NR224 Exam 1 Actual Exam Style V3 | NR
224 Fundamentals - Skills | Chamberlain
1. A nurse is caring for a patient who has been diagnosed with Clostridium difficile (C. diff).
Which hand hygiene method is most appropriate after providing care?
A. Washing hands with soap and water.
B. Using an alcohol-based hand sanitizer.
C. Wiping hands with a dry paper towel.
D. Wearing gloves so hand hygiene is not necessary.
Answer: A
Rationale: Soap and water must be used for hand hygiene when caring for patients with C.
diff because alcohol-based rubs are ineffective against spores. The mechanical friction of
washing hands under running water helps remove the spores from the skin surface. This is
a critical component of contact precautions in the healthcare setting.
2. When assessing a patient’s blood pressure, the nurse notes that the cuff is too small for the
patient’s arm. What effect will this have on the reading?
A. The blood pressure reading will be falsely low.
B. The blood pressure reading will be falsely high.
C. The blood pressure reading will be accurate regardless of size.
,D. The systolic pressure will be low and diastolic will be high.
Answer: B
Rationale: Using a blood pressure cuff that is too narrow or too small will result in a falsely
elevated blood pressure reading. A cuff that is too large would conversely result in a falsely
low reading. Ensuring the correct cuff size is essential for clinical accuracy and patient
safety.
3. A nurse is using the SBAR technique to communicate with a healthcare provider. Which
information should the nurse include in the ‘B’ (Background) section?
A. The patient’s current vital signs.
B. The nurse’s recommendation for a change in treatment.
C. A description of the current problem or situation.
D. The patient’s admitting diagnosis and relevant medical history.
Answer: D
Rationale: The ‘Background’ portion of SBAR focuses on providing the context of the
patient’s situation, such as the admitting diagnosis and medical history. ‘S’ stands for
Situation, which describes what is happening right now. ‘A’ is for Assessment, and ‘R’ is for
Recommendation, completing the standardized communication tool.
4. According to Maslow’s Hierarchy of Needs, which patient need should the nurse prioritize
first?
A. Self-actualization through learning a new skill.
, B. Safety and security by preventing falls.
C. Physiological needs like oxygen and nutrition.
D. Love and belonging by allowing family visits.
Answer: C
Rationale: Maslow’s Hierarchy prioritizes physiological needs, such as breathing, food, and
water, as the foundation of human health. Only after these basic survival needs are met can
the nurse focus on safety, social, or self-esteem needs. Prioritizing physiological stability is
a fundamental principle of nursing triage.
5. A nurse is preparing to provide oral care to an unconscious patient. Which action is the
priority for patient safety?
A. Using a large amount of water to rinse the mouth.
B. Positioning the patient in a side-lying (lateral) position.
C. Brushing the teeth while the patient is in a supine position.
D. Asking the patient to spit out the toothpaste.
Answer: B
Rationale: An unconscious patient is at high risk for aspiration during oral hygiene. Placing
the patient in a side-lying position allows fluids to drain out of the mouth rather than into
the airway. Suction equipment should also be readily available at the bedside during the
procedure.
224 Fundamentals - Skills | Chamberlain
1. A nurse is caring for a patient who has been diagnosed with Clostridium difficile (C. diff).
Which hand hygiene method is most appropriate after providing care?
A. Washing hands with soap and water.
B. Using an alcohol-based hand sanitizer.
C. Wiping hands with a dry paper towel.
D. Wearing gloves so hand hygiene is not necessary.
Answer: A
Rationale: Soap and water must be used for hand hygiene when caring for patients with C.
diff because alcohol-based rubs are ineffective against spores. The mechanical friction of
washing hands under running water helps remove the spores from the skin surface. This is
a critical component of contact precautions in the healthcare setting.
2. When assessing a patient’s blood pressure, the nurse notes that the cuff is too small for the
patient’s arm. What effect will this have on the reading?
A. The blood pressure reading will be falsely low.
B. The blood pressure reading will be falsely high.
C. The blood pressure reading will be accurate regardless of size.
,D. The systolic pressure will be low and diastolic will be high.
Answer: B
Rationale: Using a blood pressure cuff that is too narrow or too small will result in a falsely
elevated blood pressure reading. A cuff that is too large would conversely result in a falsely
low reading. Ensuring the correct cuff size is essential for clinical accuracy and patient
safety.
3. A nurse is using the SBAR technique to communicate with a healthcare provider. Which
information should the nurse include in the ‘B’ (Background) section?
A. The patient’s current vital signs.
B. The nurse’s recommendation for a change in treatment.
C. A description of the current problem or situation.
D. The patient’s admitting diagnosis and relevant medical history.
Answer: D
Rationale: The ‘Background’ portion of SBAR focuses on providing the context of the
patient’s situation, such as the admitting diagnosis and medical history. ‘S’ stands for
Situation, which describes what is happening right now. ‘A’ is for Assessment, and ‘R’ is for
Recommendation, completing the standardized communication tool.
4. According to Maslow’s Hierarchy of Needs, which patient need should the nurse prioritize
first?
A. Self-actualization through learning a new skill.
, B. Safety and security by preventing falls.
C. Physiological needs like oxygen and nutrition.
D. Love and belonging by allowing family visits.
Answer: C
Rationale: Maslow’s Hierarchy prioritizes physiological needs, such as breathing, food, and
water, as the foundation of human health. Only after these basic survival needs are met can
the nurse focus on safety, social, or self-esteem needs. Prioritizing physiological stability is
a fundamental principle of nursing triage.
5. A nurse is preparing to provide oral care to an unconscious patient. Which action is the
priority for patient safety?
A. Using a large amount of water to rinse the mouth.
B. Positioning the patient in a side-lying (lateral) position.
C. Brushing the teeth while the patient is in a supine position.
D. Asking the patient to spit out the toothpaste.
Answer: B
Rationale: An unconscious patient is at high risk for aspiration during oral hygiene. Placing
the patient in a side-lying position allows fluids to drain out of the mouth rather than into
the airway. Suction equipment should also be readily available at the bedside during the
procedure.
