NR224 Final Exam Actual Exam Style V3 |
NR 224 Fundamentals - Skills |
Chamberlain
1. When preparing to perform hand hygiene with soap and water, which action should the
nurse take first?
A. Adjust the water temperature to be warm.
B. Apply 3 to 5 mL of liquid soap to the hands.
C. Rub the hands together vigorously for 15 seconds.
D. Wet the hands and wrists under running water.
Answer: A
Rationale: The nurse should first adjust the water temperature to be warm to avoid skin
irritation and facilitate lathering. Hot water can strip the skin of natural oils and increase
the risk of dermatitis. After the temperature is set, the nurse can proceed to wet the hands
and apply soap.
2. A nurse is assessing a patient’s radial pulse and finds it to be irregular. What is the most
appropriate next step?
A. Count the radial pulse for a full 60 seconds.
B. Assess the apical pulse for one full minute.
C. Document the finding and notify the physician immediately.
,D. Use a Doppler ultrasound to confirm the pulse rate.
Answer: B
Rationale: If a peripheral pulse is irregular, the nurse should assess the apical pulse for
one full minute to get an accurate heart rate. This allows the nurse to identify the specific
rhythm and any deficits between the apical and radial sites. It is the gold standard for
assessing cardiac rhythm when irregularities are noted.
3. The nurse is preparing to insert an indwelling urinary catheter. Which action is essential to
maintain surgical asepsis?
A. Keeping the sterile field at least 6 inches away from the body.
B. Wearing clean gloves to open the sterile catheter kit.
C. Ensuring the sterile field remains above waist level.
D. Cleaning the labia minora before the labia majora.
Answer: C
Rationale: Surgical asepsis requires that sterile objects remain above the level of the waist
to prevent contamination. Anything held below the waist is considered contaminated
because it is out of the nurse’s line of vision. Maintaining this boundary is critical for
preventing healthcare-associated infections during invasive procedures.
4. A patient is on contact precautions for MRSA. Which personal protective equipment (PPE)
must the nurse don before entering the room?
A. Mask and goggles.
, B. Gown and gloves.
C. N95 respirator and gloves.
D. Gown, gloves, and a mask.
Answer: B
Rationale: Contact precautions require the use of a gown and gloves to prevent the
transmission of organisms through direct or indirect contact. The gown prevents
contamination of clothing, while gloves prevent hand carriage. These items must be donned
before entering the patient’s environment.
5. The nurse is teaching a patient how to use a cane for the first time. On which side should
the patient hold the cane?
A. The weaker side to provide direct support.
B. The stronger side to improve balance and support.
C. The side that feels most comfortable to the patient.
D. Both sides simultaneously using two canes.
Answer: B
Rationale: A cane should always be held on the stronger side of the body. This helps shift
weight away from the weaker leg and provides a wider base of support for balance. The
cane and the weaker leg should move forward together during ambulation.
NR 224 Fundamentals - Skills |
Chamberlain
1. When preparing to perform hand hygiene with soap and water, which action should the
nurse take first?
A. Adjust the water temperature to be warm.
B. Apply 3 to 5 mL of liquid soap to the hands.
C. Rub the hands together vigorously for 15 seconds.
D. Wet the hands and wrists under running water.
Answer: A
Rationale: The nurse should first adjust the water temperature to be warm to avoid skin
irritation and facilitate lathering. Hot water can strip the skin of natural oils and increase
the risk of dermatitis. After the temperature is set, the nurse can proceed to wet the hands
and apply soap.
2. A nurse is assessing a patient’s radial pulse and finds it to be irregular. What is the most
appropriate next step?
A. Count the radial pulse for a full 60 seconds.
B. Assess the apical pulse for one full minute.
C. Document the finding and notify the physician immediately.
,D. Use a Doppler ultrasound to confirm the pulse rate.
Answer: B
Rationale: If a peripheral pulse is irregular, the nurse should assess the apical pulse for
one full minute to get an accurate heart rate. This allows the nurse to identify the specific
rhythm and any deficits between the apical and radial sites. It is the gold standard for
assessing cardiac rhythm when irregularities are noted.
3. The nurse is preparing to insert an indwelling urinary catheter. Which action is essential to
maintain surgical asepsis?
A. Keeping the sterile field at least 6 inches away from the body.
B. Wearing clean gloves to open the sterile catheter kit.
C. Ensuring the sterile field remains above waist level.
D. Cleaning the labia minora before the labia majora.
Answer: C
Rationale: Surgical asepsis requires that sterile objects remain above the level of the waist
to prevent contamination. Anything held below the waist is considered contaminated
because it is out of the nurse’s line of vision. Maintaining this boundary is critical for
preventing healthcare-associated infections during invasive procedures.
4. A patient is on contact precautions for MRSA. Which personal protective equipment (PPE)
must the nurse don before entering the room?
A. Mask and goggles.
, B. Gown and gloves.
C. N95 respirator and gloves.
D. Gown, gloves, and a mask.
Answer: B
Rationale: Contact precautions require the use of a gown and gloves to prevent the
transmission of organisms through direct or indirect contact. The gown prevents
contamination of clothing, while gloves prevent hand carriage. These items must be donned
before entering the patient’s environment.
5. The nurse is teaching a patient how to use a cane for the first time. On which side should
the patient hold the cane?
A. The weaker side to provide direct support.
B. The stronger side to improve balance and support.
C. The side that feels most comfortable to the patient.
D. Both sides simultaneously using two canes.
Answer: B
Rationale: A cane should always be held on the stronger side of the body. This helps shift
weight away from the weaker leg and provides a wider base of support for balance. The
cane and the weaker leg should move forward together during ambulation.
