NR224 Exam 4 Actual Exam Style V2 | NR
224 Fundamentals - Skills | Chamberlain
1. A nurse is preparing a sterile field for a dressing change. Which action by the nurse would
break the sterile field?
A. Opening the outermost flap of a sterile kit away from the body.
B. Dropping a sterile gauze pad onto the field from 6 inches above.
C. Keeping sterile gloved hands above the waist level.
D. Reaching over the sterile field to pick up a pair of forceps.
Answer: D
Rationale: Reaching over a sterile field is a violation of surgical asepsis because
microorganisms from the nurse’s clothing or skin can fall onto the field. Sterile objects
must only touch other sterile objects to maintain integrity. The nurse should always work
around the perimeter of the field to avoid cross-contamination.
2. The nurse is caring for a postoperative patient who is at risk for deep vein thrombosis
(DVT). Which intervention is most effective for prevention?
A. Massaging the patient’s calves twice daily.
B. Placing a pillow under the patient’s knees.
C. Assisting the patient with early ambulation.
,D. Restricting oral fluid intake.
Answer: C
Rationale: Early ambulation is the primary nursing intervention to prevent DVT because it
promotes venous return through muscle contraction. Massaging calves is contraindicated
as it may dislodge an existing clot. Placing pillows under the knees can actually impede
venous flow and increase the risk of thrombus formation.
3. When suctioning a patient with a tracheostomy, which action should the nurse take to
prevent hypoxia?
A. Pre-oxygenate the patient with 100% oxygen.
B. Suction for at least 20 seconds each time.
C. Apply suction while inserting the catheter.
D. Use the highest possible suction pressure.
Answer: A
Rationale: Pre-oxygenation with 100% oxygen before suctioning is critical to provide a
reserve for the patient during the procedure. Suctioning should never last longer than 10 to
15 seconds to prevent significant drops in oxygen saturation. Suction should only be
applied intermittently while withdrawing the catheter, not during insertion.
4. A patient is 24 hours postoperative following abdominal surgery. The nurse notes the
patient’s wound has eviscerated. What is the immediate priority action?
A. Push the protruding organs back into the abdominal cavity.
, B. Cover the wound with sterile towels soaked in normal saline.
C. Apply a dry sterile pressure dressing to the site.
D. Place the patient in a high-Fowler’s position.
Answer: B
Rationale: Evisceration is a medical emergency where internal organs protrude through
an incision. The nurse must cover the exposed tissue with sterile, saline-soaked dressings
to keep the organs moist and prevent infection. This is followed by immediate notification
of the surgeon and keeping the patient in a low-Fowler’s position with knees flexed.
5. Which assessment finding is an early sign of hypoxia in a patient with a respiratory
disorder?
A. Restlessness and agitation.
B. Cyanosis of the lips and nail beds.
C. Bradycardia and hypotension.
D. Decreased respiratory rate.
Answer: A
Rationale: Restlessness, agitation, and apprehension are the earliest clinical signs of
hypoxia as the brain is sensitive to falling oxygen levels. Cyanosis is considered a late sign
and indicates severe oxygen deprivation. Nursing interventions should focus on assessing
the patient’s mental status alongside vital signs when respiratory distress is suspected.
224 Fundamentals - Skills | Chamberlain
1. A nurse is preparing a sterile field for a dressing change. Which action by the nurse would
break the sterile field?
A. Opening the outermost flap of a sterile kit away from the body.
B. Dropping a sterile gauze pad onto the field from 6 inches above.
C. Keeping sterile gloved hands above the waist level.
D. Reaching over the sterile field to pick up a pair of forceps.
Answer: D
Rationale: Reaching over a sterile field is a violation of surgical asepsis because
microorganisms from the nurse’s clothing or skin can fall onto the field. Sterile objects
must only touch other sterile objects to maintain integrity. The nurse should always work
around the perimeter of the field to avoid cross-contamination.
2. The nurse is caring for a postoperative patient who is at risk for deep vein thrombosis
(DVT). Which intervention is most effective for prevention?
A. Massaging the patient’s calves twice daily.
B. Placing a pillow under the patient’s knees.
C. Assisting the patient with early ambulation.
,D. Restricting oral fluid intake.
Answer: C
Rationale: Early ambulation is the primary nursing intervention to prevent DVT because it
promotes venous return through muscle contraction. Massaging calves is contraindicated
as it may dislodge an existing clot. Placing pillows under the knees can actually impede
venous flow and increase the risk of thrombus formation.
3. When suctioning a patient with a tracheostomy, which action should the nurse take to
prevent hypoxia?
A. Pre-oxygenate the patient with 100% oxygen.
B. Suction for at least 20 seconds each time.
C. Apply suction while inserting the catheter.
D. Use the highest possible suction pressure.
Answer: A
Rationale: Pre-oxygenation with 100% oxygen before suctioning is critical to provide a
reserve for the patient during the procedure. Suctioning should never last longer than 10 to
15 seconds to prevent significant drops in oxygen saturation. Suction should only be
applied intermittently while withdrawing the catheter, not during insertion.
4. A patient is 24 hours postoperative following abdominal surgery. The nurse notes the
patient’s wound has eviscerated. What is the immediate priority action?
A. Push the protruding organs back into the abdominal cavity.
, B. Cover the wound with sterile towels soaked in normal saline.
C. Apply a dry sterile pressure dressing to the site.
D. Place the patient in a high-Fowler’s position.
Answer: B
Rationale: Evisceration is a medical emergency where internal organs protrude through
an incision. The nurse must cover the exposed tissue with sterile, saline-soaked dressings
to keep the organs moist and prevent infection. This is followed by immediate notification
of the surgeon and keeping the patient in a low-Fowler’s position with knees flexed.
5. Which assessment finding is an early sign of hypoxia in a patient with a respiratory
disorder?
A. Restlessness and agitation.
B. Cyanosis of the lips and nail beds.
C. Bradycardia and hypotension.
D. Decreased respiratory rate.
Answer: A
Rationale: Restlessness, agitation, and apprehension are the earliest clinical signs of
hypoxia as the brain is sensitive to falling oxygen levels. Cyanosis is considered a late sign
and indicates severe oxygen deprivation. Nursing interventions should focus on assessing
the patient’s mental status alongside vital signs when respiratory distress is suspected.
