NR226/NR 226 Exam 4 V2 | Fundamentals of
Patient Care Q&A with Rationale | Chamberlain
University
1. A nurse is witnessing an informed consent for an elective surgical procedure. What is the
nurse’s primary responsibility in this process?
A. Witnessing the patient’s signature and verifying their identity.
B. Ensuring the patient has received all necessary information from the surgeon.
C. Explaining the risks and benefits of the surgery to the patient.
D. Describing the alternative treatments available to the patient.
Correct Answer: A
Explanation: The nurse acts as a witness to the patient’s signature on the consent form. It
is the nurse’s responsibility to confirm the patient is signing voluntarily and appears
competent. The surgeon is the individual responsible for explaining the procedure details,
risks, and alternatives.
2. During the preoperative assessment, a patient reports a latex allergy. Which of the
following foods should the nurse recognize as potentially cross-reactive?
A. Bananas, avocados, and chestnuts.
B. Strawberries and blueberries.
C. Milk and dairy products.
,D. Shellfish and iodine-based products.
Correct Answer: A
Explanation: Patients with latex allergies often exhibit cross-sensitivities to certain foods
like bananas and avocados. This occurs because the proteins in these foods are structurally
similar to the proteins found in rubber latex. Identifying these triggers is crucial for
preventing intraoperative anaphylaxis.
3. A postoperative patient has not voided for 8 hours after surgery. What is the priority
nursing action?
A. Insert an indwelling urinary catheter immediately.
B. Increase the rate of the patient’s intravenous fluids.
C. Perform a bladder scan to assess for urinary retention.
D. Encourage the patient to increase oral fluid intake.
Correct Answer: C
Explanation: A bladder scan is a non-invasive method to determine the amount of urine
currently in the bladder. This assessment should be performed before invasive measures
like catheterization. Anesthesia and opioids can lead to temporary urinary retention,
necessitating careful monitoring of output.
4. A nurse is caring for a patient with a Stage 3 pressure injury. Which description best
matches this stage?
A. Non-blanchable erythema of intact skin.
, B. Full-thickness tissue loss with exposed bone, tendon, or muscle.
C. Partial-thickness loss of dermis presenting as a shallow open ulcer.
D. Full-thickness skin loss involving damage to subcutaneous tissue.
Correct Answer: D
Explanation: Stage 3 pressure injuries involve full-thickness skin loss where subcutaneous
fat may be visible. However, bone, tendon, and muscle are not yet exposed at this stage.
Slough may be present, and the wound may include undermining or tunneling.
5. When performing tracheostomy care, which action should the nurse take to maintain a
sterile field?
A. Clean the inner cannula with tap water and a clean cloth.
B. Remove the old ties before securing the new ones.
C. Apply a clean, non-sterile dressing around the tracheostomy tube.
D. Use sterile gloves and sterile saline to clean the stoma site.
Correct Answer: D
Explanation: Tracheostomy care is a sterile procedure to prevent lower respiratory tract
infections. The nurse must use sterile gloves and sterile supplies when handling the inner
cannula and the stoma site. Using tap water or non-sterile items would introduce
pathogens into the airway.
Patient Care Q&A with Rationale | Chamberlain
University
1. A nurse is witnessing an informed consent for an elective surgical procedure. What is the
nurse’s primary responsibility in this process?
A. Witnessing the patient’s signature and verifying their identity.
B. Ensuring the patient has received all necessary information from the surgeon.
C. Explaining the risks and benefits of the surgery to the patient.
D. Describing the alternative treatments available to the patient.
Correct Answer: A
Explanation: The nurse acts as a witness to the patient’s signature on the consent form. It
is the nurse’s responsibility to confirm the patient is signing voluntarily and appears
competent. The surgeon is the individual responsible for explaining the procedure details,
risks, and alternatives.
2. During the preoperative assessment, a patient reports a latex allergy. Which of the
following foods should the nurse recognize as potentially cross-reactive?
A. Bananas, avocados, and chestnuts.
B. Strawberries and blueberries.
C. Milk and dairy products.
,D. Shellfish and iodine-based products.
Correct Answer: A
Explanation: Patients with latex allergies often exhibit cross-sensitivities to certain foods
like bananas and avocados. This occurs because the proteins in these foods are structurally
similar to the proteins found in rubber latex. Identifying these triggers is crucial for
preventing intraoperative anaphylaxis.
3. A postoperative patient has not voided for 8 hours after surgery. What is the priority
nursing action?
A. Insert an indwelling urinary catheter immediately.
B. Increase the rate of the patient’s intravenous fluids.
C. Perform a bladder scan to assess for urinary retention.
D. Encourage the patient to increase oral fluid intake.
Correct Answer: C
Explanation: A bladder scan is a non-invasive method to determine the amount of urine
currently in the bladder. This assessment should be performed before invasive measures
like catheterization. Anesthesia and opioids can lead to temporary urinary retention,
necessitating careful monitoring of output.
4. A nurse is caring for a patient with a Stage 3 pressure injury. Which description best
matches this stage?
A. Non-blanchable erythema of intact skin.
, B. Full-thickness tissue loss with exposed bone, tendon, or muscle.
C. Partial-thickness loss of dermis presenting as a shallow open ulcer.
D. Full-thickness skin loss involving damage to subcutaneous tissue.
Correct Answer: D
Explanation: Stage 3 pressure injuries involve full-thickness skin loss where subcutaneous
fat may be visible. However, bone, tendon, and muscle are not yet exposed at this stage.
Slough may be present, and the wound may include undermining or tunneling.
5. When performing tracheostomy care, which action should the nurse take to maintain a
sterile field?
A. Clean the inner cannula with tap water and a clean cloth.
B. Remove the old ties before securing the new ones.
C. Apply a clean, non-sterile dressing around the tracheostomy tube.
D. Use sterile gloves and sterile saline to clean the stoma site.
Correct Answer: D
Explanation: Tracheostomy care is a sterile procedure to prevent lower respiratory tract
infections. The nurse must use sterile gloves and sterile supplies when handling the inner
cannula and the stoma site. Using tap water or non-sterile items would introduce
pathogens into the airway.
