
with soap and water is necessary to remove them from the skin. The nurse should wash
hands thoroughly after every contact with the client or their environment. This is a critical
component of contact-plus precautions.
224 Fundamentals - Skills | Chamberlain
1. A nurse is assessing a client’s IV site and notes coolness, pallor, and swelling. Which of the
following conditions should the nurse suspect?
A. Infiltration
B. Phlebitis
C. Extravasation
D. Hematoma
Answer: A
Rationale: Infiltration occurs when non-vesicant IV fluid leaks into the surrounding tissue,
causing the skin to feel cool and appear swollen. The nurse must stop the infusion and
remove the catheter immediately to prevent further tissue damage. Elevating the affected
limb can help facilitate the reabsorption of the fluid.
2. When staging a pressure injury, the nurse observes full-thickness skin loss where adipose
tissue is visible, but bone and muscle are not. Which stage is this?
A. Stage 1
B. Stage 3
C. Stage 2
,D. Stage 4
Answer: B
Rationale: A Stage 3 pressure injury involves full-thickness loss of skin with visible
subcutaneous fat. It is distinguished from Stage 4 because it does not yet expose bone,
tendon, or muscle. Proper documentation includes measuring the wound size and
assessing for any undermining.
3. A nurse is preparing to verify the placement of a newly inserted nasogastric (NG) tube.
Which method is the gold standard for verification?
A. Aspiration of gastric contents
B. Radiographic X-ray
C. Auscultation of air bolus
D. Testing the pH of aspirate
Answer: B
Rationale: Radiographic imaging is the only definitive method to confirm the tip of the NG
tube is in the stomach before starting feedings. While pH testing is a helpful bedside tool, it
is not as reliable as an X-ray. Auscultation is no longer recommended as a primary method
of verification due to safety concerns.
4. A nurse is performing sterile wound care. Which action would result in a break in the
sterile technique?
A. Keeping sterile objects within the field of vision
, B. Opening a sterile package away from the body
C. Reaching over the sterile field to pick up a gauze
D. Maintaining a 1-inch border around the sterile field
Answer: C
Rationale: Reaching over a sterile field contaminates it because microorganisms can drop
from the nurse’s sleeves or skin onto the field. The nurse should always work from the
sides or front without crossing over the sterile area. Any item that falls outside the 1-inch
border is also considered unsterile.
5. A nurse is caring for a client with Clostridioides difficile (C. diff). Which hand hygiene
practice is required?
A. Using alcohol-based hand sanitizer
B. Using chlorhexidine wipes
C. Washing hands with soap and water
D. Wearing double gloves at all times
Answer: C
Rationale: C. diff spores are resistant to alcohol-based sanitizers, so mechanical friction
with soap and water is necessary to remove them from the skin. The nurse should wash
hands thoroughly after every contact with the client or their environment. This is a critical
component of contact-plus precautions.
