NR224 Exam 3 Actual Exam Style V3 | NR
224 Fundamentals - Skills | Chamberlain
1. A nurse is assessing a patient’s wound and notes a thick, yellow-to-green drainage. How
should the nurse document this type of exudate?
A. Purulent drainage
B. Sanguineous drainage
C. Serous drainage
D. Serosanguineous drainage
Answer: A
Rationale: Purulent drainage is characterized by a thick consistency and colors ranging
from yellow to green, often indicating an infection. Serous drainage is clear and watery,
while sanguineous is bright red and indicates active bleeding. The nurse must accurately
document these findings to track the progress of wound healing or the development of
complications.
2. When performing tracheostomy suctioning, what is the maximum amount of time the
nurse should apply suction?
A. 5 seconds
B. Only while inserting the catheter
C. 20 to 30 seconds
,D. 10 to 15 seconds
Answer: D
Rationale: Suction should only be applied for 10 to 15 seconds to prevent hypoxia and
mucosal damage. Suctioning for longer than 15 seconds can lead to a significant drop in
oxygen saturation and cardiac arrhythmias. It is also important to allow the patient to rest
and re-oxygenate between passes of the suction catheter.
3. A nurse is preparing to administer a cleansing enema. In which position should the nurse
place the patient?
A. High-Fowler’s position
B. Right side-lying (Sims’) position
C. Left side-lying (Sims’) position
D. Supine with legs elevated
Answer: C
Rationale: The left side-lying (Sims’) position allows the enema solution to flow downward
by gravity into the sigmoid colon and rectum. Placing the patient on the right side would
hinder the flow due to the anatomical curve of the colon. Proper positioning is essential for
the effectiveness of the procedure and the comfort of the patient.
4. While monitoring a patient with a chest tube, the nurse notes continuous bubbling in the
water-seal chamber. What does this finding suggest?
A. The system is functioning normally.
, B. The lung has fully re-expanded.
C. There is an air leak in the system.
D. The suction pressure is set too high.
Answer: C
Rationale: Continuous bubbling in the water-seal chamber typically indicates an air leak
between the patient and the drainage system. Intermittent bubbling is expected when the
patient coughs or exhales if a pneumothorax is present. The nurse should immediately
assess the tubing and the insertion site to locate and rectify the leak.
5. A nurse is caring for a patient who is at high risk for aspiration. Which action is most
appropriate during mealtime?
A. Place the patient in a semi-Fowler’s position.
B. Instruct the patient to use a straw for all liquids.
C. Flex the patient’s head to a chin-tuck position when swallowing.
D. Encourage the patient to talk while chewing.
Answer: C
Rationale: The chin-tuck position helps close off the trachea and opens the esophagus,
which reduces the risk of aspiration. Using a straw can actually increase the risk of
aspiration because it delivers a large volume of liquid to the back of the throat quickly. The
224 Fundamentals - Skills | Chamberlain
1. A nurse is assessing a patient’s wound and notes a thick, yellow-to-green drainage. How
should the nurse document this type of exudate?
A. Purulent drainage
B. Sanguineous drainage
C. Serous drainage
D. Serosanguineous drainage
Answer: A
Rationale: Purulent drainage is characterized by a thick consistency and colors ranging
from yellow to green, often indicating an infection. Serous drainage is clear and watery,
while sanguineous is bright red and indicates active bleeding. The nurse must accurately
document these findings to track the progress of wound healing or the development of
complications.
2. When performing tracheostomy suctioning, what is the maximum amount of time the
nurse should apply suction?
A. 5 seconds
B. Only while inserting the catheter
C. 20 to 30 seconds
,D. 10 to 15 seconds
Answer: D
Rationale: Suction should only be applied for 10 to 15 seconds to prevent hypoxia and
mucosal damage. Suctioning for longer than 15 seconds can lead to a significant drop in
oxygen saturation and cardiac arrhythmias. It is also important to allow the patient to rest
and re-oxygenate between passes of the suction catheter.
3. A nurse is preparing to administer a cleansing enema. In which position should the nurse
place the patient?
A. High-Fowler’s position
B. Right side-lying (Sims’) position
C. Left side-lying (Sims’) position
D. Supine with legs elevated
Answer: C
Rationale: The left side-lying (Sims’) position allows the enema solution to flow downward
by gravity into the sigmoid colon and rectum. Placing the patient on the right side would
hinder the flow due to the anatomical curve of the colon. Proper positioning is essential for
the effectiveness of the procedure and the comfort of the patient.
4. While monitoring a patient with a chest tube, the nurse notes continuous bubbling in the
water-seal chamber. What does this finding suggest?
A. The system is functioning normally.
, B. The lung has fully re-expanded.
C. There is an air leak in the system.
D. The suction pressure is set too high.
Answer: C
Rationale: Continuous bubbling in the water-seal chamber typically indicates an air leak
between the patient and the drainage system. Intermittent bubbling is expected when the
patient coughs or exhales if a pneumothorax is present. The nurse should immediately
assess the tubing and the insertion site to locate and rectify the leak.
5. A nurse is caring for a patient who is at high risk for aspiration. Which action is most
appropriate during mealtime?
A. Place the patient in a semi-Fowler’s position.
B. Instruct the patient to use a straw for all liquids.
C. Flex the patient’s head to a chin-tuck position when swallowing.
D. Encourage the patient to talk while chewing.
Answer: C
Rationale: The chin-tuck position helps close off the trachea and opens the esophagus,
which reduces the risk of aspiration. Using a straw can actually increase the risk of
aspiration because it delivers a large volume of liquid to the back of the throat quickly. The
