,NR224/NR 224 Exam 2 | Fundamentals of Nursing |
Chamberlain University | Q & A | 2026/2027 Edition
(PDF)
1. Which of the following best describes the primary purpose of regular range-of-motion (ROM)
exercises for an immobile patient?
A) To prevent muscle atrophy and joint contractures
B) To increase the patient's overall muscle mass
C) To eliminate the need for physical therapy
D) To reduce the patient's pain levels
Correct Answer: To prevent muscle atrophy and joint contractures
Rationale: Regular ROM exercises maintain joint flexibility, prevent contractures, and preserve muscle
function in immobile patients. They do not significantly increase muscle mass, replace physical therapy,
or directly reduce pain, though they may indirectly reduce discomfort from stiffness.
2. What is the most appropriate nursing intervention when a patient experiences orthostatic
hypotension?
A) Assist the patient to a sitting or lying position and monitor vital signs
B) Encourage the patient to stand up quickly to improve circulation
C) Administer a bolus of intravenous fluids immediately
D) Place the patient in Trendelenburg position
Correct Answer: Assist the patient to a sitting or lying position and monitor vital signs
Rationale: Orthostatic hypotension (drop of 20 mmHg systolic or 10 mmHg diastolic within 3 minutes of
standing) requires immediate safety measures. Assisting the patient to sit or lie down prevents falls and
allows for reassessment. Quick standing worsens symptoms, and Trendelenburg position is no longer
routinely recommended.
,3. According to the Braden Scale, which factor is assessed to determine pressure ulcer risk?
A) Sensory perception, moisture, activity, mobility, nutrition, friction/shear
B) Age, gender, weight, height, and ethnicity
C) Pain level, anxiety, depression, and social support
D) Blood pressure, heart rate, respiratory rate, and temperature
Correct Answer: Sensory perception, moisture, activity, mobility, nutrition, friction/shear
Rationale: The Braden Scale evaluates six subscales: sensory perception, moisture, activity, mobility,
nutrition, and friction/shear. Lower scores indicate higher pressure ulcer risk. The other options list
demographic or vital sign parameters not included in this validated risk assessment tool.
4. A nurse is caring for a patient with a Stage 2 pressure injury. Which finding is most consistent with this
stage?
A) Nonblanchable erythema of intact skin
B) Partial-thickness skin loss with exposed dermis
C) Full-thickness tissue loss with subcutaneous fat visible
D) Full-thickness tissue loss with exposed bone
Correct Answer: Partial-thickness skin loss with exposed dermis
Rationale: Stage 2 pressure injury presents as partial-thickness skin loss with exposed dermis, appearing
as a shallow open ulcer or intact/ruptured blister. Stage 1 is nonblanchable erythema, Stage 3 involves
subcutaneous fat, and Stage 4 involves exposed muscle or bone.
5. Which of the following oxygen delivery devices delivers the most precise fraction of inspired oxygen
(FiO₂)?
A) Nasal cannula
B) Simple face mask
C) Venturi mask
D) Nonrebreather mask
, Correct Answer: Venturi mask
Rationale: The Venturi mask delivers a precise FiO₂ regardless of the patient's breathing pattern, making
it ideal for patients with COPD who require controlled oxygen therapy. Nasal cannula (24–44%), simple
mask (40–60%), and nonrebreather (80–95%) provide less precise oxygen concentrations.
6. A patient with a new tracheostomy requires suctioning. What is the maximum amount of time the
nurse should apply suction?
A) 5–10 seconds
B) 10–15 seconds
C) 20–25 seconds
D) 30–35 seconds
Correct Answer: 10–15 seconds
Rationale: Tracheostomy suctioning should be limited to 10–15 seconds per pass to prevent hypoxia and
mucosal trauma. The patient should be preoxygenated before suctioning, and no more than three
passes should be attempted.
7. Which of the following findings is an early sign of hypoxia?
A) Cyanosis
B) Bradycardia
C) Restlessness and anxiety
D) Confusion
Correct Answer: Restlessness and anxiety
Rationale: Early signs of hypoxia include restlessness, anxiety, tachycardia, and elevated blood pressure.
Cyanosis, bradycardia, and confusion are late signs that indicate significant oxygen deprivation and
require immediate intervention.
Chamberlain University | Q & A | 2026/2027 Edition
(PDF)
1. Which of the following best describes the primary purpose of regular range-of-motion (ROM)
exercises for an immobile patient?
A) To prevent muscle atrophy and joint contractures
B) To increase the patient's overall muscle mass
C) To eliminate the need for physical therapy
D) To reduce the patient's pain levels
Correct Answer: To prevent muscle atrophy and joint contractures
Rationale: Regular ROM exercises maintain joint flexibility, prevent contractures, and preserve muscle
function in immobile patients. They do not significantly increase muscle mass, replace physical therapy,
or directly reduce pain, though they may indirectly reduce discomfort from stiffness.
2. What is the most appropriate nursing intervention when a patient experiences orthostatic
hypotension?
A) Assist the patient to a sitting or lying position and monitor vital signs
B) Encourage the patient to stand up quickly to improve circulation
C) Administer a bolus of intravenous fluids immediately
D) Place the patient in Trendelenburg position
Correct Answer: Assist the patient to a sitting or lying position and monitor vital signs
Rationale: Orthostatic hypotension (drop of 20 mmHg systolic or 10 mmHg diastolic within 3 minutes of
standing) requires immediate safety measures. Assisting the patient to sit or lie down prevents falls and
allows for reassessment. Quick standing worsens symptoms, and Trendelenburg position is no longer
routinely recommended.
,3. According to the Braden Scale, which factor is assessed to determine pressure ulcer risk?
A) Sensory perception, moisture, activity, mobility, nutrition, friction/shear
B) Age, gender, weight, height, and ethnicity
C) Pain level, anxiety, depression, and social support
D) Blood pressure, heart rate, respiratory rate, and temperature
Correct Answer: Sensory perception, moisture, activity, mobility, nutrition, friction/shear
Rationale: The Braden Scale evaluates six subscales: sensory perception, moisture, activity, mobility,
nutrition, and friction/shear. Lower scores indicate higher pressure ulcer risk. The other options list
demographic or vital sign parameters not included in this validated risk assessment tool.
4. A nurse is caring for a patient with a Stage 2 pressure injury. Which finding is most consistent with this
stage?
A) Nonblanchable erythema of intact skin
B) Partial-thickness skin loss with exposed dermis
C) Full-thickness tissue loss with subcutaneous fat visible
D) Full-thickness tissue loss with exposed bone
Correct Answer: Partial-thickness skin loss with exposed dermis
Rationale: Stage 2 pressure injury presents as partial-thickness skin loss with exposed dermis, appearing
as a shallow open ulcer or intact/ruptured blister. Stage 1 is nonblanchable erythema, Stage 3 involves
subcutaneous fat, and Stage 4 involves exposed muscle or bone.
5. Which of the following oxygen delivery devices delivers the most precise fraction of inspired oxygen
(FiO₂)?
A) Nasal cannula
B) Simple face mask
C) Venturi mask
D) Nonrebreather mask
, Correct Answer: Venturi mask
Rationale: The Venturi mask delivers a precise FiO₂ regardless of the patient's breathing pattern, making
it ideal for patients with COPD who require controlled oxygen therapy. Nasal cannula (24–44%), simple
mask (40–60%), and nonrebreather (80–95%) provide less precise oxygen concentrations.
6. A patient with a new tracheostomy requires suctioning. What is the maximum amount of time the
nurse should apply suction?
A) 5–10 seconds
B) 10–15 seconds
C) 20–25 seconds
D) 30–35 seconds
Correct Answer: 10–15 seconds
Rationale: Tracheostomy suctioning should be limited to 10–15 seconds per pass to prevent hypoxia and
mucosal trauma. The patient should be preoxygenated before suctioning, and no more than three
passes should be attempted.
7. Which of the following findings is an early sign of hypoxia?
A) Cyanosis
B) Bradycardia
C) Restlessness and anxiety
D) Confusion
Correct Answer: Restlessness and anxiety
Rationale: Early signs of hypoxia include restlessness, anxiety, tachycardia, and elevated blood pressure.
Cyanosis, bradycardia, and confusion are late signs that indicate significant oxygen deprivation and
require immediate intervention.
