NR224 Exam 3 Actual Exam Style V2 | NR
224 Fundamentals - Skills | Chamberlain
1. A nurse is preparing to perform nasopharyngeal suctioning for a patient. Which action
should the nurse take first?
A. Insert the catheter into the naris during inspiration.
B. Assess the patient’s pulse oximetry and heart rate.
C. Apply suction while inserting the catheter.
D. Lubricate the tip of the catheter with petroleum jelly.
Answer: B
Rationale: Prior to any suctioning procedure, the nurse must establish a baseline for the
patient’s respiratory and cardiovascular status. This allows the nurse to monitor for
complications such as hypoxia or bradycardia during the procedure. Assessing the patient
first ensures the intervention is necessary and safe.
2. Which oxygen delivery device provides the highest concentration of oxygen (FiO2) to a
spontaneously breathing patient?
A. Non-rebreather mask at 15 L/min
B. Simple face mask at 10 L/min
C. Venturi mask at 40%
,D. Nasal cannula at 6 L/min
Answer: A
Rationale: A non-rebreather mask with a reservoir bag can deliver between 60% and 90%
oxygen when the flow rate is set between 10-15 L/min. This is much higher than the 44%
maximum of a nasal cannula or the 60% maximum of a simple mask. The nurse must
ensure the reservoir bag remains inflated to prevent the patient from inhaling room air.
3. A nurse is caring for a patient with a Stage 3 pressure injury. How should the nurse
describe this wound in the medical record?
A. Non-blanchable erythema of intact skin.
B. Partial-thickness skin loss with exposed dermis.
C. Full-thickness skin loss with visible adipose tissue.
D. Full-thickness skin loss with exposed bone and tendon.
Answer: C
Rationale: A Stage 3 pressure injury involves full-thickness loss of skin, where adipose
(fat) is visible in the ulcer. Granulation tissue and epibole (rolled wound edges) are often
present, but bone, tendon, and muscle are not yet exposed. If muscle or bone were visible, it
would be classified as Stage 4.
4. The nurse is administering a large-volume cleansing enema. If the patient complains of
abdominal cramping, what is the priority nursing action?
A. Lower the enema container to slow the rate of flow.
, B. Stop the procedure and notify the provider.
C. Raise the enema container to finish the procedure faster.
D. Instruct the patient to hold their breath and bear down.
Answer: A
Rationale: Abdominal cramping during an enema is often caused by the rapid distention of
the colon. By lowering the container, the nurse slows the flow rate, which usually alleviates
the cramping and allows the patient to tolerate the volume. Stopping the procedure
completely is not necessary unless the patient’s condition significantly worsens.
5. A patient is receiving continuous enteral feedings through a nasogastric (NG) tube. Which
nursing action is most effective in preventing aspiration?
A. Checking gastric residual volumes every 12 hours.
B. Verifying tube placement by auscultating an air bolus.
C. Flushing the tube with 30 mL of water before and after feedings.
D. Keeping the head of the bed elevated to at least 30 to 45 degrees.
Answer: D
Rationale: Maintaining the head of the bed (HOB) at 30 to 45 degrees uses gravity to keep
the feeding in the stomach and reduce the risk of reflux and aspiration. This is a primary
safety intervention for any patient with an enteral tube. While residual checks and flushing
224 Fundamentals - Skills | Chamberlain
1. A nurse is preparing to perform nasopharyngeal suctioning for a patient. Which action
should the nurse take first?
A. Insert the catheter into the naris during inspiration.
B. Assess the patient’s pulse oximetry and heart rate.
C. Apply suction while inserting the catheter.
D. Lubricate the tip of the catheter with petroleum jelly.
Answer: B
Rationale: Prior to any suctioning procedure, the nurse must establish a baseline for the
patient’s respiratory and cardiovascular status. This allows the nurse to monitor for
complications such as hypoxia or bradycardia during the procedure. Assessing the patient
first ensures the intervention is necessary and safe.
2. Which oxygen delivery device provides the highest concentration of oxygen (FiO2) to a
spontaneously breathing patient?
A. Non-rebreather mask at 15 L/min
B. Simple face mask at 10 L/min
C. Venturi mask at 40%
,D. Nasal cannula at 6 L/min
Answer: A
Rationale: A non-rebreather mask with a reservoir bag can deliver between 60% and 90%
oxygen when the flow rate is set between 10-15 L/min. This is much higher than the 44%
maximum of a nasal cannula or the 60% maximum of a simple mask. The nurse must
ensure the reservoir bag remains inflated to prevent the patient from inhaling room air.
3. A nurse is caring for a patient with a Stage 3 pressure injury. How should the nurse
describe this wound in the medical record?
A. Non-blanchable erythema of intact skin.
B. Partial-thickness skin loss with exposed dermis.
C. Full-thickness skin loss with visible adipose tissue.
D. Full-thickness skin loss with exposed bone and tendon.
Answer: C
Rationale: A Stage 3 pressure injury involves full-thickness loss of skin, where adipose
(fat) is visible in the ulcer. Granulation tissue and epibole (rolled wound edges) are often
present, but bone, tendon, and muscle are not yet exposed. If muscle or bone were visible, it
would be classified as Stage 4.
4. The nurse is administering a large-volume cleansing enema. If the patient complains of
abdominal cramping, what is the priority nursing action?
A. Lower the enema container to slow the rate of flow.
, B. Stop the procedure and notify the provider.
C. Raise the enema container to finish the procedure faster.
D. Instruct the patient to hold their breath and bear down.
Answer: A
Rationale: Abdominal cramping during an enema is often caused by the rapid distention of
the colon. By lowering the container, the nurse slows the flow rate, which usually alleviates
the cramping and allows the patient to tolerate the volume. Stopping the procedure
completely is not necessary unless the patient’s condition significantly worsens.
5. A patient is receiving continuous enteral feedings through a nasogastric (NG) tube. Which
nursing action is most effective in preventing aspiration?
A. Checking gastric residual volumes every 12 hours.
B. Verifying tube placement by auscultating an air bolus.
C. Flushing the tube with 30 mL of water before and after feedings.
D. Keeping the head of the bed elevated to at least 30 to 45 degrees.
Answer: D
Rationale: Maintaining the head of the bed (HOB) at 30 to 45 degrees uses gravity to keep
the feeding in the stomach and reduce the risk of reflux and aspiration. This is a primary
safety intervention for any patient with an enteral tube. While residual checks and flushing
