NR226/NR 226 Final Exam V2 | Fundamentals of
Patient Care Q&A with Rationale | Chamberlain
University
1. A nurse is performing an admission assessment for a new client. Which of the following
findings should the nurse document as subjective data?
A. The client’s blood pressure is 142/90 mmHg.
B. The client reports a sharp pain in their abdomen.
C. The nurse observes a 2 cm stage II pressure injury on the coccyx.
D. The client has a productive cough with yellow sputum.
Correct Answer: B
Explanation: Subjective data consists of information that the client describes and can only
be verified by the client. Pain is a classic example of subjective data because it is the client’s
perception and cannot be directly measured by the nurse. Objective data, such as blood
pressure or physical findings, are measurable and observable by the practitioner during an
assessment.
2. When caring for a client who has Clostridium difficile (C. diff), which infection control
precaution is mandatory for the nurse to implement?
A. Standard precautions only.
B. Airborne precautions with an N95 mask.
,C. Contact precautions including soap and water hand hygiene.
D. Droplet precautions with a surgical mask.
Correct Answer: C
Explanation: Clostridium difficile is transmitted via the fecal-oral route through contact
with contaminated surfaces. Hand hygiene must be performed with soap and water
because alcohol-based rubs are ineffective against C. diff spores. Using contact precautions,
including gowns and gloves, prevents the spread of the pathogen within the healthcare
facility.
3. A nurse is assessing a client for orthostatic hypotension. Which of the following actions
should the nurse take first?
A. Assist the client to a standing position.
B. Encourage the client to drink 500 mL of water.
C. Have the client sit on the side of the bed for 5 minutes.
D. Measure the client’s blood pressure while lying supine.
Correct Answer: D
Explanation: The proper sequence for orthostatic blood pressure assessment starts with a
baseline measurement while the client is supine. Following the supine reading,
measurements are taken while the client is sitting and then standing, usually with 1 to 3
minutes of rest in between. This systematic approach allows the nurse to identify
significant drops in blood pressure upon position changes.
, 4. A nurse is preparing to administer a liquid medication to an infant. Which of the following
methods is the safest for administration?
A. Mix the medication with the infant’s full bottle of formula.
B. Use a medicine cup and pour it into the back of the throat.
C. Tilt the infant’s head back to ensure they swallow.
D. Place an oral syringe in the side of the infant’s mouth.
Correct Answer: D
Explanation: Administering liquid medication via an oral syringe in the side of the mouth
prevents choking and aspiration. Mixing medication with a full bottle of formula is avoided
because if the infant does not finish the bottle, the exact dose received is unknown.
Positioning the syringe along the inner cheek allows the infant to swallow naturally at their
own pace.
5. A nurse is caring for a client who is immobile. Which of the following is a priority
intervention to prevent deep vein thrombosis (DVT)?
A. Apply sequential compression devices (SCDs) as ordered.
B. Massage the client’s lower extremities twice daily.
C. Maintain the client in a high-Fowler’s position.
D. Restrict the client’s fluid intake to 1,000 mL/day.
Correct Answer: A
Patient Care Q&A with Rationale | Chamberlain
University
1. A nurse is performing an admission assessment for a new client. Which of the following
findings should the nurse document as subjective data?
A. The client’s blood pressure is 142/90 mmHg.
B. The client reports a sharp pain in their abdomen.
C. The nurse observes a 2 cm stage II pressure injury on the coccyx.
D. The client has a productive cough with yellow sputum.
Correct Answer: B
Explanation: Subjective data consists of information that the client describes and can only
be verified by the client. Pain is a classic example of subjective data because it is the client’s
perception and cannot be directly measured by the nurse. Objective data, such as blood
pressure or physical findings, are measurable and observable by the practitioner during an
assessment.
2. When caring for a client who has Clostridium difficile (C. diff), which infection control
precaution is mandatory for the nurse to implement?
A. Standard precautions only.
B. Airborne precautions with an N95 mask.
,C. Contact precautions including soap and water hand hygiene.
D. Droplet precautions with a surgical mask.
Correct Answer: C
Explanation: Clostridium difficile is transmitted via the fecal-oral route through contact
with contaminated surfaces. Hand hygiene must be performed with soap and water
because alcohol-based rubs are ineffective against C. diff spores. Using contact precautions,
including gowns and gloves, prevents the spread of the pathogen within the healthcare
facility.
3. A nurse is assessing a client for orthostatic hypotension. Which of the following actions
should the nurse take first?
A. Assist the client to a standing position.
B. Encourage the client to drink 500 mL of water.
C. Have the client sit on the side of the bed for 5 minutes.
D. Measure the client’s blood pressure while lying supine.
Correct Answer: D
Explanation: The proper sequence for orthostatic blood pressure assessment starts with a
baseline measurement while the client is supine. Following the supine reading,
measurements are taken while the client is sitting and then standing, usually with 1 to 3
minutes of rest in between. This systematic approach allows the nurse to identify
significant drops in blood pressure upon position changes.
, 4. A nurse is preparing to administer a liquid medication to an infant. Which of the following
methods is the safest for administration?
A. Mix the medication with the infant’s full bottle of formula.
B. Use a medicine cup and pour it into the back of the throat.
C. Tilt the infant’s head back to ensure they swallow.
D. Place an oral syringe in the side of the infant’s mouth.
Correct Answer: D
Explanation: Administering liquid medication via an oral syringe in the side of the mouth
prevents choking and aspiration. Mixing medication with a full bottle of formula is avoided
because if the infant does not finish the bottle, the exact dose received is unknown.
Positioning the syringe along the inner cheek allows the infant to swallow naturally at their
own pace.
5. A nurse is caring for a client who is immobile. Which of the following is a priority
intervention to prevent deep vein thrombosis (DVT)?
A. Apply sequential compression devices (SCDs) as ordered.
B. Massage the client’s lower extremities twice daily.
C. Maintain the client in a high-Fowler’s position.
D. Restrict the client’s fluid intake to 1,000 mL/day.
Correct Answer: A
