NR226/NR 226 Final Exam V1 | Fundamentals of
Patient Care Q&A with Rationale | Chamberlain
University
1. A nurse is caring for a patient who is two days postoperative. The nurse notes that the
patient’s surgical wound has separated and internal organs are protruding. Which action
should the nurse take first?
A. Notify the surgeon immediately to prepare for emergency surgery.
B. Apply a sterile dressing soaked in sterile normal saline over the protruding organs.
C. Place the patient in a low-Fowler’s position with knees bent.
D. Assess the patient’s vital signs and level of consciousness.
Correct Answer: B
Explanation: Evisceration is a medical emergency that requires immediate intervention to
protect the exposed organs from drying out and becoming infected. Covering the organs
with a sterile, saline-soaked dressing is the highest priority action to maintain tissue
integrity. The nurse should then call for help and ensure the patient remains still to prevent
further protrusion.
2. When assessing a patient’s radial pulse, the nurse notes that the rhythm is irregular. Which
action should the nurse perform next to obtain an accurate measurement?
A. Document the finding and continue with the physical assessment.
B. Count the radial pulse for a full 60 seconds.
,C. Palpate the carotid pulse to compare the rhythm.
D. Measure the apical pulse for one full minute.
Correct Answer: D
Explanation: If a peripheral pulse is irregular, the apical pulse must be assessed for one
full minute to determine the actual heart rate and rhythm. This provides the most accurate
clinical data regarding the patient’s cardiac status. Documenting an irregular peripheral
pulse without verifying it apically is an incomplete nursing assessment.
3. A nurse is preparing to administer an intramuscular injection to a lean adult patient. Which
needle length and gauge would be most appropriate for the ventrogluteal site?
A. 5/8 inch, 25 gauge
B. 2 inch, 20 gauge
C. 1 inch, 18 gauge
D. 1.5 inch, 22 gauge
Correct Answer: D
Explanation: For a ventrogluteal injection in an average-sized adult, a 1.5-inch needle is
typically required to ensure the medication reaches the muscle tissue. A 21 to 23 gauge
needle is appropriate for the viscosity of most IM medications. Using a needle that is too
short may result in the medication being deposited into subcutaneous tissue, leading to
irritation and poor absorption.
, 4. A nurse is caring for a patient who has been diagnosed with Clostridium difficile (C. diff).
Which infection control measure is mandatory when exiting the patient’s room?
A. Use an alcohol-based hand sanitizer for at least 15 seconds.
B. Ensure the patient wears a mask during all nurse-patient interactions.
C. Dispose of the gown and gloves in the regular trash outside the room.
D. Wash hands with antimicrobial soap and water.
Correct Answer: D
Explanation: Clostridium difficile spores are resistant to alcohol-based hand sanitizers,
making mechanical friction with soap and water necessary for removal. Hand hygiene must
be performed before leaving the patient’s room to prevent the spread of spores to other
areas. Contact precautions are required for this pathogen, but a mask for the patient is only
necessary for respiratory infections.
5. The nurse is assessing a patient using the Braden Scale. Which score would indicate that
the patient is at the highest risk for developing a pressure injury?
A. 23
B. 18
C. 14
D. 9
Correct Answer: D
Patient Care Q&A with Rationale | Chamberlain
University
1. A nurse is caring for a patient who is two days postoperative. The nurse notes that the
patient’s surgical wound has separated and internal organs are protruding. Which action
should the nurse take first?
A. Notify the surgeon immediately to prepare for emergency surgery.
B. Apply a sterile dressing soaked in sterile normal saline over the protruding organs.
C. Place the patient in a low-Fowler’s position with knees bent.
D. Assess the patient’s vital signs and level of consciousness.
Correct Answer: B
Explanation: Evisceration is a medical emergency that requires immediate intervention to
protect the exposed organs from drying out and becoming infected. Covering the organs
with a sterile, saline-soaked dressing is the highest priority action to maintain tissue
integrity. The nurse should then call for help and ensure the patient remains still to prevent
further protrusion.
2. When assessing a patient’s radial pulse, the nurse notes that the rhythm is irregular. Which
action should the nurse perform next to obtain an accurate measurement?
A. Document the finding and continue with the physical assessment.
B. Count the radial pulse for a full 60 seconds.
,C. Palpate the carotid pulse to compare the rhythm.
D. Measure the apical pulse for one full minute.
Correct Answer: D
Explanation: If a peripheral pulse is irregular, the apical pulse must be assessed for one
full minute to determine the actual heart rate and rhythm. This provides the most accurate
clinical data regarding the patient’s cardiac status. Documenting an irregular peripheral
pulse without verifying it apically is an incomplete nursing assessment.
3. A nurse is preparing to administer an intramuscular injection to a lean adult patient. Which
needle length and gauge would be most appropriate for the ventrogluteal site?
A. 5/8 inch, 25 gauge
B. 2 inch, 20 gauge
C. 1 inch, 18 gauge
D. 1.5 inch, 22 gauge
Correct Answer: D
Explanation: For a ventrogluteal injection in an average-sized adult, a 1.5-inch needle is
typically required to ensure the medication reaches the muscle tissue. A 21 to 23 gauge
needle is appropriate for the viscosity of most IM medications. Using a needle that is too
short may result in the medication being deposited into subcutaneous tissue, leading to
irritation and poor absorption.
, 4. A nurse is caring for a patient who has been diagnosed with Clostridium difficile (C. diff).
Which infection control measure is mandatory when exiting the patient’s room?
A. Use an alcohol-based hand sanitizer for at least 15 seconds.
B. Ensure the patient wears a mask during all nurse-patient interactions.
C. Dispose of the gown and gloves in the regular trash outside the room.
D. Wash hands with antimicrobial soap and water.
Correct Answer: D
Explanation: Clostridium difficile spores are resistant to alcohol-based hand sanitizers,
making mechanical friction with soap and water necessary for removal. Hand hygiene must
be performed before leaving the patient’s room to prevent the spread of spores to other
areas. Contact precautions are required for this pathogen, but a mask for the patient is only
necessary for respiratory infections.
5. The nurse is assessing a patient using the Braden Scale. Which score would indicate that
the patient is at the highest risk for developing a pressure injury?
A. 23
B. 18
C. 14
D. 9
Correct Answer: D
