,NR 224 Fundamentals Skills Final Exam|
Chamberlain College | Latest 2026/2027 Update
(PDF)
1. A nursing student is performing a head-to-toe assessment on a client admitted for heart failure.
When auscultating the client's lungs, the student hears crackling sounds during inspiration that do not
clear with coughing. These sounds are most consistent with which finding?
A) Wheezing caused by narrowed airways during the expiratory phase
B) Crackles caused by fluid accumulation in the alveoli and small airways
C) Pleural friction rub caused by inflammation of the pleural surfaces
D) Stridor caused by upper airway obstruction
Correct Answer: Crackles caused by fluid accumulation in the alveoli and small airways
Rationale: Crackles are discontinuous, short, high-pitched sounds heard during inspiration that do not
clear with coughing. They result from fluid accumulation in the alveoli and small airways, commonly
seen in heart failure and pulmonary edema. Wheezing is a continuous musical sound, pleural friction
rub is a grating sound, and stridor is a high-pitched inspiratory sound indicating upper airway
obstruction.
2. During a health history interview, a nurse asks the client, "Describe for me your typical diet over a
24-hour day. What foods do you prefer? Have you noticed a change in your weight recently?" This
series of questions would likely occur during which phase of a patient-centered interview?
A) Setting the stage
B) Gathering information about the client's chief concerns
C) Collecting the assessment
D) Termination
Correct Answer: Collecting the assessment
Rationale: Collecting the assessment involves gathering detailed information about the client's health
status, including diet, preferences, and weight changes. This is the data collection phase of the nursing
,process where the nurse systematically gathers subjective and objective data. Setting the stage
involves introductions, gathering information focuses on chief concerns, and termination involves
summarizing and planning.
3. A nurse checks a client's intravenous (IV) line in the right arm and sees inflammation where the
catheter enters the skin. The nurse applies light pressure just above the IV site, and the client reports
tenderness. The nurse checks to see if the IV line is running at the correct rate. This is an example of
which phase of the nursing process?
A) Assessment
B) Diagnosis
C) Planning
D) Implementation
Correct Answer: Assessment
Rationale: Assessment is the systematic collection of data through observation, palpation, and other
techniques. The nurse is gathering data about the IV site, including inflammation, tenderness, and
infusion rate. Diagnosis involves interpreting the data, planning involves goal setting, and
implementation involves carrying out interventions.
4. A nurse is performing a physical assessment on a client with abdominal pain. Which sequence
should the nurse use for the abdominal assessment?
A) Inspection, palpation, percussion, auscultation
B) Inspection, auscultation, percussion, palpation
C) Auscultation, inspection, palpation, percussion
D) Palpation, inspection, auscultation, percussion
Correct Answer: Inspection, auscultation, percussion, palpation
Rationale: The correct sequence for abdominal assessment is inspection, auscultation, percussion, and
palpation. Auscultation is performed before percussion and palpation because these techniques can
alter bowel sounds. Palpation is performed last to prevent guarding and discomfort.
, 5. A nurse is assessing a client's pain. Which of the following is an objective finding?
A) The client reports pain as "aching" and "constant"
B) The client rates pain as 7 on a 0-10 scale
C) The nurse observes the client grimacing and guarding the abdomen
D) The client states the pain radiates to the back
Correct Answer: The nurse observes the client grimacing and guarding the abdomen
Rationale: Objective data are observable and measurable findings that the nurse can verify through
the senses. Grimacing and guarding are directly observed by the nurse. The client's reported pain
characteristics, rating, and radiation are subjective data based on the client's perception.
6. A nurse is preparing to perform hand hygiene. Which action is most effective in preventing the
spread of infection?
A) Using alcohol-based hand rub when hands are visibly soiled
B) Performing hand hygiene before and after client contact
C) Wearing gloves as a substitute for hand hygiene
D) Using a towel to turn off the faucet
Correct Answer: Performing hand hygiene before and after client contact
Rationale: Hand hygiene before and after client contact is the single most effective measure to
prevent the spread of infection. Alcohol-based hand rubs are not effective when hands are visibly
soiled. Gloves do not replace hand hygiene. Using a towel to turn off the faucet is a technique but not
the primary prevention measure.
7. A nurse is preparing to enter the room of a client on airborne precautions. Which PPE is required?
A) Gloves only
B) Mask and gloves
C) N95 respirator and gloves
D) N95 respirator, gown, and gloves
Chamberlain College | Latest 2026/2027 Update
(PDF)
1. A nursing student is performing a head-to-toe assessment on a client admitted for heart failure.
When auscultating the client's lungs, the student hears crackling sounds during inspiration that do not
clear with coughing. These sounds are most consistent with which finding?
A) Wheezing caused by narrowed airways during the expiratory phase
B) Crackles caused by fluid accumulation in the alveoli and small airways
C) Pleural friction rub caused by inflammation of the pleural surfaces
D) Stridor caused by upper airway obstruction
Correct Answer: Crackles caused by fluid accumulation in the alveoli and small airways
Rationale: Crackles are discontinuous, short, high-pitched sounds heard during inspiration that do not
clear with coughing. They result from fluid accumulation in the alveoli and small airways, commonly
seen in heart failure and pulmonary edema. Wheezing is a continuous musical sound, pleural friction
rub is a grating sound, and stridor is a high-pitched inspiratory sound indicating upper airway
obstruction.
2. During a health history interview, a nurse asks the client, "Describe for me your typical diet over a
24-hour day. What foods do you prefer? Have you noticed a change in your weight recently?" This
series of questions would likely occur during which phase of a patient-centered interview?
A) Setting the stage
B) Gathering information about the client's chief concerns
C) Collecting the assessment
D) Termination
Correct Answer: Collecting the assessment
Rationale: Collecting the assessment involves gathering detailed information about the client's health
status, including diet, preferences, and weight changes. This is the data collection phase of the nursing
,process where the nurse systematically gathers subjective and objective data. Setting the stage
involves introductions, gathering information focuses on chief concerns, and termination involves
summarizing and planning.
3. A nurse checks a client's intravenous (IV) line in the right arm and sees inflammation where the
catheter enters the skin. The nurse applies light pressure just above the IV site, and the client reports
tenderness. The nurse checks to see if the IV line is running at the correct rate. This is an example of
which phase of the nursing process?
A) Assessment
B) Diagnosis
C) Planning
D) Implementation
Correct Answer: Assessment
Rationale: Assessment is the systematic collection of data through observation, palpation, and other
techniques. The nurse is gathering data about the IV site, including inflammation, tenderness, and
infusion rate. Diagnosis involves interpreting the data, planning involves goal setting, and
implementation involves carrying out interventions.
4. A nurse is performing a physical assessment on a client with abdominal pain. Which sequence
should the nurse use for the abdominal assessment?
A) Inspection, palpation, percussion, auscultation
B) Inspection, auscultation, percussion, palpation
C) Auscultation, inspection, palpation, percussion
D) Palpation, inspection, auscultation, percussion
Correct Answer: Inspection, auscultation, percussion, palpation
Rationale: The correct sequence for abdominal assessment is inspection, auscultation, percussion, and
palpation. Auscultation is performed before percussion and palpation because these techniques can
alter bowel sounds. Palpation is performed last to prevent guarding and discomfort.
, 5. A nurse is assessing a client's pain. Which of the following is an objective finding?
A) The client reports pain as "aching" and "constant"
B) The client rates pain as 7 on a 0-10 scale
C) The nurse observes the client grimacing and guarding the abdomen
D) The client states the pain radiates to the back
Correct Answer: The nurse observes the client grimacing and guarding the abdomen
Rationale: Objective data are observable and measurable findings that the nurse can verify through
the senses. Grimacing and guarding are directly observed by the nurse. The client's reported pain
characteristics, rating, and radiation are subjective data based on the client's perception.
6. A nurse is preparing to perform hand hygiene. Which action is most effective in preventing the
spread of infection?
A) Using alcohol-based hand rub when hands are visibly soiled
B) Performing hand hygiene before and after client contact
C) Wearing gloves as a substitute for hand hygiene
D) Using a towel to turn off the faucet
Correct Answer: Performing hand hygiene before and after client contact
Rationale: Hand hygiene before and after client contact is the single most effective measure to
prevent the spread of infection. Alcohol-based hand rubs are not effective when hands are visibly
soiled. Gloves do not replace hand hygiene. Using a towel to turn off the faucet is a technique but not
the primary prevention measure.
7. A nurse is preparing to enter the room of a client on airborne precautions. Which PPE is required?
A) Gloves only
B) Mask and gloves
C) N95 respirator and gloves
D) N95 respirator, gown, and gloves
