NR 224 FUNDAMENTALS EXAM PREDICTOR 2026 NEW EDITION Q&A
1. A nurse is assessing a client's vital signs and notes a blood pressure
of 158/94 mmHg. The client has no history of hypertension. Which
action should the nurse take first?
A. Document the findings and continue with the shift
B. Repeat the blood pressure measurement after 15 minutes
C. Notify the healthcare provider immediately
D. Administer antihypertensive medication as needed
Correct Answer: B
Explanation: When an elevated blood pressure reading is obtained
in a client without hypertension history, the nurse should first
repeat the measurement to verify accuracy before taking further
action. This prevents false diagnoses and unnecessary
interventions. Options A, C, and D are premature without
confirming the reading.
2. A nurse is teaching unlicensed assistive personnel (UAP) about
caring for a client with low platelet count. Which instruction is the
priority for measuring vital signs in this client?
A. Avoid rectal temperatures
B. Count radial pulse for 30 seconds and multiply by 2
C. Have client rest for 5 minutes before assessing HR, RR, or BP
D. Assess for nail polish prior to placing pulse oximeter
Correct Answer: A
Explanation: Clients with low platelet counts are at risk for
bleeding, and rectal temperatures can cause mucosal trauma and
bleeding. This is the priority safety intervention. While options C
, and D are good practices, they are not as critical as preventing
bleeding in thrombocytopenic clients.
3. A nurse is preparing to administer a medication via the
intramuscular route to an adult client. Which site is most
appropriate for a 3 mL injection?
A. Deltoid muscle
B. Dorsogluteal muscle
C. Ventrogluteal muscle
D. Subcutaneous tissue
Correct Answer: C
Explanation: The ventrogluteal muscle can safely accommodate up
to 3-4 mL of medication and is free from major nerves and blood
vessels, making it the safest site for large-volume IM injections.
The deltoid is limited to 1 mL, dorsogluteal has risk of sciatic nerve
injury, and subcutaneous tissue is not for IM injections.
4. A client with a history of heart failure presents with edema,
crackles in the lungs, and shortness of breath. Which fluid
imbalance is the nurse most likely to suspect?
A. Fluid volume deficit
B. Fluid volume excess
C. Hypernatremia
D. Hypocalcemia
Correct Answer: B
Explanation: The clinical presentation of edema, pulmonary
crackles, and dyspnea in a heart failure client indicates fluid
, volume excess (hypervolemia). These symptoms result from fluid
accumulation in tissues and lungs. Fluid deficit would present with
dry mucous membranes and hypotension.
5. A nurse is assessing a client's pressure ulcer and notes full-
thickness skin loss with visible subcutaneous tissue but no
exposed bone or muscle. How should this ulcer be staged?
A. Stage 1
B. Stage 2
C. Stage 3
D. Stage 4
Correct Answer: C
Explanation: Stage 3 pressure ulcers involve full-thickness skin loss
with visible subcutaneous tissue but no exposed bone, tendon, or
muscle. Stage 1 is non-blanchable erythema, Stage 2 is partial-
thickness loss, and Stage 4 has exposed bone/muscle.
6. A nurse is teaching a client about proper handwashing technique.
Which statement by the client indicates correct understanding?
A. "I should wash my hands for at least 5 seconds."
B. "I should use hot water to kill all bacteria."
C. "I should scrub all surfaces of my hands for at least 20 seconds."
D. "I only need to wash my hands after using the restroom."
Correct Answer: C
Explanation: CDC recommends scrubbing all hand surfaces for at
least 20 seconds for effective handwashing. Option A is too short,
hot water can damage skin (warm water is sufficient), and
, handwashing is needed in multiple situations beyond restroom
use.
7. A client with a nasogastric tube is experiencing nausea and
abdominal distension. Which action should the nurse take first?
A. Administer an antiemetic medication
B. Check tube patency and position
C. Increase the suction pressure
D. Notify the healthcare provider immediately
Correct Answer: B
Explanation: Nausea and distension in a client with an NG tube
suggest possible tube obstruction or dislodgement. Checking tube
patency and position is the priority assessment before other
interventions. This addresses the root cause rather than just
symptoms.
8. A nurse is caring for a client with a considering fall risk. Which
intervention is most effective in preventing falls?
A. Placing the call bell within reach
B. Keeping all side rails elevated
C. Using a bed alarm
D. Frequent rounding every 2 hours
Correct Answer: D
Explanation: Frequent rounding every 2 hours addresses the most
common reasons for falls (toilet needs, pain, position changes) and
is more effective than passive measures. Side rails elevation can
1. A nurse is assessing a client's vital signs and notes a blood pressure
of 158/94 mmHg. The client has no history of hypertension. Which
action should the nurse take first?
A. Document the findings and continue with the shift
B. Repeat the blood pressure measurement after 15 minutes
C. Notify the healthcare provider immediately
D. Administer antihypertensive medication as needed
Correct Answer: B
Explanation: When an elevated blood pressure reading is obtained
in a client without hypertension history, the nurse should first
repeat the measurement to verify accuracy before taking further
action. This prevents false diagnoses and unnecessary
interventions. Options A, C, and D are premature without
confirming the reading.
2. A nurse is teaching unlicensed assistive personnel (UAP) about
caring for a client with low platelet count. Which instruction is the
priority for measuring vital signs in this client?
A. Avoid rectal temperatures
B. Count radial pulse for 30 seconds and multiply by 2
C. Have client rest for 5 minutes before assessing HR, RR, or BP
D. Assess for nail polish prior to placing pulse oximeter
Correct Answer: A
Explanation: Clients with low platelet counts are at risk for
bleeding, and rectal temperatures can cause mucosal trauma and
bleeding. This is the priority safety intervention. While options C
, and D are good practices, they are not as critical as preventing
bleeding in thrombocytopenic clients.
3. A nurse is preparing to administer a medication via the
intramuscular route to an adult client. Which site is most
appropriate for a 3 mL injection?
A. Deltoid muscle
B. Dorsogluteal muscle
C. Ventrogluteal muscle
D. Subcutaneous tissue
Correct Answer: C
Explanation: The ventrogluteal muscle can safely accommodate up
to 3-4 mL of medication and is free from major nerves and blood
vessels, making it the safest site for large-volume IM injections.
The deltoid is limited to 1 mL, dorsogluteal has risk of sciatic nerve
injury, and subcutaneous tissue is not for IM injections.
4. A client with a history of heart failure presents with edema,
crackles in the lungs, and shortness of breath. Which fluid
imbalance is the nurse most likely to suspect?
A. Fluid volume deficit
B. Fluid volume excess
C. Hypernatremia
D. Hypocalcemia
Correct Answer: B
Explanation: The clinical presentation of edema, pulmonary
crackles, and dyspnea in a heart failure client indicates fluid
, volume excess (hypervolemia). These symptoms result from fluid
accumulation in tissues and lungs. Fluid deficit would present with
dry mucous membranes and hypotension.
5. A nurse is assessing a client's pressure ulcer and notes full-
thickness skin loss with visible subcutaneous tissue but no
exposed bone or muscle. How should this ulcer be staged?
A. Stage 1
B. Stage 2
C. Stage 3
D. Stage 4
Correct Answer: C
Explanation: Stage 3 pressure ulcers involve full-thickness skin loss
with visible subcutaneous tissue but no exposed bone, tendon, or
muscle. Stage 1 is non-blanchable erythema, Stage 2 is partial-
thickness loss, and Stage 4 has exposed bone/muscle.
6. A nurse is teaching a client about proper handwashing technique.
Which statement by the client indicates correct understanding?
A. "I should wash my hands for at least 5 seconds."
B. "I should use hot water to kill all bacteria."
C. "I should scrub all surfaces of my hands for at least 20 seconds."
D. "I only need to wash my hands after using the restroom."
Correct Answer: C
Explanation: CDC recommends scrubbing all hand surfaces for at
least 20 seconds for effective handwashing. Option A is too short,
hot water can damage skin (warm water is sufficient), and
, handwashing is needed in multiple situations beyond restroom
use.
7. A client with a nasogastric tube is experiencing nausea and
abdominal distension. Which action should the nurse take first?
A. Administer an antiemetic medication
B. Check tube patency and position
C. Increase the suction pressure
D. Notify the healthcare provider immediately
Correct Answer: B
Explanation: Nausea and distension in a client with an NG tube
suggest possible tube obstruction or dislodgement. Checking tube
patency and position is the priority assessment before other
interventions. This addresses the root cause rather than just
symptoms.
8. A nurse is caring for a client with a considering fall risk. Which
intervention is most effective in preventing falls?
A. Placing the call bell within reach
B. Keeping all side rails elevated
C. Using a bed alarm
D. Frequent rounding every 2 hours
Correct Answer: D
Explanation: Frequent rounding every 2 hours addresses the most
common reasons for falls (toilet needs, pain, position changes) and
is more effective than passive measures. Side rails elevation can
