,NR 224 Fundamentals – Skills Exam
Prep — Comprehensive Review +
Practice MCQs — Chamberlain
University
1. A nurse is caring for a patient admitted with exacerbation of heart failure. The patient is dyspneic, has an
SpO₂ of 88% on room air, and reports sleeping on three pillows at home. Using the nursing process, which
action should the nurse perform FIRST?
A. Administer supplemental oxygen per protocol
B. Document the edema and pillow use as findings
C. Assess the patient's lung sounds and respiratory rate
D. Contact the provider to request a diuretic adjustment
Correct Answer: C. Assess the patient's lung sounds and respiratory rate
Rationale: Assessment is the first step of the nursing process and must precede any intervention. While oxygen
administration is urgent, the nurse must first assess to determine the severity and appropriate intervention.
The nursing process follows ADPIE: Assessment, Diagnosis, Planning, Implementation, Evaluation.
2. During a clinical rotation, a nurse observes that a post-operative patient is increasingly confused and restless
24 hours after surgery. The patient's vital signs are stable, but the patient is attempting to remove the IV line.
Which cue represents an abnormal finding requiring immediate analysis?
A. Stable vital signs indicating adequate perfusion
B. Patient age of 58 years, within normal surgical risk range
C. New-onset confusion and restlessness in the post-operative period
,D. Attempt to remove IV line, which is common post-anesthesia
Correct Answer: C. New-onset confusion and restlessness in the post-operative period
Rationale: New-onset confusion in a post-operative patient is an abnormal cue that may indicate hypoxia,
infection, or medication adverse effects, requiring immediate analysis. Stable vitals and age are expected
findings.
3. A nurse is developing a care plan for a patient with a new colostomy. The patient states, "I don't think I can
ever learn to change this bag myself." Which expected outcome is most appropriate?
A. The patient will verbalize understanding of the need for a permanent colostomy
B. The patient will state feeling less anxious about the ostomy within 24 hours
C. The patient will demonstrate independent ostomy bag change with 90% accuracy by discharge
D. The nurse will provide ostomy care education using a teach-back method daily
Correct Answer: C. The patient will demonstrate independent ostomy bag change with 90% accuracy by
discharge
Rationale: Expected outcomes must be patient-centered, measurable, and realistic. Demonstrating the skill
with accuracy is a measurable outcome that directly addresses the knowledge deficit. Option D is a nursing
intervention, not a patient outcome.
4. A nurse is prioritizing care for four patients. Patient A has a new ileostomy and reports incisional pain of
6/10. Patient B has stable vital signs but needs a scheduled wound dressing change. Patient C has a potassium
level of 5.8 mEq/L and is on a cardiac monitor. Patient D needs assistance with a bed bath. Using Maslow's
hierarchy of needs, which patient should the nurse see FIRST?
, A. Patient A, because uncontrolled pain is a physiological need
B. Patient B, because wound care prevents infection
C. Patient C, because a potassium of 5.8 mEq/L is a life-threatening electrolyte imbalance
D. Patient D, because hygiene promotes self-esteem
Correct Answer: C. Patient C, because a potassium of 5.8 mEq/L is a life-threatening electrolyte imbalance
Rationale: Maslow's hierarchy prioritizes physiological needs first, but among physiological needs, life-
threatening conditions take priority. A potassium of 5.8 mEq/L (hyperkalemia) can cause fatal cardiac
dysrhythmias. Pain is important but not immediately life-threatening.
5. Which of the following best describes the primary purpose of the nursing process?
A. To provide a legal framework for documenting patient care
B. To serve as a systematic method for critical thinking and clinical decision-making
C. To establish protocols for medication administration
D. To replace the need for clinical judgment in patient care
Correct Answer: B. To serve as a systematic method for critical thinking and clinical decision-making
Rationale: The nursing process is a systematic, patient-centered framework that guides nurses in critical
thinking and clinical decision-making through the five steps of ADPIE. It does not replace clinical judgment.
6. What is the correct order of the steps in the nursing process?
A. Assessment → Planning → Diagnosis → Implementation → Evaluation
Prep — Comprehensive Review +
Practice MCQs — Chamberlain
University
1. A nurse is caring for a patient admitted with exacerbation of heart failure. The patient is dyspneic, has an
SpO₂ of 88% on room air, and reports sleeping on three pillows at home. Using the nursing process, which
action should the nurse perform FIRST?
A. Administer supplemental oxygen per protocol
B. Document the edema and pillow use as findings
C. Assess the patient's lung sounds and respiratory rate
D. Contact the provider to request a diuretic adjustment
Correct Answer: C. Assess the patient's lung sounds and respiratory rate
Rationale: Assessment is the first step of the nursing process and must precede any intervention. While oxygen
administration is urgent, the nurse must first assess to determine the severity and appropriate intervention.
The nursing process follows ADPIE: Assessment, Diagnosis, Planning, Implementation, Evaluation.
2. During a clinical rotation, a nurse observes that a post-operative patient is increasingly confused and restless
24 hours after surgery. The patient's vital signs are stable, but the patient is attempting to remove the IV line.
Which cue represents an abnormal finding requiring immediate analysis?
A. Stable vital signs indicating adequate perfusion
B. Patient age of 58 years, within normal surgical risk range
C. New-onset confusion and restlessness in the post-operative period
,D. Attempt to remove IV line, which is common post-anesthesia
Correct Answer: C. New-onset confusion and restlessness in the post-operative period
Rationale: New-onset confusion in a post-operative patient is an abnormal cue that may indicate hypoxia,
infection, or medication adverse effects, requiring immediate analysis. Stable vitals and age are expected
findings.
3. A nurse is developing a care plan for a patient with a new colostomy. The patient states, "I don't think I can
ever learn to change this bag myself." Which expected outcome is most appropriate?
A. The patient will verbalize understanding of the need for a permanent colostomy
B. The patient will state feeling less anxious about the ostomy within 24 hours
C. The patient will demonstrate independent ostomy bag change with 90% accuracy by discharge
D. The nurse will provide ostomy care education using a teach-back method daily
Correct Answer: C. The patient will demonstrate independent ostomy bag change with 90% accuracy by
discharge
Rationale: Expected outcomes must be patient-centered, measurable, and realistic. Demonstrating the skill
with accuracy is a measurable outcome that directly addresses the knowledge deficit. Option D is a nursing
intervention, not a patient outcome.
4. A nurse is prioritizing care for four patients. Patient A has a new ileostomy and reports incisional pain of
6/10. Patient B has stable vital signs but needs a scheduled wound dressing change. Patient C has a potassium
level of 5.8 mEq/L and is on a cardiac monitor. Patient D needs assistance with a bed bath. Using Maslow's
hierarchy of needs, which patient should the nurse see FIRST?
, A. Patient A, because uncontrolled pain is a physiological need
B. Patient B, because wound care prevents infection
C. Patient C, because a potassium of 5.8 mEq/L is a life-threatening electrolyte imbalance
D. Patient D, because hygiene promotes self-esteem
Correct Answer: C. Patient C, because a potassium of 5.8 mEq/L is a life-threatening electrolyte imbalance
Rationale: Maslow's hierarchy prioritizes physiological needs first, but among physiological needs, life-
threatening conditions take priority. A potassium of 5.8 mEq/L (hyperkalemia) can cause fatal cardiac
dysrhythmias. Pain is important but not immediately life-threatening.
5. Which of the following best describes the primary purpose of the nursing process?
A. To provide a legal framework for documenting patient care
B. To serve as a systematic method for critical thinking and clinical decision-making
C. To establish protocols for medication administration
D. To replace the need for clinical judgment in patient care
Correct Answer: B. To serve as a systematic method for critical thinking and clinical decision-making
Rationale: The nursing process is a systematic, patient-centered framework that guides nurses in critical
thinking and clinical decision-making through the five steps of ADPIE. It does not replace clinical judgment.
6. What is the correct order of the steps in the nursing process?
A. Assessment → Planning → Diagnosis → Implementation → Evaluation
