NR226/NR 226 Exam 4 V1 | Fundamentals of
Patient Care Q&A with Rationale | Chamberlain
University
1. A nurse is preparing a patient for surgery and realizes the informed consent hasn’t been
signed. What is the nurse’s primary responsibility regarding the consent process?
A. Explain the risks and benefits of the procedure to the patient.
B. Obtain the signature after providing clinical details of the surgery.
C. Witness the patient’s signature on the consent form.
D. Select a surrogate to sign if the patient expresses any anxiety.
Correct Answer: C
Explanation: The nurse’s role in informed consent is primarily to act as a witness to the
patient’s signature. This confirms that the patient is signing voluntarily and appears to be
competent to do so. The responsibility for explaining the surgical procedure, including
risks and alternatives, lies solely with the healthcare provider performing the surgery.
2. Following abdominal surgery, a patient is encouraged to use an incentive spirometer.
Which outcome indicates the patient is using the device correctly?
A. The patient performs rapid, shallow breaths into the device.
B. The patient forcefully exhales into the mouthpiece for five seconds.
C. The patient achieves a sustained, deep inhalation to lift the marker.
,D. The patient uses the device once every 24 hours while awake.
Correct Answer: C
Explanation: Incentive spirometry is designed to promote deep breathing and lung
expansion through sustained inhalation. This helps prevent postoperative complications
such as atelectasis by opening collapsed alveoli. Proper technique involves a slow, deep
breath in, rather than a forceful exhalation or rapid breathing.
3. A patient in the PACU is displaying signs of respiratory depression. Which assessment
finding is most concerning to the nurse?
A. Patient reporting a pain score of 4 out of 10.
B. An oxygen saturation level of 94% on room air.
C. A pulse rate of 88 beats per minute.
D. A respiratory rate of 8 breaths per minute.
Correct Answer: D
Explanation: A respiratory rate of 8 is significantly below the normal range and indicates
respiratory depression, often caused by anesthesia or opioid analgesics. This requires
immediate intervention to ensure adequate ventilation and prevent hypoxia. Monitoring
the rate and depth of respirations is a critical component of postoperative recovery care.
4. A nurse is assessing a surgical wound and notices a protrusion of internal organs through
the incision. What is the immediate priority action?
A. Push the organs back into the abdominal cavity gently.
, B. Cover the organs with sterile towels moistened with normal saline.
C. Apply a dry, sterile gauze dressing over the site.
D. Ask the patient to cough to check for further protrusion.
Correct Answer: B
Explanation: Wound evisceration is a medical emergency that requires keeping the
exposed tissues moist and sterile. Using sterile saline-soaked dressings prevents the organs
from drying out and reduces the risk of infection. The nurse must also stay with the patient
and notify the surgical team immediately while keeping the patient in a low-Fowler’s
position.
5. Which clinical manifestation is an early sign of hypoxia in a patient with impaired
oxygenation?
A. Cyanosis of the lips and nail beds.
B. Restlessness and apprehension.
C. A significant decrease in heart rate.
D. Bradypnea or slow breathing.
Correct Answer: B
Explanation: Restlessness, irritability, and apprehension are early compensatory
mechanisms of the body as it attempts to cope with declining oxygen levels. These
neurological changes often appear before physical signs like cyanosis, which is a late
Patient Care Q&A with Rationale | Chamberlain
University
1. A nurse is preparing a patient for surgery and realizes the informed consent hasn’t been
signed. What is the nurse’s primary responsibility regarding the consent process?
A. Explain the risks and benefits of the procedure to the patient.
B. Obtain the signature after providing clinical details of the surgery.
C. Witness the patient’s signature on the consent form.
D. Select a surrogate to sign if the patient expresses any anxiety.
Correct Answer: C
Explanation: The nurse’s role in informed consent is primarily to act as a witness to the
patient’s signature. This confirms that the patient is signing voluntarily and appears to be
competent to do so. The responsibility for explaining the surgical procedure, including
risks and alternatives, lies solely with the healthcare provider performing the surgery.
2. Following abdominal surgery, a patient is encouraged to use an incentive spirometer.
Which outcome indicates the patient is using the device correctly?
A. The patient performs rapid, shallow breaths into the device.
B. The patient forcefully exhales into the mouthpiece for five seconds.
C. The patient achieves a sustained, deep inhalation to lift the marker.
,D. The patient uses the device once every 24 hours while awake.
Correct Answer: C
Explanation: Incentive spirometry is designed to promote deep breathing and lung
expansion through sustained inhalation. This helps prevent postoperative complications
such as atelectasis by opening collapsed alveoli. Proper technique involves a slow, deep
breath in, rather than a forceful exhalation or rapid breathing.
3. A patient in the PACU is displaying signs of respiratory depression. Which assessment
finding is most concerning to the nurse?
A. Patient reporting a pain score of 4 out of 10.
B. An oxygen saturation level of 94% on room air.
C. A pulse rate of 88 beats per minute.
D. A respiratory rate of 8 breaths per minute.
Correct Answer: D
Explanation: A respiratory rate of 8 is significantly below the normal range and indicates
respiratory depression, often caused by anesthesia or opioid analgesics. This requires
immediate intervention to ensure adequate ventilation and prevent hypoxia. Monitoring
the rate and depth of respirations is a critical component of postoperative recovery care.
4. A nurse is assessing a surgical wound and notices a protrusion of internal organs through
the incision. What is the immediate priority action?
A. Push the organs back into the abdominal cavity gently.
, B. Cover the organs with sterile towels moistened with normal saline.
C. Apply a dry, sterile gauze dressing over the site.
D. Ask the patient to cough to check for further protrusion.
Correct Answer: B
Explanation: Wound evisceration is a medical emergency that requires keeping the
exposed tissues moist and sterile. Using sterile saline-soaked dressings prevents the organs
from drying out and reduces the risk of infection. The nurse must also stay with the patient
and notify the surgical team immediately while keeping the patient in a low-Fowler’s
position.
5. Which clinical manifestation is an early sign of hypoxia in a patient with impaired
oxygenation?
A. Cyanosis of the lips and nail beds.
B. Restlessness and apprehension.
C. A significant decrease in heart rate.
D. Bradypnea or slow breathing.
Correct Answer: B
Explanation: Restlessness, irritability, and apprehension are early compensatory
mechanisms of the body as it attempts to cope with declining oxygen levels. These
neurological changes often appear before physical signs like cyanosis, which is a late
