NR224 Exam 2 Actual Exam Style V3 | NR
224 Fundamentals - Skills | Chamberlain
1. A nurse is caring for an older adult patient who is at high risk for falls. Which of the
following is the priority nursing action?
A. Keep all four side rails in the up position.
B. Place the call light within the patient’s reach.
C. Apply a vest restraint while the patient is in bed.
D. Encourage the patient to get up without assistance.
Answer: B
Rationale: Ensuring the call light is within reach is a fundamental safety intervention that
allows the patient to request help before attempting to move. Keeping four side rails up is
often considered a physical restraint and may increase the risk of injury if the patient tries
to climb over them. Safety protocols prioritize non-restrictive measures to prevent falls in
the clinical setting.
2. The nurse is preparing to perform a sterile dressing change. Which action would violate the
principles of surgical asepsis?
A. Keeping sterile gloved hands above the waist level.
B. Reaching over the sterile field to pick up a container.
C. Dropping a sterile gauze pad onto the center of the field.
,D. Opening the outermost flap of the sterile kit away from the body.
Answer: B
Rationale: Reaching over a sterile field is a violation of aseptic technique because
microorganisms can fall from the nurse’s arm onto the sterile surface. The nurse should
always work around the perimeter of the field to maintain sterility. Maintaining hands
above the waist and opening flaps away from the body are correct practices for surgical
asepsis.
3. A patient has a pressure injury that presents as a shallow open ulcer with a red-pink wound
bed without slough. Which stage should the nurse document?
A. Stage 2
B. Stage 1
C. Stage 3
D. Stage 4
Answer: A
Rationale: Stage 2 pressure injuries involve partial-thickness loss of the dermis and
present as a shallow open ulcer with a red-pink wound bed. Stage 1 involves non-
blanchable erythema of intact skin, while Stage 3 involves full-thickness tissue loss where
subcutaneous fat may be visible. Accurate staging is critical for determining the
appropriate wound care interventions and monitoring healing progress.
, 4. When assessing a patient’s wound, the nurse notes clear, watery drainage. How should this
drainage be documented?
A. Serosanguineous
B. Purulent
C. Sanguineous
D. Serous
Answer: D
Rationale: Serous drainage is clear and watery, consisting of the fluid portion of the blood
and serous membranes. Sanguineous drainage contains large amounts of red blood cells,
while purulent drainage indicates infection and contains pus. Serosanguineous drainage is
a mixture of clear and blood-tinged fluid commonly seen in surgical incisions.
5. A nurse is teaching a patient how to use an incentive spirometer. What instruction should
the nurse include?
A. Inhale slowly and deeply through the mouthpiece.
B. Exhale forcefully into the mouthpiece.
C. Hold your breath for at least 15 seconds.
D. Use the device once every 4 hours while awake.
Answer: A
224 Fundamentals - Skills | Chamberlain
1. A nurse is caring for an older adult patient who is at high risk for falls. Which of the
following is the priority nursing action?
A. Keep all four side rails in the up position.
B. Place the call light within the patient’s reach.
C. Apply a vest restraint while the patient is in bed.
D. Encourage the patient to get up without assistance.
Answer: B
Rationale: Ensuring the call light is within reach is a fundamental safety intervention that
allows the patient to request help before attempting to move. Keeping four side rails up is
often considered a physical restraint and may increase the risk of injury if the patient tries
to climb over them. Safety protocols prioritize non-restrictive measures to prevent falls in
the clinical setting.
2. The nurse is preparing to perform a sterile dressing change. Which action would violate the
principles of surgical asepsis?
A. Keeping sterile gloved hands above the waist level.
B. Reaching over the sterile field to pick up a container.
C. Dropping a sterile gauze pad onto the center of the field.
,D. Opening the outermost flap of the sterile kit away from the body.
Answer: B
Rationale: Reaching over a sterile field is a violation of aseptic technique because
microorganisms can fall from the nurse’s arm onto the sterile surface. The nurse should
always work around the perimeter of the field to maintain sterility. Maintaining hands
above the waist and opening flaps away from the body are correct practices for surgical
asepsis.
3. A patient has a pressure injury that presents as a shallow open ulcer with a red-pink wound
bed without slough. Which stage should the nurse document?
A. Stage 2
B. Stage 1
C. Stage 3
D. Stage 4
Answer: A
Rationale: Stage 2 pressure injuries involve partial-thickness loss of the dermis and
present as a shallow open ulcer with a red-pink wound bed. Stage 1 involves non-
blanchable erythema of intact skin, while Stage 3 involves full-thickness tissue loss where
subcutaneous fat may be visible. Accurate staging is critical for determining the
appropriate wound care interventions and monitoring healing progress.
, 4. When assessing a patient’s wound, the nurse notes clear, watery drainage. How should this
drainage be documented?
A. Serosanguineous
B. Purulent
C. Sanguineous
D. Serous
Answer: D
Rationale: Serous drainage is clear and watery, consisting of the fluid portion of the blood
and serous membranes. Sanguineous drainage contains large amounts of red blood cells,
while purulent drainage indicates infection and contains pus. Serosanguineous drainage is
a mixture of clear and blood-tinged fluid commonly seen in surgical incisions.
5. A nurse is teaching a patient how to use an incentive spirometer. What instruction should
the nurse include?
A. Inhale slowly and deeply through the mouthpiece.
B. Exhale forcefully into the mouthpiece.
C. Hold your breath for at least 15 seconds.
D. Use the device once every 4 hours while awake.
Answer: A
