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NR224 Fundamentals Skills Final Exam
Review Questions and Correct Answers
Tachycardia Ans: — A heart rate that exceeds the normal resting
rate, often defined as a heart rate over 100 beats per minute.
Bradycardia Ans: — A slower than normal heart rate, typically
defined as a heart rate below 60 beats per minute.
Factors causing tachycardia Ans: — Exercise, Fever/heat, Anxiety,
Loss of blood, Positive chronotropic drugs.
Factors causing bradycardia Ans: — Hypothermia, Long-term
exercise (athletes), Unrelieved severe pain, Negative chronotropic
drugs, Lying down.
Blood pressure assessment questions Ans: — Have you had AV
fistulas or a mastectomy?
Cuff selection for blood pressure Ans: — Based on the size of the
client's arm.
Cuff placement for blood pressure Ans: — Align cuff artery mark
with brachial artery.
Importance of proper cuff placement Ans: — Ensures that proper
pressure is applied during inflation.
Blood pressure reading action Ans: — Return in 30 minutes and
retake the blood pressure.
Priority instruction for UAP with low platelet count Ans: — Avoid
rectal temperatures.
Client to see first based on vital signs Ans: — 88-year-old male
client admitted with pneumonia, RR 28, SPo2 89%.
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Clients at risk for tachypnea Ans: — Client admitted with several
rib fractures, Woman who is 9 months pregnant, A 3 pack per day
smoker with pneumonia.
Risk Factors for Pressure Ulcer Development Ans: — -Very thin
and very obese people
-Age related changes
-Fluid loss during illness
-Moisture/fluids/stool against the skin
-Diseases of the skin
-Immobility
-Comorbidities
Skin assessment Ans: — -Color
-Odor
-Consistency
-Amount
-Measurements(Length x width x depth)
-Type of tissue(granulation, eschar, slough)
Healing process Ans: — Primary Intention: Wound that is closed
Secondary Intention: Wound edges not approximated
Tertiary Intention: Wound that is left open for several days; then
wo approximated
Desiccation Ans: — drying out
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Maceration Ans: — Softening or breaking down the skin due to
exposure to moisture
Pressure Ans: — "pressure" areas of the skin that are more at risk
for breakdown
Trauma Ans: — caused by physical harm to the area
Edema Ans: — swelling
Necrosis Ans: — tissue death in area slows other tissue healing
Hemorrhage Ans: — -bleeding
-May be seen externally, or may be internal and careful assessment
needed to assess
Dehiscence Ans: — Incision fails to heal properly, or tissues
separate
Evisceration Ans: — Protrusion of visceral organs through a
surgical wo
Stages of pressure injuries Ans: — Stage I — nonblanchable
erythema of intact skin
Stage II — partial-thickness skin loss
Stage III — full-thickness tissue loss; SC fat is visible
Stage IV — full-thickness tissue loss with extensive destruction.
Exposed bone, tendon or muscle.
Deep-Tissue Pressure Injury- persistent non-blanchable deep
discoloration of red, maroon, purple
Unstageable Pressure Injury- obscured full thickness loss
© 2025 All rights reserved
NR224 Fundamentals Skills Final Exam
Review Questions and Correct Answers
Tachycardia Ans: — A heart rate that exceeds the normal resting
rate, often defined as a heart rate over 100 beats per minute.
Bradycardia Ans: — A slower than normal heart rate, typically
defined as a heart rate below 60 beats per minute.
Factors causing tachycardia Ans: — Exercise, Fever/heat, Anxiety,
Loss of blood, Positive chronotropic drugs.
Factors causing bradycardia Ans: — Hypothermia, Long-term
exercise (athletes), Unrelieved severe pain, Negative chronotropic
drugs, Lying down.
Blood pressure assessment questions Ans: — Have you had AV
fistulas or a mastectomy?
Cuff selection for blood pressure Ans: — Based on the size of the
client's arm.
Cuff placement for blood pressure Ans: — Align cuff artery mark
with brachial artery.
Importance of proper cuff placement Ans: — Ensures that proper
pressure is applied during inflation.
Blood pressure reading action Ans: — Return in 30 minutes and
retake the blood pressure.
Priority instruction for UAP with low platelet count Ans: — Avoid
rectal temperatures.
Client to see first based on vital signs Ans: — 88-year-old male
client admitted with pneumonia, RR 28, SPo2 89%.
© 2025 All rights reserved
, 2 | Page
Clients at risk for tachypnea Ans: — Client admitted with several
rib fractures, Woman who is 9 months pregnant, A 3 pack per day
smoker with pneumonia.
Risk Factors for Pressure Ulcer Development Ans: — -Very thin
and very obese people
-Age related changes
-Fluid loss during illness
-Moisture/fluids/stool against the skin
-Diseases of the skin
-Immobility
-Comorbidities
Skin assessment Ans: — -Color
-Odor
-Consistency
-Amount
-Measurements(Length x width x depth)
-Type of tissue(granulation, eschar, slough)
Healing process Ans: — Primary Intention: Wound that is closed
Secondary Intention: Wound edges not approximated
Tertiary Intention: Wound that is left open for several days; then
wo approximated
Desiccation Ans: — drying out
© 2025 All rights reserved
, 3 | Page
Maceration Ans: — Softening or breaking down the skin due to
exposure to moisture
Pressure Ans: — "pressure" areas of the skin that are more at risk
for breakdown
Trauma Ans: — caused by physical harm to the area
Edema Ans: — swelling
Necrosis Ans: — tissue death in area slows other tissue healing
Hemorrhage Ans: — -bleeding
-May be seen externally, or may be internal and careful assessment
needed to assess
Dehiscence Ans: — Incision fails to heal properly, or tissues
separate
Evisceration Ans: — Protrusion of visceral organs through a
surgical wo
Stages of pressure injuries Ans: — Stage I — nonblanchable
erythema of intact skin
Stage II — partial-thickness skin loss
Stage III — full-thickness tissue loss; SC fat is visible
Stage IV — full-thickness tissue loss with extensive destruction.
Exposed bone, tendon or muscle.
Deep-Tissue Pressure Injury- persistent non-blanchable deep
discoloration of red, maroon, purple
Unstageable Pressure Injury- obscured full thickness loss
© 2025 All rights reserved
