NR224 Exam 2 Actual Exam Style V2 | NR
224 Fundamentals - Skills | Chamberlain
1. A nurse is preparing to perform a sterile procedure. Which action would compromise the
sterile field?
A. Reaching across the sterile field to pick up a dressing.
B. Holding sterile gloved hands above the waist level at all times.
C. Opening the outermost flap of the sterile kit away from the body.
D. Maintaining a one-inch border around the edge of the sterile drape.
Answer: A
Rationale: Reaching across a sterile field is a violation of aseptic technique because
microorganisms from the nurse’s non-sterile sleeves can fall onto the field. To maintain
sterility, the nurse must move around the field or reach from the sides to access items.
Sterile objects must always remain within the line of vision and above the waist to ensure
they have not been contaminated.
2. When administering an intramuscular (IM) injection using the Z-track method, what is the
primary purpose of this technique?
A. To ensure the medication is absorbed more rapidly into the bloodstream.
B. To prevent the medication from leaking back into the subcutaneous tissue.
C. To reduce the amount of pain the patient feels during the needle insertion.
,D. To allow the nurse to use a shorter and thinner needle for the injection.
Answer: B
Rationale: The Z-track method involves pulling the skin and subcutaneous tissue to one
side before inserting the needle into the muscle. When the tissue is released after the
injection, the zig-zag path seals the medication within the muscle layer. This technique is
specifically recommended for medications that are irritating to the subcutaneous tissues or
may cause skin staining.
3. A nurse is caring for a patient with a Stage 3 pressure injury. Which characteristic is most
representative of this stage?
A. Non-blanchable erythema of intact skin over a bony prominence.
B. Partial-thickness skin loss involving the epidermis and dermis.
C. Full-thickness tissue loss where the base is covered by slough or eschar.
D. Full-thickness skin loss with visible subcutaneous fat but no bone exposure.
Answer: D
Rationale: Stage 3 pressure injuries involve full-thickness skin loss where subcutaneous
fat may be visible, but bone, tendon, and muscle are not yet exposed. Slough may be
present but does not obscure the depth of tissue loss. This stage is more severe than Stage
2, which only involves the epidermis and dermis, but less severe than Stage 4 where deep
structures are visible.
, 4. A nurse is preparing to suction a patient’s tracheostomy. What is the maximum amount of
time the nurse should apply suction during a single pass?
A. 5 seconds
B. 20 to 25 seconds
C. 10 to 15 seconds
D. 30 seconds
Answer: C
Rationale: Suctioning should be limited to 10 to 15 seconds per pass to prevent hypoxia
and vagal stimulation, which can lead to bradycardia. The nurse must allow the patient to
recover and re-oxygenate between passes to maintain physiological stability. Prolonged
suctioning can lead to significant respiratory distress and damage to the tracheal mucosa.
5. A patient requires an enema. In which position should the nurse place the patient to
facilitate the flow of fluid into the sigmoid colon?
A. Supine with legs slightly elevated
B. Right side-lying with the left knee flexed
C. Left side-lying (Sims’ position) with the right knee flexed
D. Prone position with a pillow under the abdomen
Answer: C
224 Fundamentals - Skills | Chamberlain
1. A nurse is preparing to perform a sterile procedure. Which action would compromise the
sterile field?
A. Reaching across the sterile field to pick up a dressing.
B. Holding sterile gloved hands above the waist level at all times.
C. Opening the outermost flap of the sterile kit away from the body.
D. Maintaining a one-inch border around the edge of the sterile drape.
Answer: A
Rationale: Reaching across a sterile field is a violation of aseptic technique because
microorganisms from the nurse’s non-sterile sleeves can fall onto the field. To maintain
sterility, the nurse must move around the field or reach from the sides to access items.
Sterile objects must always remain within the line of vision and above the waist to ensure
they have not been contaminated.
2. When administering an intramuscular (IM) injection using the Z-track method, what is the
primary purpose of this technique?
A. To ensure the medication is absorbed more rapidly into the bloodstream.
B. To prevent the medication from leaking back into the subcutaneous tissue.
C. To reduce the amount of pain the patient feels during the needle insertion.
,D. To allow the nurse to use a shorter and thinner needle for the injection.
Answer: B
Rationale: The Z-track method involves pulling the skin and subcutaneous tissue to one
side before inserting the needle into the muscle. When the tissue is released after the
injection, the zig-zag path seals the medication within the muscle layer. This technique is
specifically recommended for medications that are irritating to the subcutaneous tissues or
may cause skin staining.
3. A nurse is caring for a patient with a Stage 3 pressure injury. Which characteristic is most
representative of this stage?
A. Non-blanchable erythema of intact skin over a bony prominence.
B. Partial-thickness skin loss involving the epidermis and dermis.
C. Full-thickness tissue loss where the base is covered by slough or eschar.
D. Full-thickness skin loss with visible subcutaneous fat but no bone exposure.
Answer: D
Rationale: Stage 3 pressure injuries involve full-thickness skin loss where subcutaneous
fat may be visible, but bone, tendon, and muscle are not yet exposed. Slough may be
present but does not obscure the depth of tissue loss. This stage is more severe than Stage
2, which only involves the epidermis and dermis, but less severe than Stage 4 where deep
structures are visible.
, 4. A nurse is preparing to suction a patient’s tracheostomy. What is the maximum amount of
time the nurse should apply suction during a single pass?
A. 5 seconds
B. 20 to 25 seconds
C. 10 to 15 seconds
D. 30 seconds
Answer: C
Rationale: Suctioning should be limited to 10 to 15 seconds per pass to prevent hypoxia
and vagal stimulation, which can lead to bradycardia. The nurse must allow the patient to
recover and re-oxygenate between passes to maintain physiological stability. Prolonged
suctioning can lead to significant respiratory distress and damage to the tracheal mucosa.
5. A patient requires an enema. In which position should the nurse place the patient to
facilitate the flow of fluid into the sigmoid colon?
A. Supine with legs slightly elevated
B. Right side-lying with the left knee flexed
C. Left side-lying (Sims’ position) with the right knee flexed
D. Prone position with a pillow under the abdomen
Answer: C
