NR224 Exam 1 Actual Exam Style V2 | NR
224 Fundamentals - Skills | Chamberlain
1. A nurse is caring for a patient who has been diagnosed with Clostridium difficile (C. diff).
Which action is the most appropriate for hand hygiene in this scenario?
A. Wash hands with soap and water for at least 20 seconds.
B. Use alcohol-based hand sanitizer before and after patient contact.
C. Wear gloves at all times to avoid the need for hand hygiene.
D. Use a chlorhexidine gluconate (CHG) wipe on the hands.
Answer: A
Rationale: Alcohol-based sanitizers are ineffective against the spores produced by
Clostridium difficile. Friction from handwashing with soap and water is required to
physically remove these spores from the skin. The nurse must prioritize this method to
prevent the spread of infection to other patients.
2. Where is the apical pulse most accurately auscultated in an adult patient?
A. Second intercostal space, right sternal border.
B. Fourth intercostal space, left midaxillary line.
C. Fifth intercostal space, left midclavicular line.
D. Second intercostal space, left sternal border.
,Answer: C
Rationale: The apical pulse, also known as the point of maximal impulse (PMI), is located
at the fifth intercostal space at the left midclavicular line. This location allows the nurse to
listen directly over the apex of the heart for the most accurate assessment. It is the
preferred site when the radial pulse is irregular or when administering cardiac
medications.
3. Which component of the nursing process involves the nurse collecting subjective and
objective data?
A. Assessment
B. Planning
C. Implementation
D. Diagnosis
Answer: A
Rationale: Assessment is the first step of the nursing process where the nurse gathers all
relevant health information about the patient. This includes physical examination findings
as objective data and patient statements as subjective data. A thorough assessment is
necessary to form an accurate nursing diagnosis and care plan.
4. A nurse is preparing to lift a heavy object. Which technique demonstrates proper body
mechanics?
A. Bend at the waist to reach the object.
, B. Keep the feet close together to maintain a narrow base of support.
C. Twist the torso while lifting to move the object to the side.
D. Keep the object close to the body while lifting.
Answer: D
Rationale: Keeping the object close to the body’s center of gravity reduces the strain on the
back muscles and prevents injury. The nurse should also maintain a wide base of support
by keeping the feet shoulder-width apart. Bending at the knees and using the large leg
muscles is essential for safe lifting.
5. When assessing a patient’s blood pressure, the nurse notices the cuff is too small for the
patient’s arm. What impact will this have on the reading?
A. The reading will be falsely low.
B. The reading will be accurate regardless of size.
C. The reading will be falsely high.
D. The systolic pressure will be low, but the diastolic will be high.
Answer: C
Rationale: A blood pressure cuff that is too narrow or too tight results in a falsely high
blood pressure reading. The cuff bladder must encircle at least 80% of the arm’s
circumference to provide an accurate measurement. Selecting the correct cuff size is a
critical step in obtaining reliable vital signs.
224 Fundamentals - Skills | Chamberlain
1. A nurse is caring for a patient who has been diagnosed with Clostridium difficile (C. diff).
Which action is the most appropriate for hand hygiene in this scenario?
A. Wash hands with soap and water for at least 20 seconds.
B. Use alcohol-based hand sanitizer before and after patient contact.
C. Wear gloves at all times to avoid the need for hand hygiene.
D. Use a chlorhexidine gluconate (CHG) wipe on the hands.
Answer: A
Rationale: Alcohol-based sanitizers are ineffective against the spores produced by
Clostridium difficile. Friction from handwashing with soap and water is required to
physically remove these spores from the skin. The nurse must prioritize this method to
prevent the spread of infection to other patients.
2. Where is the apical pulse most accurately auscultated in an adult patient?
A. Second intercostal space, right sternal border.
B. Fourth intercostal space, left midaxillary line.
C. Fifth intercostal space, left midclavicular line.
D. Second intercostal space, left sternal border.
,Answer: C
Rationale: The apical pulse, also known as the point of maximal impulse (PMI), is located
at the fifth intercostal space at the left midclavicular line. This location allows the nurse to
listen directly over the apex of the heart for the most accurate assessment. It is the
preferred site when the radial pulse is irregular or when administering cardiac
medications.
3. Which component of the nursing process involves the nurse collecting subjective and
objective data?
A. Assessment
B. Planning
C. Implementation
D. Diagnosis
Answer: A
Rationale: Assessment is the first step of the nursing process where the nurse gathers all
relevant health information about the patient. This includes physical examination findings
as objective data and patient statements as subjective data. A thorough assessment is
necessary to form an accurate nursing diagnosis and care plan.
4. A nurse is preparing to lift a heavy object. Which technique demonstrates proper body
mechanics?
A. Bend at the waist to reach the object.
, B. Keep the feet close together to maintain a narrow base of support.
C. Twist the torso while lifting to move the object to the side.
D. Keep the object close to the body while lifting.
Answer: D
Rationale: Keeping the object close to the body’s center of gravity reduces the strain on the
back muscles and prevents injury. The nurse should also maintain a wide base of support
by keeping the feet shoulder-width apart. Bending at the knees and using the large leg
muscles is essential for safe lifting.
5. When assessing a patient’s blood pressure, the nurse notices the cuff is too small for the
patient’s arm. What impact will this have on the reading?
A. The reading will be falsely low.
B. The reading will be accurate regardless of size.
C. The reading will be falsely high.
D. The systolic pressure will be low, but the diastolic will be high.
Answer: C
Rationale: A blood pressure cuff that is too narrow or too tight results in a falsely high
blood pressure reading. The cuff bladder must encircle at least 80% of the arm’s
circumference to provide an accurate measurement. Selecting the correct cuff size is a
critical step in obtaining reliable vital signs.
