NUR 210 EXAM 1 COMPREHENSIVE
ASSESSMENT QUESTIONS & ANSWERS
(CHAMBERLAIN) 100% GUARANTEE
PASS
1. A nurse is performing a primary assessment on a patient found unresponsive. Which action
should the nurse prioritize first according to the latest clinical guidelines?
A. Assess for a carotid pulse for no more than 10 seconds.
B. Begin chest compressions at a rate of 100-120 per minute.
C. Open the airway using the head-tilt, chin-lift maneuver.
D. Determine if the patient is breathing and has a pulse simultaneously.
Answer: D
Conceptual Explanation: Current BLS guidelines suggest checking for responsiveness,
breathing, and a pulse simultaneously to reduce time to first compression.
2. When caring for a patient with C. difficile, which infection control measure is mandatory
for the nurse to perform?
A. Washing hands with soap and water after patient contact.
B. Using alcohol-based hand sanitizer after exiting the room.
C. Wearing a surgical mask within 3 feet of the patient.
,D. Utilizing a negative-pressure airflow room.
Answer: A
Conceptual Explanation: C. difficile spores are resistant to alcohol-based sanitizers;
mechanical friction and soap are required to remove them.
3. A patient is admitted with a diagnosis of fluid volume excess. Which clinical manifestation
is most characteristic of this condition?
A. Flattened neck veins when supine.
B. Increased hematocrit and BUN levels.
C. Poor skin turgor and dry mucous membranes.
D. Presence of S3 heart sound and crackles in the lungs.
Answer: D
Conceptual Explanation: Fluid volume excess leads to hypervolemia, which can cause
cardiac gallops (S3) and pulmonary edema (crackles).
4. During a sterile dressing change, the nurse notices the sterile field has been touched by a
non-sterile glove. What is the nurse’s immediate action?
A. Continue the procedure if the touch was brief.
B. Clean the contaminated area with betadine.
C. Discard the entire sterile field and start over.
D. Only replace the item that was touched.
, Answer: C
Conceptual Explanation: If any part of a sterile field is contaminated, the entire field is
considered non-sterile and must be replaced to ensure patient safety.
5. A nurse is preparing to administer digoxin to a patient. The apical pulse is 54 bpm. What is
the nurse’s next action?
A. Administer the medication and document the heart rate.
B. Wait 30 minutes and re-check the pulse.
C. Hold the dose and notify the healthcare provider.
D. Administer half of the prescribed dose.
Answer: C
Conceptual Explanation: Digoxin is typically held if the heart rate is below 60 bpm in
adults to prevent further bradycardia.
6. Which stage of a pressure injury is characterized by full-thickness skin loss with visible
adipose tissue and epibole?
A. Stage 2
B. Unstageable
C. Stage 4
D. Stage 3
Answer: D
ASSESSMENT QUESTIONS & ANSWERS
(CHAMBERLAIN) 100% GUARANTEE
PASS
1. A nurse is performing a primary assessment on a patient found unresponsive. Which action
should the nurse prioritize first according to the latest clinical guidelines?
A. Assess for a carotid pulse for no more than 10 seconds.
B. Begin chest compressions at a rate of 100-120 per minute.
C. Open the airway using the head-tilt, chin-lift maneuver.
D. Determine if the patient is breathing and has a pulse simultaneously.
Answer: D
Conceptual Explanation: Current BLS guidelines suggest checking for responsiveness,
breathing, and a pulse simultaneously to reduce time to first compression.
2. When caring for a patient with C. difficile, which infection control measure is mandatory
for the nurse to perform?
A. Washing hands with soap and water after patient contact.
B. Using alcohol-based hand sanitizer after exiting the room.
C. Wearing a surgical mask within 3 feet of the patient.
,D. Utilizing a negative-pressure airflow room.
Answer: A
Conceptual Explanation: C. difficile spores are resistant to alcohol-based sanitizers;
mechanical friction and soap are required to remove them.
3. A patient is admitted with a diagnosis of fluid volume excess. Which clinical manifestation
is most characteristic of this condition?
A. Flattened neck veins when supine.
B. Increased hematocrit and BUN levels.
C. Poor skin turgor and dry mucous membranes.
D. Presence of S3 heart sound and crackles in the lungs.
Answer: D
Conceptual Explanation: Fluid volume excess leads to hypervolemia, which can cause
cardiac gallops (S3) and pulmonary edema (crackles).
4. During a sterile dressing change, the nurse notices the sterile field has been touched by a
non-sterile glove. What is the nurse’s immediate action?
A. Continue the procedure if the touch was brief.
B. Clean the contaminated area with betadine.
C. Discard the entire sterile field and start over.
D. Only replace the item that was touched.
, Answer: C
Conceptual Explanation: If any part of a sterile field is contaminated, the entire field is
considered non-sterile and must be replaced to ensure patient safety.
5. A nurse is preparing to administer digoxin to a patient. The apical pulse is 54 bpm. What is
the nurse’s next action?
A. Administer the medication and document the heart rate.
B. Wait 30 minutes and re-check the pulse.
C. Hold the dose and notify the healthcare provider.
D. Administer half of the prescribed dose.
Answer: C
Conceptual Explanation: Digoxin is typically held if the heart rate is below 60 bpm in
adults to prevent further bradycardia.
6. Which stage of a pressure injury is characterized by full-thickness skin loss with visible
adipose tissue and epibole?
A. Stage 2
B. Unstageable
C. Stage 4
D. Stage 3
Answer: D
