NR224 Final Exam Actual Exam Style V1 |
NR 224 Fundamentals - Skills |
Chamberlain
1. A nurse is preparing to assess a patient’s blood pressure. Which finding would most likely
result in a falsely high blood pressure reading?
A. The patient’s arm is positioned above the level of the heart.
B. The blood pressure cuff is too wide for the patient’s arm.
C. The blood pressure cuff is wrapped too loosely or is too narrow.
D. The nurse deflates the cuff too rapidly during the measurement.
Answer: C
Rationale: Using a cuff that is too narrow or applied too loosely requires more inflation
pressure to occlude the artery, leading to a falsely high reading. The nurse should ensure
the bladder width is 40% of the arm circumference to ensure accuracy. Proper cuff sizing is
a fundamental skill that prevents clinical errors in patient management.
2. Which of the following is the most reliable method for the initial confirmation of a
nasogastric (NG) tube placement?
A. Obtaining an abdominal X-ray to visualize the tube position.
B. Auscultating for a ‘whoosh’ sound while injecting 30 mL of air.
C. Testing the pH level of the aspirated gastric contents.
,D. Observing the color and consistency of the fluid aspirated from the tube.
Answer: A
Rationale: An abdominal X-ray is the gold standard for verifying the correct anatomical
placement of a nasogastric tube before any fluids are administered. While pH testing can be
used for ongoing verification, it is not as definitive as a radiograph. This step is critical to
prevent the life-threatening complication of pulmonary aspiration.
3. A nurse is maintaining a sterile field for a dressing change. Which action would violate the
principles of surgical asepsis?
A. Holding sterile objects above the level of the waist.
B. Keeping the sterile field within the direct line of vision.
C. Reaching across the sterile field to pick up a gauze sponge.
D. Discarding any item that touches the outer 1-inch border of the field.
Answer: C
Rationale: Reaching over a sterile field is a violation of aseptic technique because
microorganisms from the nurse’s clothing or skin can fall onto the sterile surface. The
nurse must maintain a clear boundary and always approach the field from the sides or
front without crossing over it. Proper aseptic technique is vital for preventing healthcare-
associated infections during invasive procedures.
, 4. A Registered Nurse (RN) is delegating tasks to an Assistive Personnel (AP). Which task is
most appropriate to delegate?
A. Assessing a new admission’s skin integrity and risk for pressure ulcers.
B. Performing a bed bath and oral hygiene for a stable patient.
C. Providing discharge instructions to a patient about wound care.
D. Evaluating the effectiveness of a patient’s pain medication.
Answer: B
Rationale: Standard nursing tasks like hygiene, feeding, and basic mobility for stable
patients are appropriate to delegate to assistive personnel. Tasks involving assessment,
patient education, or clinical judgment must be performed by the RN. The RN remains
accountable for the outcome of the delegated task and must ensure the AP is competent to
perform it.
5. According to the CDC, when is it mandatory to use soap and water for hand hygiene
instead of alcohol-based hand rub?
A. When the nurse’s hands are visibly soiled with blood or body fluids.
B. Immediately after removing clean gloves after a routine assessment.
C. Before entering the room of a patient who has a suppressed immune system.
D. After touching a patient’s intact skin during a physical exam.
Answer: A
NR 224 Fundamentals - Skills |
Chamberlain
1. A nurse is preparing to assess a patient’s blood pressure. Which finding would most likely
result in a falsely high blood pressure reading?
A. The patient’s arm is positioned above the level of the heart.
B. The blood pressure cuff is too wide for the patient’s arm.
C. The blood pressure cuff is wrapped too loosely or is too narrow.
D. The nurse deflates the cuff too rapidly during the measurement.
Answer: C
Rationale: Using a cuff that is too narrow or applied too loosely requires more inflation
pressure to occlude the artery, leading to a falsely high reading. The nurse should ensure
the bladder width is 40% of the arm circumference to ensure accuracy. Proper cuff sizing is
a fundamental skill that prevents clinical errors in patient management.
2. Which of the following is the most reliable method for the initial confirmation of a
nasogastric (NG) tube placement?
A. Obtaining an abdominal X-ray to visualize the tube position.
B. Auscultating for a ‘whoosh’ sound while injecting 30 mL of air.
C. Testing the pH level of the aspirated gastric contents.
,D. Observing the color and consistency of the fluid aspirated from the tube.
Answer: A
Rationale: An abdominal X-ray is the gold standard for verifying the correct anatomical
placement of a nasogastric tube before any fluids are administered. While pH testing can be
used for ongoing verification, it is not as definitive as a radiograph. This step is critical to
prevent the life-threatening complication of pulmonary aspiration.
3. A nurse is maintaining a sterile field for a dressing change. Which action would violate the
principles of surgical asepsis?
A. Holding sterile objects above the level of the waist.
B. Keeping the sterile field within the direct line of vision.
C. Reaching across the sterile field to pick up a gauze sponge.
D. Discarding any item that touches the outer 1-inch border of the field.
Answer: C
Rationale: Reaching over a sterile field is a violation of aseptic technique because
microorganisms from the nurse’s clothing or skin can fall onto the sterile surface. The
nurse must maintain a clear boundary and always approach the field from the sides or
front without crossing over it. Proper aseptic technique is vital for preventing healthcare-
associated infections during invasive procedures.
, 4. A Registered Nurse (RN) is delegating tasks to an Assistive Personnel (AP). Which task is
most appropriate to delegate?
A. Assessing a new admission’s skin integrity and risk for pressure ulcers.
B. Performing a bed bath and oral hygiene for a stable patient.
C. Providing discharge instructions to a patient about wound care.
D. Evaluating the effectiveness of a patient’s pain medication.
Answer: B
Rationale: Standard nursing tasks like hygiene, feeding, and basic mobility for stable
patients are appropriate to delegate to assistive personnel. Tasks involving assessment,
patient education, or clinical judgment must be performed by the RN. The RN remains
accountable for the outcome of the delegated task and must ensure the AP is competent to
perform it.
5. According to the CDC, when is it mandatory to use soap and water for hand hygiene
instead of alcohol-based hand rub?
A. When the nurse’s hands are visibly soiled with blood or body fluids.
B. Immediately after removing clean gloves after a routine assessment.
C. Before entering the room of a patient who has a suppressed immune system.
D. After touching a patient’s intact skin during a physical exam.
Answer: A
