NR224 Exam 4 Actual Exam Style V1 | NR
224 Fundamentals - Skills | Chamberlain
1. A nurse is caring for a patient who has not voided for 8 hours following the removal of an
indwelling catheter. What is the priority nursing action?
A. Increase fluid intake to 2000 mL per day
B. Perform a bladder scan to assess for retention
C. Insert a new straight catheter immediately
D. Encourage the patient to walk to the bathroom
Answer: B
Rationale: A bladder scan is a non-invasive tool used to determine the amount of urine
remaining in the bladder. It helps the nurse decide if further interventions like
catheterization are necessary. Assessing the situation first is consistent with the nursing
process before taking invasive action.
2. Which clinical finding should the nurse expect when assessing a patient with a newly
created ileostomy?
A. Formed, brown stool
B. Liquid to semi-liquid stool consistency
C. Hard, pellet-like stool
,D. Absence of drainage for the first week
Answer: B
Rationale: An ileostomy bypasses the large intestine where most water absorption occurs,
resulting in liquid output. The stool consistency is typically green or yellow initially and
stays thin throughout the life of the ostomy. Formed stool is expected in a colostomy
involving the descending or sigmoid colon.
3. The nurse is preparing to administer an intramuscular (IM) injection to an average-sized
adult. Which needle gauge and length are most appropriate?
A. 25-gauge, 5/8 inch
B. 18-gauge, 1.5 inch
C. 27-gauge, 1/2 inch
D. 22-gauge, 1.5 inch
Answer: D
Rationale: A 22-gauge, 1.5-inch needle is standard for adult IM injections in the
ventrogluteal or vastus lateralis muscles. The length ensures the medication reaches the
muscle tissue rather than the subcutaneous layer. Smaller gauges like 25 or 27 are typically
reserved for subcutaneous injections or immunizations.
4. A patient with a stage 3 pressure injury is being treated with a hydrocolloid dressing. What
is the primary purpose of this type of dressing?
A. To provide a dry environment for the wound to scab
, B. To allow oxygen to freely circulate through the wound bed
C. To debride the wound through mechanical friction
D. To maintain a moist healing environment and promote autolysis
Answer: D
Rationale: Hydrocolloid dressings are occlusive and maintain a moist environment which
is essential for granulation. They facilitate autolytic debridement by using the body’s own
enzymes to break down necrotic tissue. These dressings are generally not used for heavily
draining wounds but are effective for stage 2 and 3 injuries.
5. When performing suctioning on a patient with a tracheostomy, how long should the nurse
apply suction?
A. At least 30 seconds to ensure all mucus is removed
B. No longer than 10 to 15 seconds
C. Until the patient begins to cough vigorously
D. Only during the insertion of the catheter
Answer: B
Rationale: Suctioning should be limited to 10-15 seconds to prevent hypoxia and mucosal
damage. Prolonged suctioning can lead to significant drops in oxygen saturation and
cardiac arrhythmias. It is important to allow the patient to recover and oxygenate between
passes.
224 Fundamentals - Skills | Chamberlain
1. A nurse is caring for a patient who has not voided for 8 hours following the removal of an
indwelling catheter. What is the priority nursing action?
A. Increase fluid intake to 2000 mL per day
B. Perform a bladder scan to assess for retention
C. Insert a new straight catheter immediately
D. Encourage the patient to walk to the bathroom
Answer: B
Rationale: A bladder scan is a non-invasive tool used to determine the amount of urine
remaining in the bladder. It helps the nurse decide if further interventions like
catheterization are necessary. Assessing the situation first is consistent with the nursing
process before taking invasive action.
2. Which clinical finding should the nurse expect when assessing a patient with a newly
created ileostomy?
A. Formed, brown stool
B. Liquid to semi-liquid stool consistency
C. Hard, pellet-like stool
,D. Absence of drainage for the first week
Answer: B
Rationale: An ileostomy bypasses the large intestine where most water absorption occurs,
resulting in liquid output. The stool consistency is typically green or yellow initially and
stays thin throughout the life of the ostomy. Formed stool is expected in a colostomy
involving the descending or sigmoid colon.
3. The nurse is preparing to administer an intramuscular (IM) injection to an average-sized
adult. Which needle gauge and length are most appropriate?
A. 25-gauge, 5/8 inch
B. 18-gauge, 1.5 inch
C. 27-gauge, 1/2 inch
D. 22-gauge, 1.5 inch
Answer: D
Rationale: A 22-gauge, 1.5-inch needle is standard for adult IM injections in the
ventrogluteal or vastus lateralis muscles. The length ensures the medication reaches the
muscle tissue rather than the subcutaneous layer. Smaller gauges like 25 or 27 are typically
reserved for subcutaneous injections or immunizations.
4. A patient with a stage 3 pressure injury is being treated with a hydrocolloid dressing. What
is the primary purpose of this type of dressing?
A. To provide a dry environment for the wound to scab
, B. To allow oxygen to freely circulate through the wound bed
C. To debride the wound through mechanical friction
D. To maintain a moist healing environment and promote autolysis
Answer: D
Rationale: Hydrocolloid dressings are occlusive and maintain a moist environment which
is essential for granulation. They facilitate autolytic debridement by using the body’s own
enzymes to break down necrotic tissue. These dressings are generally not used for heavily
draining wounds but are effective for stage 2 and 3 injuries.
5. When performing suctioning on a patient with a tracheostomy, how long should the nurse
apply suction?
A. At least 30 seconds to ensure all mucus is removed
B. No longer than 10 to 15 seconds
C. Until the patient begins to cough vigorously
D. Only during the insertion of the catheter
Answer: B
Rationale: Suctioning should be limited to 10-15 seconds to prevent hypoxia and mucosal
damage. Prolonged suctioning can lead to significant drops in oxygen saturation and
cardiac arrhythmias. It is important to allow the patient to recover and oxygenate between
passes.
