,NR 224 Fundamentals Skills Exam 2 | Chamberlain
1. A nurse is assessing a client's wound and notes that the wound edges are separated and underlying
tissue is visible. Which term should the nurse use to document this finding?
A) Dehiscence
B) Evisceration
C) Granulation
D) Epithelialization
Correct Answer: Dehiscence
Rationale: Dehiscence refers to the partial or total separation of wound layers, often occurring in
abdominal surgical wounds. Evisceration is the protrusion of internal organs through a completely
separated wound, which is a surgical emergency. Granulation and epithelialization are normal phases
of wound healing, not complications.
2. A client with a Stage 3 pressure injury has full-thickness tissue loss with visible subcutaneous fat.
Which assessment finding is most consistent with this stage?
A) Intact skin with nonblanchable redness
B) Partial-thickness skin loss with exposed dermis
C) Full-thickness tissue loss with visible adipose tissue
D) Full-thickness tissue loss with exposed bone or tendon
Correct Answer: Full-thickness tissue loss with visible adipose tissue
Rationale: Stage 3 pressure injuries involve full-thickness tissue loss where subcutaneous fat may be
visible, but bone, tendon, or muscle are not exposed. Stage 1 presents with intact skin and
nonblanchable redness, Stage 2 involves partial-thickness skin loss, and Stage 4 involves exposed
bone, tendon, or muscle.
3. A nurse is preparing to administer a subcutaneous injection. Which needle size is most appropriate
for this route?
,A) 18 gauge, 1.5 inch
B) 25 gauge, 5/8 inch
C) 22 gauge, 1 inch
D) 30 gauge, 1.5 inch
Correct Answer: 25 gauge, 5/8 inch
Rationale: Subcutaneous injections require a 25 to 27 gauge needle that is 3/8 to 5/8 inches long to
reach subcutaneous tissue without entering muscle. An 18 gauge, 1.5-inch needle is too large and long
for subcutaneous use. A 30 gauge needle is typically used for intradermal injections, and a 22 gauge,
1-inch needle may be used for intramuscular injections.
4. A nurse is teaching a client about using a cane. Which instruction should the nurse include?
A) Hold the cane on the weaker side
B) Hold the cane on the stronger side
C) Move the cane and weaker leg together
D) Use the cane only when climbing stairs
Correct Answer: Hold the cane on the stronger side
Rationale: A cane should be held on the client's stronger side to provide support while the weaker leg
moves forward. The cane and the weaker leg advance together. This provides a wider base of support
and improves balance. The cane is used for all ambulation, not only stairs.
5. A nurse is assessing a client's Braden Scale score. Which subscale assesses the client's ability to
change and control body position?
A) Sensory perception
B) Moisture
C) Activity
D) Mobility
, Correct Answer: Mobility
Rationale: The Braden Scale mobility subscale assesses the client's ability to change and control body
position. Sensory perception assesses the ability to respond to pressure-related discomfort, moisture
assesses skin exposure to moisture, and activity assesses the degree of physical activity. A lower score
indicates higher risk for pressure injury development.
6. A nurse is preparing to administer ear drops to an adult client. Which action should the nurse take?
A) Pull the auricle downward and back
B) Pull the auricle upward and back
C) Instill the drops directly onto the eardrum
D) Warm the drops in a microwave before administration
Correct Answer: Pull the auricle upward and back
Rationale: For adults, the auricle should be pulled upward and back to straighten the ear canal and
allow the medication to reach the tympanic membrane. For children, the auricle is pulled downward
and back. Drops should not be instilled directly onto the eardrum, and medications should be warmed
to room temperature, not microwaved.
7. A nurse is caring for a client who has been on bed rest for several days. Which complication should
the nurse monitor for related to immobility?
A) Increased peristalsis
B) Decreased heart rate
C) Orthostatic hypotension
D) Increased muscle mass
Correct Answer: Orthostatic hypotension
Rationale: Orthostatic hypotension is a common cardiovascular complication of immobility, occurring
due to decreased venous return and impaired autonomic reflexes. Immobility also causes decreased
1. A nurse is assessing a client's wound and notes that the wound edges are separated and underlying
tissue is visible. Which term should the nurse use to document this finding?
A) Dehiscence
B) Evisceration
C) Granulation
D) Epithelialization
Correct Answer: Dehiscence
Rationale: Dehiscence refers to the partial or total separation of wound layers, often occurring in
abdominal surgical wounds. Evisceration is the protrusion of internal organs through a completely
separated wound, which is a surgical emergency. Granulation and epithelialization are normal phases
of wound healing, not complications.
2. A client with a Stage 3 pressure injury has full-thickness tissue loss with visible subcutaneous fat.
Which assessment finding is most consistent with this stage?
A) Intact skin with nonblanchable redness
B) Partial-thickness skin loss with exposed dermis
C) Full-thickness tissue loss with visible adipose tissue
D) Full-thickness tissue loss with exposed bone or tendon
Correct Answer: Full-thickness tissue loss with visible adipose tissue
Rationale: Stage 3 pressure injuries involve full-thickness tissue loss where subcutaneous fat may be
visible, but bone, tendon, or muscle are not exposed. Stage 1 presents with intact skin and
nonblanchable redness, Stage 2 involves partial-thickness skin loss, and Stage 4 involves exposed
bone, tendon, or muscle.
3. A nurse is preparing to administer a subcutaneous injection. Which needle size is most appropriate
for this route?
,A) 18 gauge, 1.5 inch
B) 25 gauge, 5/8 inch
C) 22 gauge, 1 inch
D) 30 gauge, 1.5 inch
Correct Answer: 25 gauge, 5/8 inch
Rationale: Subcutaneous injections require a 25 to 27 gauge needle that is 3/8 to 5/8 inches long to
reach subcutaneous tissue without entering muscle. An 18 gauge, 1.5-inch needle is too large and long
for subcutaneous use. A 30 gauge needle is typically used for intradermal injections, and a 22 gauge,
1-inch needle may be used for intramuscular injections.
4. A nurse is teaching a client about using a cane. Which instruction should the nurse include?
A) Hold the cane on the weaker side
B) Hold the cane on the stronger side
C) Move the cane and weaker leg together
D) Use the cane only when climbing stairs
Correct Answer: Hold the cane on the stronger side
Rationale: A cane should be held on the client's stronger side to provide support while the weaker leg
moves forward. The cane and the weaker leg advance together. This provides a wider base of support
and improves balance. The cane is used for all ambulation, not only stairs.
5. A nurse is assessing a client's Braden Scale score. Which subscale assesses the client's ability to
change and control body position?
A) Sensory perception
B) Moisture
C) Activity
D) Mobility
, Correct Answer: Mobility
Rationale: The Braden Scale mobility subscale assesses the client's ability to change and control body
position. Sensory perception assesses the ability to respond to pressure-related discomfort, moisture
assesses skin exposure to moisture, and activity assesses the degree of physical activity. A lower score
indicates higher risk for pressure injury development.
6. A nurse is preparing to administer ear drops to an adult client. Which action should the nurse take?
A) Pull the auricle downward and back
B) Pull the auricle upward and back
C) Instill the drops directly onto the eardrum
D) Warm the drops in a microwave before administration
Correct Answer: Pull the auricle upward and back
Rationale: For adults, the auricle should be pulled upward and back to straighten the ear canal and
allow the medication to reach the tympanic membrane. For children, the auricle is pulled downward
and back. Drops should not be instilled directly onto the eardrum, and medications should be warmed
to room temperature, not microwaved.
7. A nurse is caring for a client who has been on bed rest for several days. Which complication should
the nurse monitor for related to immobility?
A) Increased peristalsis
B) Decreased heart rate
C) Orthostatic hypotension
D) Increased muscle mass
Correct Answer: Orthostatic hypotension
Rationale: Orthostatic hypotension is a common cardiovascular complication of immobility, occurring
due to decreased venous return and impaired autonomic reflexes. Immobility also causes decreased
