# NR 224 Fundamentals of Nursing Final Examination
## Comprehensive Practice Questions with Rationales
---
**Question 1**
A nurse is preparing to administer an enteral feeding to a client who has a nasogastric (NG) tube. Which
of the following actions should the nurse take first?
A. Flush the tube with 30 mL of water
B. Verify tube placement by aspirating gastric contents
C. Check the residual volume
D. Elevate the head of the bed to 30 degrees
💫RATIONALE✔️✔️: The nurse must first verify tube placement before any other actions to prevent
accidental administration into the lungs. Aspirating gastric contents and checking pH is the most reliable
method.
💫ANSWER✔️✔️: B. Verify tube placement by aspirating gastric contents
---
**Question 2**
A client is receiving oxygen via nasal cannula at 2 L/min. Which of the following nursing actions is most
important?
A. Apply water-soluble lubricant to the nares
,B. Check the oxygen flow rate every 8 hours
C. Humidify the oxygen
D. Assess the client's skin under the tubing
💫RATIONALE✔️✔️: Skin breakdown can occur from the tubing rubbing against the nares and ears;
therefore, assessing the skin is the priority intervention.
💫ANSWER✔️✔️: D. Assess the client's skin under the tubing
---
**Question 3**
A nurse is performing a sterile dressing change for a client with a surgical wound. Which action indicates
the need for additional teaching?
A. Opening the sterile kit away from the body
B. Using sterile gloves during the procedure
C. Cleaning the wound from the outer edges toward the center
D. Holding the sterile drape at arm's length
💫RATIONALE✔️✔️: Wounds should be cleaned from the center outward (not outer to center) to prevent
contamination of the wound with microorganisms from the surrounding skin.
💫ANSWER✔️✔️: C. Cleaning the wound from the outer edges toward the center
---
**Question 4**
,A client who is 2 days post-operative reports pain at the surgical site rated 8 out of 10 on the pain scale.
Which of the following interventions should the nurse implement first?
A. Administer prescribed analgesic medication
B. Reposition the client to relieve pressure on the wound
C. Assess the surgical site for signs of infection
D. Apply a cold pack to the area
💫RATIONALE✔️✔️: The nurse should first assess the surgical site for signs of infection, dehiscence, or
evisceration before administering pain medication to identify potential complications.
💫ANSWER✔️✔️: C. Assess the surgical site for signs of infection
---
**Question 5**
A nurse is calculating the intake and output for a client over 8 hours. The client consumed 240 mL of
water, 180 mL of milk, and 120 mL of juice. The client voided 500 mL and had 100 mL of emesis. What is
the client's net fluid balance?
A. +60 mL
B. -60 mL
C. +140 mL
D. -140 mL
💫RATIONALE✔️✔️: Total intake = 240 + 180 + 120 = 540 mL; total output = 500 + 100 = 600 mL; net
balance = 540 - 600 = -60 mL (negative fluid balance).
💫ANSWER✔️✔️: B. -60 mL
, ---
**Question 6**
A nurse is providing care for a client with a new colostomy. Which of the following observations should
the nurse report to the healthcare provider immediately?
A. Stoma appears dark purple and edematous
B. Stoma is moist and pink
C. Moderate amount of liquid stool in the pouch
D. Peristomal skin is slightly red
💫RATIONALE✔️✔️: A dark purple stoma indicates ischemia or necrosis, which requires immediate
intervention to prevent tissue death and preserve bowel function.
💫ANSWER✔️✔️: A. Stoma appears dark purple and edematous
---
**Question 7**
A nurse is preparing to insert an indwelling urinary catheter for a female client. Which of the following
actions is correct?
A. Separate the labia with the dominant hand after cleaning
B. Use sterile technique throughout the procedure
C. Insert the catheter until urine flow is obtained, then advance 1-2 inches
D. Inflate the balloon with 30 mL of sterile water
## Comprehensive Practice Questions with Rationales
---
**Question 1**
A nurse is preparing to administer an enteral feeding to a client who has a nasogastric (NG) tube. Which
of the following actions should the nurse take first?
A. Flush the tube with 30 mL of water
B. Verify tube placement by aspirating gastric contents
C. Check the residual volume
D. Elevate the head of the bed to 30 degrees
💫RATIONALE✔️✔️: The nurse must first verify tube placement before any other actions to prevent
accidental administration into the lungs. Aspirating gastric contents and checking pH is the most reliable
method.
💫ANSWER✔️✔️: B. Verify tube placement by aspirating gastric contents
---
**Question 2**
A client is receiving oxygen via nasal cannula at 2 L/min. Which of the following nursing actions is most
important?
A. Apply water-soluble lubricant to the nares
,B. Check the oxygen flow rate every 8 hours
C. Humidify the oxygen
D. Assess the client's skin under the tubing
💫RATIONALE✔️✔️: Skin breakdown can occur from the tubing rubbing against the nares and ears;
therefore, assessing the skin is the priority intervention.
💫ANSWER✔️✔️: D. Assess the client's skin under the tubing
---
**Question 3**
A nurse is performing a sterile dressing change for a client with a surgical wound. Which action indicates
the need for additional teaching?
A. Opening the sterile kit away from the body
B. Using sterile gloves during the procedure
C. Cleaning the wound from the outer edges toward the center
D. Holding the sterile drape at arm's length
💫RATIONALE✔️✔️: Wounds should be cleaned from the center outward (not outer to center) to prevent
contamination of the wound with microorganisms from the surrounding skin.
💫ANSWER✔️✔️: C. Cleaning the wound from the outer edges toward the center
---
**Question 4**
,A client who is 2 days post-operative reports pain at the surgical site rated 8 out of 10 on the pain scale.
Which of the following interventions should the nurse implement first?
A. Administer prescribed analgesic medication
B. Reposition the client to relieve pressure on the wound
C. Assess the surgical site for signs of infection
D. Apply a cold pack to the area
💫RATIONALE✔️✔️: The nurse should first assess the surgical site for signs of infection, dehiscence, or
evisceration before administering pain medication to identify potential complications.
💫ANSWER✔️✔️: C. Assess the surgical site for signs of infection
---
**Question 5**
A nurse is calculating the intake and output for a client over 8 hours. The client consumed 240 mL of
water, 180 mL of milk, and 120 mL of juice. The client voided 500 mL and had 100 mL of emesis. What is
the client's net fluid balance?
A. +60 mL
B. -60 mL
C. +140 mL
D. -140 mL
💫RATIONALE✔️✔️: Total intake = 240 + 180 + 120 = 540 mL; total output = 500 + 100 = 600 mL; net
balance = 540 - 600 = -60 mL (negative fluid balance).
💫ANSWER✔️✔️: B. -60 mL
, ---
**Question 6**
A nurse is providing care for a client with a new colostomy. Which of the following observations should
the nurse report to the healthcare provider immediately?
A. Stoma appears dark purple and edematous
B. Stoma is moist and pink
C. Moderate amount of liquid stool in the pouch
D. Peristomal skin is slightly red
💫RATIONALE✔️✔️: A dark purple stoma indicates ischemia or necrosis, which requires immediate
intervention to prevent tissue death and preserve bowel function.
💫ANSWER✔️✔️: A. Stoma appears dark purple and edematous
---
**Question 7**
A nurse is preparing to insert an indwelling urinary catheter for a female client. Which of the following
actions is correct?
A. Separate the labia with the dominant hand after cleaning
B. Use sterile technique throughout the procedure
C. Insert the catheter until urine flow is obtained, then advance 1-2 inches
D. Inflate the balloon with 30 mL of sterile water
