NURS 222 FINAL EXAM-COMPLETE QUESTIONS AND
ANSWERS PLUS DETAILED RATIONALES|NEWEST
STUDYGUIDE | EXAM PREP | DOWNLOAD INSTANT PDF
2027-2028
1. A nurse is reviewing a patient's medical history before administering a newly prescribed
antihypertensive medication. Which action represents the nurse's primary ethical and legal
responsibility regarding safe medication administration?
A. Verifying the patient's insurance coverage for the drug
B. Confirming the prescription details against the nurse's clinical preference
C. Identifying the patient using two unique identifiers and validating the six rights
D. Asking the patient's family to confirm the daily dosage routine
Answer: C
The nurse's primary ethical and legal responsibility is to ensure patient safety by verifying two
unique identifiers and systematically confirming the six rights of medication administration
before giving any drug. This practice directly reduces adverse drug events and adheres to
established standards of nursing practice and risk management guidelines.
2. A patient admitted with acute heart failure exacerbation exhibits dyspnea, crackles in
bilateral lower lungs, and an oxygen saturation of 88% on room air. Which intervention
should the nurse implement first?
A. Administer a prescribed oral loop diuretic with a glass of water
B. Elevate the head of the bed to a high-Fowler's position and apply supplemental oxygen
C. Obtain a stat 12-lead electrocardiogram
D. Draw blood samples for complete blood count and metabolic panel
Answer: B
Elevating the head of the bed lowers the diaphragm and decreases venous return, which
reduces cardiac workload and immediately improves chest expansion. Applying supplemental
oxygen addresses acute hypoxemia directly, making airway and oxygenation the priority
intervention according to standard clinical resuscitation frameworks.
3. An older adult client receiving intravenous fluids displays dynamic signs of fluid volume
overload, including jugular venous distention and a third heart sound (S3). What is the
appropriate immediate nursing response?
A. Increase the IV flow rate to clear the tubing
B. Slow the IV infusion to a keep-vein-open rate and notify the healthcare provider
,C. Administer a bolus of normal saline solution
D. Position the patient flat in the supine position
Answer: B
Slowing the infusion rate minimizes the risk of worsening pulmonary edema and
hypervolemia while ensuring vascular access remains clear. Immediately contacting the
primary care provider allows for prompt order modifications, such as diuretic administration,
to manage fluid overload safely.
4. A nurse assesses a postoperative client's surgical site and observes purulent drainage,
localized warmth, and a body temperature of 101.8°F (38.8°C). Which nursing diagnosis
receives the highest priority?
A. Impaired Physical Mobility related to surgical pain
B. Risk for Deficient Fluid Volume related to fever
C. Acute Pain related to tissue trauma
D. Risk for Systemic Infection related to localized surgical site infection
Answer: D
Localized infection signs paired with a significant systemic febrile response signal a risk of
progression to systemic sepsis. Prioritizing systemic infection risk directs immediate diagnostic
sampling, culture collection, and targeted antimicrobial management to prevent severe clinical
deterioration.
5. While preparing to perform a sterile dressing change on a central line, the nurse
accidentally touches the edge of the sterile field with a non-sterile glove. What is the correct
corrective action?
A. Disinfect the touched area with an alcohol swab and continue
B. Discard the contaminated field and setup, then re-establish a new sterile field
C. Proceed with the procedure using extra caution around the touched edge
D. Cover the contaminated area with a sterile towel and proceed
Answer: B
A sterile field is considered completely unsterile once touched by a non-sterile item. To
maintain strict surgical asepsis and minimize client risk for healthcare-associated central line-
associated bloodstream infections, the entire setup must be discarded and replaced
immediately.
6. A client with a diagnosis of Type 1 Diabetes Mellitus presents with diaphoresis, tremors,
and a blood glucose level of 54 mg/dL. Which nursing action takes immediate priority?
A. Administer 15 to 20 grams of fast-acting simple carbohydrates orally
,B. Administer 10 units of regular insulin subcutaneously
C. Provide a high-protein, high-fat meal immediately
D. Recheck the blood glucose level in 45 minutes without intervention
Answer: A
The client is experiencing symptomatic hypoglycemia. The standard rule of 15 dictates
immediate oral administration of 15 to 20 grams of fast-acting simple carbohydrates to rapidly
elevate blood glucose levels and restore cerebral glucose supply, preventing neurological
complications.
7. A healthcare provider prescribes 1,000 mL of 0.9% Normal Saline to infuse over 8
hours. The drop factor of the manual tubing is 15 drops/mL. What is the correct flow rate
in drops per minute (gtt/min)?
A. 21 gtt/min
B. 31 gtt/min
C. 42 gtt/min
D. 125 gtt/min
Answer: B
To calculate the flow rate: Total volume (1,000 mL) divided by total time in minutes (8 hours x
60 minutes = 480 minutes) multiplied by the drop factor (15 gtt/mL). 1, = 2.083
mL/min. 2.083 x 15 = 31.25 gtt/min, which rounds to 31 gtt/min. Accurate IV flow calculation
prevents fluid under- or over-infusion.
8. When assessing an immobilised client for pressure injury development, which
anatomical site requires the most frequent inspection while in the supine position?
A. Patella
B. Sacrum and heels
C. Greater trochanter
D. Acromion process
Answer: B
In the supine position, body weight exerts maximum pressure over bony prominences directly
resting on the mattress, primarily the sacrum, coccyx, and calcaneus (heels). Frequent
inspection, turn schedules, and pressure-offloading interventions targeting these areas reduce
localized tissue ischemia.
9. A patient with chronic obstructive pulmonary disease (COPD) is receiving oxygen via
nasal cannula. Why must the nurse exercise caution when increasing the oxygen flow rate
above 2 liters per minute?
, A. High oxygen levels cause hyperventilation and metabolic alkalosis
B. Elevated arterial oxygen tension can eliminate the hypoxic drive to breathe
C. High flow rates cause severe tracheal ulceration within minutes
D. Oxygen therapy increases red blood cell destruction in COPD patients
Answer: B
Clients with end-stage COPD often rely on a hypoxic drive (low arterial oxygen tension) to
stimulate respiration because their central chemoreceptors are desensitized to chronic
hypercapnia. Excessive oxygen administration suppresses this drive, potentially leading to
hypoventilation, severe carbon dioxide retention, and respiratory arrest.
10. A nurse observes a red, raised area on a patient's forearm following an intradermal
tuberculin skin test (PPD). At what time frame post-injection should the nurse officially
read and document the induration size?
A. 12 to 24 hours
B. 24 to 36 hours
C. 48 to 72 hours
D. 96 to 120 hours
Answer: C
Delayed-type hypersensitivity cell-mediated reactions to tuberculin purified protein derivative
peak between 48 and 72 hours post-injection. Evaluation prior to 48 hours or after 72 hours
yields unreliable results and invalidates screening interpretation.
11. A charge nurse delegates tasks on a medical-surgical unit. Which task is most
appropriate to delegate to a licensed practical nurse (LPN)?
A. Initial admission physical assessment of a newly admitted surgical client
B. Developing the primary plan of care for a client with complex multisystem failure
C. Administering routine oral maintenance medications to a stable client
D. Providing discharge teaching regarding complex medication reconciliation
Answer: C
LPN scope of practice includes administering routine oral medications to clinically stable
clients under the supervision of a registered nurse. Initial assessments, care plan development,
and primary discharge education require advanced nursing judgment reserved for registered
nurses.
12. A client scheduled for an elective abdominal procedure states, "I signed the consent
form, but I really do not understand what the surgeon is going to cut or what the risks
are." Which action should the nurse take?
ANSWERS PLUS DETAILED RATIONALES|NEWEST
STUDYGUIDE | EXAM PREP | DOWNLOAD INSTANT PDF
2027-2028
1. A nurse is reviewing a patient's medical history before administering a newly prescribed
antihypertensive medication. Which action represents the nurse's primary ethical and legal
responsibility regarding safe medication administration?
A. Verifying the patient's insurance coverage for the drug
B. Confirming the prescription details against the nurse's clinical preference
C. Identifying the patient using two unique identifiers and validating the six rights
D. Asking the patient's family to confirm the daily dosage routine
Answer: C
The nurse's primary ethical and legal responsibility is to ensure patient safety by verifying two
unique identifiers and systematically confirming the six rights of medication administration
before giving any drug. This practice directly reduces adverse drug events and adheres to
established standards of nursing practice and risk management guidelines.
2. A patient admitted with acute heart failure exacerbation exhibits dyspnea, crackles in
bilateral lower lungs, and an oxygen saturation of 88% on room air. Which intervention
should the nurse implement first?
A. Administer a prescribed oral loop diuretic with a glass of water
B. Elevate the head of the bed to a high-Fowler's position and apply supplemental oxygen
C. Obtain a stat 12-lead electrocardiogram
D. Draw blood samples for complete blood count and metabolic panel
Answer: B
Elevating the head of the bed lowers the diaphragm and decreases venous return, which
reduces cardiac workload and immediately improves chest expansion. Applying supplemental
oxygen addresses acute hypoxemia directly, making airway and oxygenation the priority
intervention according to standard clinical resuscitation frameworks.
3. An older adult client receiving intravenous fluids displays dynamic signs of fluid volume
overload, including jugular venous distention and a third heart sound (S3). What is the
appropriate immediate nursing response?
A. Increase the IV flow rate to clear the tubing
B. Slow the IV infusion to a keep-vein-open rate and notify the healthcare provider
,C. Administer a bolus of normal saline solution
D. Position the patient flat in the supine position
Answer: B
Slowing the infusion rate minimizes the risk of worsening pulmonary edema and
hypervolemia while ensuring vascular access remains clear. Immediately contacting the
primary care provider allows for prompt order modifications, such as diuretic administration,
to manage fluid overload safely.
4. A nurse assesses a postoperative client's surgical site and observes purulent drainage,
localized warmth, and a body temperature of 101.8°F (38.8°C). Which nursing diagnosis
receives the highest priority?
A. Impaired Physical Mobility related to surgical pain
B. Risk for Deficient Fluid Volume related to fever
C. Acute Pain related to tissue trauma
D. Risk for Systemic Infection related to localized surgical site infection
Answer: D
Localized infection signs paired with a significant systemic febrile response signal a risk of
progression to systemic sepsis. Prioritizing systemic infection risk directs immediate diagnostic
sampling, culture collection, and targeted antimicrobial management to prevent severe clinical
deterioration.
5. While preparing to perform a sterile dressing change on a central line, the nurse
accidentally touches the edge of the sterile field with a non-sterile glove. What is the correct
corrective action?
A. Disinfect the touched area with an alcohol swab and continue
B. Discard the contaminated field and setup, then re-establish a new sterile field
C. Proceed with the procedure using extra caution around the touched edge
D. Cover the contaminated area with a sterile towel and proceed
Answer: B
A sterile field is considered completely unsterile once touched by a non-sterile item. To
maintain strict surgical asepsis and minimize client risk for healthcare-associated central line-
associated bloodstream infections, the entire setup must be discarded and replaced
immediately.
6. A client with a diagnosis of Type 1 Diabetes Mellitus presents with diaphoresis, tremors,
and a blood glucose level of 54 mg/dL. Which nursing action takes immediate priority?
A. Administer 15 to 20 grams of fast-acting simple carbohydrates orally
,B. Administer 10 units of regular insulin subcutaneously
C. Provide a high-protein, high-fat meal immediately
D. Recheck the blood glucose level in 45 minutes without intervention
Answer: A
The client is experiencing symptomatic hypoglycemia. The standard rule of 15 dictates
immediate oral administration of 15 to 20 grams of fast-acting simple carbohydrates to rapidly
elevate blood glucose levels and restore cerebral glucose supply, preventing neurological
complications.
7. A healthcare provider prescribes 1,000 mL of 0.9% Normal Saline to infuse over 8
hours. The drop factor of the manual tubing is 15 drops/mL. What is the correct flow rate
in drops per minute (gtt/min)?
A. 21 gtt/min
B. 31 gtt/min
C. 42 gtt/min
D. 125 gtt/min
Answer: B
To calculate the flow rate: Total volume (1,000 mL) divided by total time in minutes (8 hours x
60 minutes = 480 minutes) multiplied by the drop factor (15 gtt/mL). 1, = 2.083
mL/min. 2.083 x 15 = 31.25 gtt/min, which rounds to 31 gtt/min. Accurate IV flow calculation
prevents fluid under- or over-infusion.
8. When assessing an immobilised client for pressure injury development, which
anatomical site requires the most frequent inspection while in the supine position?
A. Patella
B. Sacrum and heels
C. Greater trochanter
D. Acromion process
Answer: B
In the supine position, body weight exerts maximum pressure over bony prominences directly
resting on the mattress, primarily the sacrum, coccyx, and calcaneus (heels). Frequent
inspection, turn schedules, and pressure-offloading interventions targeting these areas reduce
localized tissue ischemia.
9. A patient with chronic obstructive pulmonary disease (COPD) is receiving oxygen via
nasal cannula. Why must the nurse exercise caution when increasing the oxygen flow rate
above 2 liters per minute?
, A. High oxygen levels cause hyperventilation and metabolic alkalosis
B. Elevated arterial oxygen tension can eliminate the hypoxic drive to breathe
C. High flow rates cause severe tracheal ulceration within minutes
D. Oxygen therapy increases red blood cell destruction in COPD patients
Answer: B
Clients with end-stage COPD often rely on a hypoxic drive (low arterial oxygen tension) to
stimulate respiration because their central chemoreceptors are desensitized to chronic
hypercapnia. Excessive oxygen administration suppresses this drive, potentially leading to
hypoventilation, severe carbon dioxide retention, and respiratory arrest.
10. A nurse observes a red, raised area on a patient's forearm following an intradermal
tuberculin skin test (PPD). At what time frame post-injection should the nurse officially
read and document the induration size?
A. 12 to 24 hours
B. 24 to 36 hours
C. 48 to 72 hours
D. 96 to 120 hours
Answer: C
Delayed-type hypersensitivity cell-mediated reactions to tuberculin purified protein derivative
peak between 48 and 72 hours post-injection. Evaluation prior to 48 hours or after 72 hours
yields unreliable results and invalidates screening interpretation.
11. A charge nurse delegates tasks on a medical-surgical unit. Which task is most
appropriate to delegate to a licensed practical nurse (LPN)?
A. Initial admission physical assessment of a newly admitted surgical client
B. Developing the primary plan of care for a client with complex multisystem failure
C. Administering routine oral maintenance medications to a stable client
D. Providing discharge teaching regarding complex medication reconciliation
Answer: C
LPN scope of practice includes administering routine oral medications to clinically stable
clients under the supervision of a registered nurse. Initial assessments, care plan development,
and primary discharge education require advanced nursing judgment reserved for registered
nurses.
12. A client scheduled for an elective abdominal procedure states, "I signed the consent
form, but I really do not understand what the surgeon is going to cut or what the risks
are." Which action should the nurse take?
