# NR 224 Fundamentals of Nursing Final
Examination
## Comprehensive Practice Questions with
Rationales
---
**Question 1**
A nurse is preparing to administer an enteral feeding through a nasogastric tube. Which of the following
actions should the nurse take to verify proper tube placement?
A. Auscultate over the stomach while injecting air
B. Check the pH of aspirated gastric contents
C. Observe the client for coughing or choking
D. Measure the external length of the tube
💫RATIONALE✔️✔️: pH testing of aspirated gastric contents is the most reliable method to verify NG tube
placement, with gastric pH typically between 1-5.
💫ANSWER✔️✔️: B. Check the pH of aspirated gastric contents
---
**Question 2**
A client has an order for 750 mL of 0.9% normal saline to be infused over 6 hours. The drop factor is 20
gtt/mL. What is the drip rate in drops per minute?
,A. 31 gtt/min
B. 42 gtt/min
C. 52 gtt/min
D. 62 gtt/min
💫RATIONALE✔️✔️: 750 mL/6 hours = 125 mL/hour; 125 mL/hour × 20 gtt/mL = 2500 gtt/hour; 2500/60
minutes = 41.6 gtt/min (round to 42 gtt/min).
💫ANSWER✔️✔️: B. 42 gtt/min
---
**Question 3**
A nurse is performing a sterile dressing change for a client with a surgical wound. Which of the following
actions indicates a break in sterile technique?
A. Opening the sterile kit away from the body
B. Using sterile gloves during the procedure
C. Drying the wound with sterile gauze
D. Reaching over the sterile field to obtain supplies
💫RATIONALE✔️✔️: Reaching over the sterile field contaminates the field and violates sterile technique.
💫ANSWER✔️✔️: D. Reaching over the sterile field to obtain supplies
---
,**Question 4**
A client is 3 days post-operative and reports shortness of breath and chest pain. The nurse notes the
client's oxygen saturation is 89% on room air. Which of the following conditions should the nurse
suspect?
A. Atelectasis
B. Pulmonary embolism
C. Pneumonia
D. Wound infection
💫RATIONALE✔️✔️: Postoperative clients with sudden dyspnea, chest pain, and hypoxemia are at risk for
pulmonary embolism.
💫ANSWER✔️✔️: B. Pulmonary embolism
---
**Question 5**
A nurse is providing perineal care to a female client with an indwelling urinary catheter. Which of the
following actions is correct?
A. Clean from the rectum toward the urethra
B. Use the same swab for each cleaning stroke
C. Clean from the urethra toward the rectum
D. Use soap and water to clean the catheter
💫RATIONALE✔️✔️: Perineal care should be performed from the urethra toward the rectum to prevent
introducing bacteria into the urinary tract.
, 💫ANSWER✔️✔️: C. Clean from the urethra toward the rectum
---
**Question 6**
A client is experiencing nausea and vomiting. Which of the following nursing interventions should the
nurse implement first?
A. Administer an antiemetic medication
B. Assess the client's abdomen
C. Offer clear liquids in small amounts
D. Measure the client's vital signs
💫RATIONALE✔️✔️: The nurse should first assess the client's abdomen to identify the cause of nausea
and vomiting.
💫ANSWER✔️✔️: B. Assess the client's abdomen
---
**Question 7**
A nurse is assessing a client's pain level using the FLACC scale. Which of the following clients is this scale
most appropriate for?
A. An alert and oriented adult
B. A cognitively impaired older adult
C. A toddler who is non-verbal
Examination
## Comprehensive Practice Questions with
Rationales
---
**Question 1**
A nurse is preparing to administer an enteral feeding through a nasogastric tube. Which of the following
actions should the nurse take to verify proper tube placement?
A. Auscultate over the stomach while injecting air
B. Check the pH of aspirated gastric contents
C. Observe the client for coughing or choking
D. Measure the external length of the tube
💫RATIONALE✔️✔️: pH testing of aspirated gastric contents is the most reliable method to verify NG tube
placement, with gastric pH typically between 1-5.
💫ANSWER✔️✔️: B. Check the pH of aspirated gastric contents
---
**Question 2**
A client has an order for 750 mL of 0.9% normal saline to be infused over 6 hours. The drop factor is 20
gtt/mL. What is the drip rate in drops per minute?
,A. 31 gtt/min
B. 42 gtt/min
C. 52 gtt/min
D. 62 gtt/min
💫RATIONALE✔️✔️: 750 mL/6 hours = 125 mL/hour; 125 mL/hour × 20 gtt/mL = 2500 gtt/hour; 2500/60
minutes = 41.6 gtt/min (round to 42 gtt/min).
💫ANSWER✔️✔️: B. 42 gtt/min
---
**Question 3**
A nurse is performing a sterile dressing change for a client with a surgical wound. Which of the following
actions indicates a break in sterile technique?
A. Opening the sterile kit away from the body
B. Using sterile gloves during the procedure
C. Drying the wound with sterile gauze
D. Reaching over the sterile field to obtain supplies
💫RATIONALE✔️✔️: Reaching over the sterile field contaminates the field and violates sterile technique.
💫ANSWER✔️✔️: D. Reaching over the sterile field to obtain supplies
---
,**Question 4**
A client is 3 days post-operative and reports shortness of breath and chest pain. The nurse notes the
client's oxygen saturation is 89% on room air. Which of the following conditions should the nurse
suspect?
A. Atelectasis
B. Pulmonary embolism
C. Pneumonia
D. Wound infection
💫RATIONALE✔️✔️: Postoperative clients with sudden dyspnea, chest pain, and hypoxemia are at risk for
pulmonary embolism.
💫ANSWER✔️✔️: B. Pulmonary embolism
---
**Question 5**
A nurse is providing perineal care to a female client with an indwelling urinary catheter. Which of the
following actions is correct?
A. Clean from the rectum toward the urethra
B. Use the same swab for each cleaning stroke
C. Clean from the urethra toward the rectum
D. Use soap and water to clean the catheter
💫RATIONALE✔️✔️: Perineal care should be performed from the urethra toward the rectum to prevent
introducing bacteria into the urinary tract.
, 💫ANSWER✔️✔️: C. Clean from the urethra toward the rectum
---
**Question 6**
A client is experiencing nausea and vomiting. Which of the following nursing interventions should the
nurse implement first?
A. Administer an antiemetic medication
B. Assess the client's abdomen
C. Offer clear liquids in small amounts
D. Measure the client's vital signs
💫RATIONALE✔️✔️: The nurse should first assess the client's abdomen to identify the cause of nausea
and vomiting.
💫ANSWER✔️✔️: B. Assess the client's abdomen
---
**Question 7**
A nurse is assessing a client's pain level using the FLACC scale. Which of the following clients is this scale
most appropriate for?
A. An alert and oriented adult
B. A cognitively impaired older adult
C. A toddler who is non-verbal
