NR 224: Fundamentals of Nursing Final Exam Version 2 2026
|Chamberlain
1. A nurse is communicating with a client who is highly anxious about their
upcoming surgery. Which response by the nurse is therapeutic?
A. Don’t worry, you have the best surgeon in the hospital.
B. Why are you feeling so anxious right now?
C. It sounds like you are concerned about the procedure. Can you tell me more?
D. Most people feel this way before surgery; it is completely normal.
Answer: C
Rationale: Therapeutic communication involves open-ended questions and reflecting
feelings. Options A and D are non-therapeutic as they offer false reassurance or minimize
feelings, and option B uses ‘why’, which can make clients defensive.
2. A nurse is prioritizing care for four clients. Which client should the nurse
assess first?
A. A client who requested a PRN pain medication for a headache.
B. A client who needs to be discharged within the next hour.
C. A client with a respiratory rate of 28/min and oxygen saturation of 88%.
D. A client who has a dressing change due in 30 minutes.
Answer: C
Rationale: The nurse should use the ABC (Airway, Breathing, Circulation) framework. Low
oxygen saturation and tachypnea indicate a respiratory compromise that requires
immediate intervention.
,3. Which action should a nurse take to maintain a sterile field when performing
a dressing change?
A. Reach over the sterile field to pick up a gauze pad.
B. Place the sterile gloves on the bedside table after opening.
C. Allow the sterile field to touch the edge of the table.
D. Keep the sterile field within the line of vision at all times.
Answer: D
Rationale: Maintaining a sterile field requires keeping it in sight, avoiding reaching across
it, and ensuring the 1-inch border is considered contaminated.
4. A nurse is measuring orthostatic blood pressure. Which finding indicates
orthostatic hypotension?
A. A decrease in systolic blood pressure of 20 mmHg when moving from lying to standing.
B. An increase in diastolic blood pressure of 10 mmHg upon standing.
C. A decrease in heart rate of 10 beats/min upon sitting.
D. A decrease in systolic blood pressure of 5 mmHg upon standing.
Answer: A
Rationale: Orthostatic hypotension is defined as a drop in systolic blood pressure of at
least 20 mmHg or diastolic blood pressure of at least 10 mmHg within 3 minutes of
standing.
5. A nurse is caring for a client who is in wrist restraints. Which action is
essential for the nurse to perform?
A. Remove restraints every 4 hours for range of motion.
B. Check the skin integrity and pulses every 4 hours.
C. Tie the restraints to the side rails of the bed.
D. Renew the restraint order every 24 hours.
Answer: D
, Rationale: Restraint orders must be renewed every 24 hours by a provider. Skin checks
and circulation assessments usually occur every 2 hours, and restraints should be tied to
the bed frame, not the side rails.
6. During which phase of the nursing process does the nurse collect subjective
and objective data?
A. Diagnosis
B. Planning
C. Assessment
D. Implementation
Answer: C
Rationale: Assessment is the first step of the nursing process, involving the systematic
collection of data about the client’s health status.
7. A nurse observes a client’s pressure injury that has partial-thickness loss of
dermis and a shallow open ulcer without slough. How should the nurse stage
this injury?
A. Stage I
B. Stage II
C. Stage III
D. Stage IV
Answer: B
Rationale: Stage II pressure injuries involve partial-thickness skin loss with exposed
dermis, appearing as a shallow open ulcer or a serum-filled blister.
|Chamberlain
1. A nurse is communicating with a client who is highly anxious about their
upcoming surgery. Which response by the nurse is therapeutic?
A. Don’t worry, you have the best surgeon in the hospital.
B. Why are you feeling so anxious right now?
C. It sounds like you are concerned about the procedure. Can you tell me more?
D. Most people feel this way before surgery; it is completely normal.
Answer: C
Rationale: Therapeutic communication involves open-ended questions and reflecting
feelings. Options A and D are non-therapeutic as they offer false reassurance or minimize
feelings, and option B uses ‘why’, which can make clients defensive.
2. A nurse is prioritizing care for four clients. Which client should the nurse
assess first?
A. A client who requested a PRN pain medication for a headache.
B. A client who needs to be discharged within the next hour.
C. A client with a respiratory rate of 28/min and oxygen saturation of 88%.
D. A client who has a dressing change due in 30 minutes.
Answer: C
Rationale: The nurse should use the ABC (Airway, Breathing, Circulation) framework. Low
oxygen saturation and tachypnea indicate a respiratory compromise that requires
immediate intervention.
,3. Which action should a nurse take to maintain a sterile field when performing
a dressing change?
A. Reach over the sterile field to pick up a gauze pad.
B. Place the sterile gloves on the bedside table after opening.
C. Allow the sterile field to touch the edge of the table.
D. Keep the sterile field within the line of vision at all times.
Answer: D
Rationale: Maintaining a sterile field requires keeping it in sight, avoiding reaching across
it, and ensuring the 1-inch border is considered contaminated.
4. A nurse is measuring orthostatic blood pressure. Which finding indicates
orthostatic hypotension?
A. A decrease in systolic blood pressure of 20 mmHg when moving from lying to standing.
B. An increase in diastolic blood pressure of 10 mmHg upon standing.
C. A decrease in heart rate of 10 beats/min upon sitting.
D. A decrease in systolic blood pressure of 5 mmHg upon standing.
Answer: A
Rationale: Orthostatic hypotension is defined as a drop in systolic blood pressure of at
least 20 mmHg or diastolic blood pressure of at least 10 mmHg within 3 minutes of
standing.
5. A nurse is caring for a client who is in wrist restraints. Which action is
essential for the nurse to perform?
A. Remove restraints every 4 hours for range of motion.
B. Check the skin integrity and pulses every 4 hours.
C. Tie the restraints to the side rails of the bed.
D. Renew the restraint order every 24 hours.
Answer: D
, Rationale: Restraint orders must be renewed every 24 hours by a provider. Skin checks
and circulation assessments usually occur every 2 hours, and restraints should be tied to
the bed frame, not the side rails.
6. During which phase of the nursing process does the nurse collect subjective
and objective data?
A. Diagnosis
B. Planning
C. Assessment
D. Implementation
Answer: C
Rationale: Assessment is the first step of the nursing process, involving the systematic
collection of data about the client’s health status.
7. A nurse observes a client’s pressure injury that has partial-thickness loss of
dermis and a shallow open ulcer without slough. How should the nurse stage
this injury?
A. Stage I
B. Stage II
C. Stage III
D. Stage IV
Answer: B
Rationale: Stage II pressure injuries involve partial-thickness skin loss with exposed
dermis, appearing as a shallow open ulcer or a serum-filled blister.
