NR 224 FUNDAMENTALS COMPREHENSIVE EXAM
CHAMBERLAIN UNIVERSITY ACTUAL EXAM
QUESTIONS AND CORRECT VERIFIED ANSWERS
WITH RATIONALES 100% GUARANTEED PASS!!
<LATEST VERSION>
Question 1
A nurse is caring for a client who is 8 hours postoperative following abdominal
surgery. The client reports increasing abdominal pressure and suddenly coughs.
The nurse observes that the surgical incision has separated and loops of bowel are
visible through the opening. Which action should the nurse take first?
A. Apply a sterile dressing moistened with sterile normal saline over the exposed
organs.
B. Attempt to gently return the organs into the abdominal cavity.
C. Place the client in a high-Fowler position to reduce respiratory complications.
D. Apply an abdominal binder tightly around the client's abdomen.
Answer: A
Rationale: Evisceration is a surgical emergency. The exposed organs should be
protected immediately with sterile gauze or dressings moistened with sterile
normal saline to prevent tissue drying. The nurse should then notify the provider
and anticipate further intervention. The organs should never be pushed back into
the abdomen. A low-Fowler or supine position with knees flexed may decrease
tension on the wound.
,Question 2
A nurse is preparing to administer oral medications to a client. The medication
administration record lists acetaminophen 650 mg PO every 6 hours as needed for
pain. The client states, "I already received my pain medication from another nurse
about an hour ago." What is the nurse's priority action?
A. Administer the medication because it is currently listed as due.
B. Hold the medication and verify the previous administration record.
C. Ask the client whether the previous medication relieved the pain.
D. Administer half of the prescribed dose.
Answer: B
Rationale: The nurse must verify the medication administration history before
giving another dose. Administering a medication without confirming the previous
dose could result in an overdose. The nurse should review the MAR and clarify
discrepancies before administration. The client's report of receiving medication is
an important cue requiring investigation.
Question 3
During a sterile dressing change, the nurse accidentally allows a sterile glove to
touch the edge of the patient's bed. What should the nurse do?
A. Continue the procedure because the glove is still visibly clean.
B. Clean the glove with an alcohol-based hand sanitizer.
C. Replace the contaminated glove before continuing.
D. Cover the contaminated area with sterile gauze.
Answer: C
Rationale: The outer surface of a sterile glove is considered contaminated when it
contacts a nonsterile surface. The nurse should replace the glove before continuing.
Cleaning the glove does not restore sterility. Maintaining the sterile field requires
recognizing and correcting contamination immediately.
,Question 4
A client has a respiratory rate of 30/min, oxygen saturation of 86% on room air,
and increasing restlessness. Which action should the nurse take first?
A. Encourage the client to drink fluids.
B. Apply oxygen according to the prescribed or emergency protocol.
C. Document the findings and reassess in 30 minutes.
D. Place the client in a supine position.
Answer: B
Rationale: The client demonstrates significant impaired oxygenation. Restlessness
can be an early sign of hypoxemia. The nurse should address oxygenation
immediately by applying oxygen as indicated and continuing assessment. Delaying
intervention could allow respiratory compromise to worsen.
Question 5
The nurse is evaluating a client's blood pressure measurement. Which finding
could produce a falsely elevated reading?
A. Using a cuff that is too large.
B. Positioning the arm above heart level.
C. Using a cuff that is too small.
D. Allowing the client to rest quietly before measurement.
Answer: C
Rationale: A blood pressure cuff that is too small can produce a falsely elevated
blood pressure reading. The cuff should have an appropriately sized bladder for the
client's arm circumference. The arm should be supported approximately at heart
level, and the client should rest before measurement.
, Question 6
A nurse is caring for an older adult who has weakness, urinary urgency, and a
history of falls. Which intervention is most appropriate for reducing the client's fall
risk?
A. Keep all four side rails raised.
B. Place the call light within reach and establish scheduled toileting.
C. Encourage the client to walk independently to maintain strength.
D. Keep the room dark at night to promote sleep.
Answer: B
Rationale: Scheduled toileting can reduce the likelihood that the client will
attempt to get up independently because of urinary urgency. The call light should
remain accessible, and the environment should be adequately illuminated. Four
side rails may constitute a restraint and do not eliminate fall risk. Ambulation
should be assisted when needed.
Question 7
A nurse receives a prescription to administer 500 mg of a medication orally. The
available tablets contain 250 mg each. How many tablets should the nurse
administer?
A. 0.5 tablet
B. 1 tablet
C. 2 tablets
D. 4 tablets
Answer: C
Rationale: The prescribed dose is 500 mg and each tablet contains 250 mg.
Therefore, 500 ÷ 250 = 2 tablets. Medication calculations should be verified before
administration, particularly when the prescribed dose differs from the available
formulation.
CHAMBERLAIN UNIVERSITY ACTUAL EXAM
QUESTIONS AND CORRECT VERIFIED ANSWERS
WITH RATIONALES 100% GUARANTEED PASS!!
<LATEST VERSION>
Question 1
A nurse is caring for a client who is 8 hours postoperative following abdominal
surgery. The client reports increasing abdominal pressure and suddenly coughs.
The nurse observes that the surgical incision has separated and loops of bowel are
visible through the opening. Which action should the nurse take first?
A. Apply a sterile dressing moistened with sterile normal saline over the exposed
organs.
B. Attempt to gently return the organs into the abdominal cavity.
C. Place the client in a high-Fowler position to reduce respiratory complications.
D. Apply an abdominal binder tightly around the client's abdomen.
Answer: A
Rationale: Evisceration is a surgical emergency. The exposed organs should be
protected immediately with sterile gauze or dressings moistened with sterile
normal saline to prevent tissue drying. The nurse should then notify the provider
and anticipate further intervention. The organs should never be pushed back into
the abdomen. A low-Fowler or supine position with knees flexed may decrease
tension on the wound.
,Question 2
A nurse is preparing to administer oral medications to a client. The medication
administration record lists acetaminophen 650 mg PO every 6 hours as needed for
pain. The client states, "I already received my pain medication from another nurse
about an hour ago." What is the nurse's priority action?
A. Administer the medication because it is currently listed as due.
B. Hold the medication and verify the previous administration record.
C. Ask the client whether the previous medication relieved the pain.
D. Administer half of the prescribed dose.
Answer: B
Rationale: The nurse must verify the medication administration history before
giving another dose. Administering a medication without confirming the previous
dose could result in an overdose. The nurse should review the MAR and clarify
discrepancies before administration. The client's report of receiving medication is
an important cue requiring investigation.
Question 3
During a sterile dressing change, the nurse accidentally allows a sterile glove to
touch the edge of the patient's bed. What should the nurse do?
A. Continue the procedure because the glove is still visibly clean.
B. Clean the glove with an alcohol-based hand sanitizer.
C. Replace the contaminated glove before continuing.
D. Cover the contaminated area with sterile gauze.
Answer: C
Rationale: The outer surface of a sterile glove is considered contaminated when it
contacts a nonsterile surface. The nurse should replace the glove before continuing.
Cleaning the glove does not restore sterility. Maintaining the sterile field requires
recognizing and correcting contamination immediately.
,Question 4
A client has a respiratory rate of 30/min, oxygen saturation of 86% on room air,
and increasing restlessness. Which action should the nurse take first?
A. Encourage the client to drink fluids.
B. Apply oxygen according to the prescribed or emergency protocol.
C. Document the findings and reassess in 30 minutes.
D. Place the client in a supine position.
Answer: B
Rationale: The client demonstrates significant impaired oxygenation. Restlessness
can be an early sign of hypoxemia. The nurse should address oxygenation
immediately by applying oxygen as indicated and continuing assessment. Delaying
intervention could allow respiratory compromise to worsen.
Question 5
The nurse is evaluating a client's blood pressure measurement. Which finding
could produce a falsely elevated reading?
A. Using a cuff that is too large.
B. Positioning the arm above heart level.
C. Using a cuff that is too small.
D. Allowing the client to rest quietly before measurement.
Answer: C
Rationale: A blood pressure cuff that is too small can produce a falsely elevated
blood pressure reading. The cuff should have an appropriately sized bladder for the
client's arm circumference. The arm should be supported approximately at heart
level, and the client should rest before measurement.
, Question 6
A nurse is caring for an older adult who has weakness, urinary urgency, and a
history of falls. Which intervention is most appropriate for reducing the client's fall
risk?
A. Keep all four side rails raised.
B. Place the call light within reach and establish scheduled toileting.
C. Encourage the client to walk independently to maintain strength.
D. Keep the room dark at night to promote sleep.
Answer: B
Rationale: Scheduled toileting can reduce the likelihood that the client will
attempt to get up independently because of urinary urgency. The call light should
remain accessible, and the environment should be adequately illuminated. Four
side rails may constitute a restraint and do not eliminate fall risk. Ambulation
should be assisted when needed.
Question 7
A nurse receives a prescription to administer 500 mg of a medication orally. The
available tablets contain 250 mg each. How many tablets should the nurse
administer?
A. 0.5 tablet
B. 1 tablet
C. 2 tablets
D. 4 tablets
Answer: C
Rationale: The prescribed dose is 500 mg and each tablet contains 250 mg.
Therefore, 500 ÷ 250 = 2 tablets. Medication calculations should be verified before
administration, particularly when the prescribed dose differs from the available
formulation.
