NR224 Final Exam Actual Exam Style V2 |
NR 224 Fundamentals - Skills |
Chamberlain
1. A nurse is preparing to perform a physical assessment on a client. Which technique should
the nurse perform first when assessing the abdomen?
A. Palpation
B. Percussion
C. Auscultation
D. Inspection
Answer: D
Rationale: Inspection is always the first step in any physical assessment to observe for
visible abnormalities. In the abdominal assessment, auscultation follows inspection to
ensure bowel sounds are not altered by manipulation. Palpation and percussion are
performed last because they can stimulate peristalsis.
2. When providing oral care for an unconscious patient, which action is the priority for the
nurse to prevent aspiration?
A. Use a large amount of water to rinse the mouth
B. Keep the head of the bed flat
C. Position the patient in a side-lying (lateral) position
,D. Brush the teeth with a hard-bristle toothbrush
Answer: C
Rationale: Positioning an unconscious patient in a lateral position allows fluids to drain
out of the mouth by gravity rather than being inhaled. The nurse should also have suction
equipment readily available at the bedside. Keeping the head of the bed flat or using
excessive water increases the risk of fluids entering the airway.
3. Which of the following is the correct sequence for removing Personal Protective Equipment
(PPE)?
A. Gown, mask, eyewear, gloves
B. Mask, gown, gloves, eyewear
C. Gloves, eyewear, gown, mask
D. Eyewear, mask, gown, gloves
Answer: C
Rationale: The most contaminated items, the gloves, should be removed first to prevent
spreading pathogens to other areas. Eyewear and the gown are removed next, often
followed by the mask or respirator. This sequence is designed to minimize the risk of self-
contamination during the doffing process.
4. A nurse is measuring a client’s blood pressure and finds the cuff is too small. What effect
will this have on the reading?
A. The reading will be falsely low
, B. The diastolic reading will be low and systolic will be high
C. The reading will be accurate
D. The reading will be falsely high
Answer: D
Rationale: A blood pressure cuff that is too small requires more pressure to occlude the
artery, resulting in a falsely high reading. Conversely, a cuff that is too large will provide a
falsely low reading. Proper cuff sizing is essential for clinical accuracy and patient safety.
5. A client is diagnosed with Clostridium difficile (C. diff). Which infection control precaution
must the nurse implement?
A. Standard precautions only
B. Droplet precautions
C. Airborne precautions
D. Contact precautions
Answer: D
Rationale: C. diff requires contact precautions because the spores are spread through
direct and indirect contact with contaminated surfaces. Hand hygiene must be performed
with soap and water because alcohol-based rubs are ineffective against C. diff spores.
Nurses must wear gowns and gloves when entering the room to prevent transmission.
NR 224 Fundamentals - Skills |
Chamberlain
1. A nurse is preparing to perform a physical assessment on a client. Which technique should
the nurse perform first when assessing the abdomen?
A. Palpation
B. Percussion
C. Auscultation
D. Inspection
Answer: D
Rationale: Inspection is always the first step in any physical assessment to observe for
visible abnormalities. In the abdominal assessment, auscultation follows inspection to
ensure bowel sounds are not altered by manipulation. Palpation and percussion are
performed last because they can stimulate peristalsis.
2. When providing oral care for an unconscious patient, which action is the priority for the
nurse to prevent aspiration?
A. Use a large amount of water to rinse the mouth
B. Keep the head of the bed flat
C. Position the patient in a side-lying (lateral) position
,D. Brush the teeth with a hard-bristle toothbrush
Answer: C
Rationale: Positioning an unconscious patient in a lateral position allows fluids to drain
out of the mouth by gravity rather than being inhaled. The nurse should also have suction
equipment readily available at the bedside. Keeping the head of the bed flat or using
excessive water increases the risk of fluids entering the airway.
3. Which of the following is the correct sequence for removing Personal Protective Equipment
(PPE)?
A. Gown, mask, eyewear, gloves
B. Mask, gown, gloves, eyewear
C. Gloves, eyewear, gown, mask
D. Eyewear, mask, gown, gloves
Answer: C
Rationale: The most contaminated items, the gloves, should be removed first to prevent
spreading pathogens to other areas. Eyewear and the gown are removed next, often
followed by the mask or respirator. This sequence is designed to minimize the risk of self-
contamination during the doffing process.
4. A nurse is measuring a client’s blood pressure and finds the cuff is too small. What effect
will this have on the reading?
A. The reading will be falsely low
, B. The diastolic reading will be low and systolic will be high
C. The reading will be accurate
D. The reading will be falsely high
Answer: D
Rationale: A blood pressure cuff that is too small requires more pressure to occlude the
artery, resulting in a falsely high reading. Conversely, a cuff that is too large will provide a
falsely low reading. Proper cuff sizing is essential for clinical accuracy and patient safety.
5. A client is diagnosed with Clostridium difficile (C. diff). Which infection control precaution
must the nurse implement?
A. Standard precautions only
B. Droplet precautions
C. Airborne precautions
D. Contact precautions
Answer: D
Rationale: C. diff requires contact precautions because the spores are spread through
direct and indirect contact with contaminated surfaces. Hand hygiene must be performed
with soap and water because alcohol-based rubs are ineffective against C. diff spores.
Nurses must wear gowns and gloves when entering the room to prevent transmission.
