NR226/NR 226 Exam 3 V3 | Fundamentals of
Patient Care Q&A with Rationale | Chamberlain
University
1. When a nurse is caring for a patient with a Foley catheter, which action is most effective in
preventing Catheter-Associated Urinary Tract Infections (CAUTI)?
A. Cleaning the catheter tubing with alcohol swabs every shift.
B. Emptying the drainage bag once every 24 hours.
C. Applying antiseptic ointment to the urinary meatus twice daily.
D. Keeping the drainage bag below the level of the bladder at all times.
Correct Answer: D
Explanation: Maintaining the drainage bag below the level of the bladder prevents the
backflow of stagnant urine into the bladder, which significantly reduces the risk of
infection. Gravity-dependent drainage is a critical component of the CAUTI prevention
bundle. Nurses should also ensure the tubing is free of kinks and that the system remains
closed to minimize bacterial entry.
2. A nurse is assessing a patient and notes that the patient is restless, confused, and has an
increased heart rate. Which condition should the nurse suspect first?
A. Early-stage hypoxia
B. Hypercapnia
,C. Late-stage hypoxia
D. Respiratory acidosis
Correct Answer: A
Explanation: Restlessness and apprehension are the earliest clinical signs of hypoxia
because the brain is highly sensitive to decreasing oxygen levels. An increased heart rate
(tachycardia) is a compensatory mechanism used by the body to improve oxygen delivery
to tissues. Late signs of hypoxia typically include cyanosis and a decreased heart rate
(bradycardia).
3. The nurse is preparing to administer a small-volume cleansing enema. In which position
should the nurse place the patient?
A. Right-side Sims position
B. Prone position
C. Left-side Sims position
D. High Fowler’s position
Correct Answer: C
Explanation: The Left Sims position allows the enema solution to flow by gravity into the
sigmoid colon and rectum due to the anatomical curvature of the large intestine. This
positioning facilitates better distribution of the fluid and improves the effectiveness of the
procedure. It also ensures patient comfort and safety during the administration of the
enema.
, 4. When using the Braden Scale to assess a patient’s risk for pressure injuries, the nurse
understands that a lower total score indicates:
A. A lower risk for skin breakdown.
B. The patient is physically active.
C. A higher risk for skin breakdown.
D. The patient has adequate nutritional status.
Correct Answer: C
Explanation: The Braden Scale evaluates six categories: sensory perception, moisture,
activity, mobility, nutrition, and friction/shear. A lower total score, typically below 18,
signifies a higher risk for developing a pressure injury. This tool helps nurses implement
early interventions such as turning schedules and specialized surfaces to protect the
patient’s skin integrity.
5. A nurse observes a pressure injury that has full-thickness skin loss involving damage to the
subcutaneous tissue, but no bone or muscle is visible. How should this be documented?
A. Stage I
B. Stage III
C. Stage II
D. Stage IV
Correct Answer: B
Patient Care Q&A with Rationale | Chamberlain
University
1. When a nurse is caring for a patient with a Foley catheter, which action is most effective in
preventing Catheter-Associated Urinary Tract Infections (CAUTI)?
A. Cleaning the catheter tubing with alcohol swabs every shift.
B. Emptying the drainage bag once every 24 hours.
C. Applying antiseptic ointment to the urinary meatus twice daily.
D. Keeping the drainage bag below the level of the bladder at all times.
Correct Answer: D
Explanation: Maintaining the drainage bag below the level of the bladder prevents the
backflow of stagnant urine into the bladder, which significantly reduces the risk of
infection. Gravity-dependent drainage is a critical component of the CAUTI prevention
bundle. Nurses should also ensure the tubing is free of kinks and that the system remains
closed to minimize bacterial entry.
2. A nurse is assessing a patient and notes that the patient is restless, confused, and has an
increased heart rate. Which condition should the nurse suspect first?
A. Early-stage hypoxia
B. Hypercapnia
,C. Late-stage hypoxia
D. Respiratory acidosis
Correct Answer: A
Explanation: Restlessness and apprehension are the earliest clinical signs of hypoxia
because the brain is highly sensitive to decreasing oxygen levels. An increased heart rate
(tachycardia) is a compensatory mechanism used by the body to improve oxygen delivery
to tissues. Late signs of hypoxia typically include cyanosis and a decreased heart rate
(bradycardia).
3. The nurse is preparing to administer a small-volume cleansing enema. In which position
should the nurse place the patient?
A. Right-side Sims position
B. Prone position
C. Left-side Sims position
D. High Fowler’s position
Correct Answer: C
Explanation: The Left Sims position allows the enema solution to flow by gravity into the
sigmoid colon and rectum due to the anatomical curvature of the large intestine. This
positioning facilitates better distribution of the fluid and improves the effectiveness of the
procedure. It also ensures patient comfort and safety during the administration of the
enema.
, 4. When using the Braden Scale to assess a patient’s risk for pressure injuries, the nurse
understands that a lower total score indicates:
A. A lower risk for skin breakdown.
B. The patient is physically active.
C. A higher risk for skin breakdown.
D. The patient has adequate nutritional status.
Correct Answer: C
Explanation: The Braden Scale evaluates six categories: sensory perception, moisture,
activity, mobility, nutrition, and friction/shear. A lower total score, typically below 18,
signifies a higher risk for developing a pressure injury. This tool helps nurses implement
early interventions such as turning schedules and specialized surfaces to protect the
patient’s skin integrity.
5. A nurse observes a pressure injury that has full-thickness skin loss involving damage to the
subcutaneous tissue, but no bone or muscle is visible. How should this be documented?
A. Stage I
B. Stage III
C. Stage II
D. Stage IV
Correct Answer: B
