NR224 Exam 2 Actual Exam Style V1 | NR
224 Fundamentals - Skills | Chamberlain
1. A nurse is caring for a patient with a Stage 2 pressure injury on the coccyx. Which
characteristic should the nurse expect to observe during the assessment?
A. Full-thickness skin loss with visible adipose tissue.
B. Non-blanchable erythema of intact skin.
C. Partial-thickness loss of dermis presenting as a shallow open ulcer.
D. Full-thickness tissue loss with exposed bone or muscle.
Answer: C
Rationale: A Stage 2 pressure injury involves partial-thickness loss of dermis and presents
as a shallow, open ulcer with a red-pink wound bed. It may also present as an intact or
open/ruptured serum-filled blister. This stage does not include slough, bruising, or deep
tissue involvement.
2. When administering a tap-water enema, the patient reports cramping and abdominal pain.
What is the priority action by the nurse?
A. Stop the procedure and notify the healthcare provider.
B. Lower the enema container to slow the rate of flow.
C. Advance the rectal tube further into the colon.
,D. Encourage the patient to take deep breaths and continue at the same rate.
Answer: B
Rationale: Abdominal cramping during an enema is often caused by the rapid rate of fluid
instillation. Lowering the container slows the flow and usually relieves the cramping while
allowing the procedure to continue. The nurse should never force the fluid if the patient is
in significant distress, but slowing the rate is the initial intervention.
3. The nurse is preparing to perform tracheostomy suctioning for a patient. What is the
maximum amount of time the nurse should apply suction during a single pass?
A. 5 seconds
B. As long as the patient can tolerate it
C. 20 to 30 seconds
D. 10 to 15 seconds
Answer: D
Rationale: Suctioning should be limited to 10 to 15 seconds to prevent hypoxia and trauma
to the tracheal mucosa. Prolonged suctioning can lead to significant oxygen desaturation
and cardiac arrhythmias. The nurse must allow the patient to recover and re-oxygenate
between passes.
4. Which assessment finding indicates that a patient is experiencing early signs of hypoxia?
A. Cyanosis of the lips and nail beds.
, B. Decreased respiratory rate and bradycardia.
C. Restlessness, anxiety, and tachycardia.
D. Clubbing of the fingers and toes.
Answer: C
Rationale: Restlessness and anxiety are often the earliest signs of hypoxia as the brain
reacts to decreasing oxygen levels. Tachycardia occurs as the heart attempts to compensate
by pumping more oxygenated blood to the tissues. Cyanosis and bradycardia are
considered late signs of respiratory distress.
5. A nurse is providing discharge teaching for a patient with a new ileostomy. Which
statement by the patient indicates a need for further teaching?
A. ‘I will empty my pouch when it is about one-third full.’
B. ‘I will take a laxative if I go more than two days without a bowel movement.’
C. ‘I will use a skin barrier to protect the skin around my stoma.’
D. ‘I should expect my stool to be liquid in consistency.’
Answer: B
Rationale: Patients with an ileostomy should never take laxatives because they are at high
risk for severe dehydration and electrolyte imbalances. The stool from an ileostomy is
naturally liquid or semi-liquid because it bypasses the large intestine where water is
224 Fundamentals - Skills | Chamberlain
1. A nurse is caring for a patient with a Stage 2 pressure injury on the coccyx. Which
characteristic should the nurse expect to observe during the assessment?
A. Full-thickness skin loss with visible adipose tissue.
B. Non-blanchable erythema of intact skin.
C. Partial-thickness loss of dermis presenting as a shallow open ulcer.
D. Full-thickness tissue loss with exposed bone or muscle.
Answer: C
Rationale: A Stage 2 pressure injury involves partial-thickness loss of dermis and presents
as a shallow, open ulcer with a red-pink wound bed. It may also present as an intact or
open/ruptured serum-filled blister. This stage does not include slough, bruising, or deep
tissue involvement.
2. When administering a tap-water enema, the patient reports cramping and abdominal pain.
What is the priority action by the nurse?
A. Stop the procedure and notify the healthcare provider.
B. Lower the enema container to slow the rate of flow.
C. Advance the rectal tube further into the colon.
,D. Encourage the patient to take deep breaths and continue at the same rate.
Answer: B
Rationale: Abdominal cramping during an enema is often caused by the rapid rate of fluid
instillation. Lowering the container slows the flow and usually relieves the cramping while
allowing the procedure to continue. The nurse should never force the fluid if the patient is
in significant distress, but slowing the rate is the initial intervention.
3. The nurse is preparing to perform tracheostomy suctioning for a patient. What is the
maximum amount of time the nurse should apply suction during a single pass?
A. 5 seconds
B. As long as the patient can tolerate it
C. 20 to 30 seconds
D. 10 to 15 seconds
Answer: D
Rationale: Suctioning should be limited to 10 to 15 seconds to prevent hypoxia and trauma
to the tracheal mucosa. Prolonged suctioning can lead to significant oxygen desaturation
and cardiac arrhythmias. The nurse must allow the patient to recover and re-oxygenate
between passes.
4. Which assessment finding indicates that a patient is experiencing early signs of hypoxia?
A. Cyanosis of the lips and nail beds.
, B. Decreased respiratory rate and bradycardia.
C. Restlessness, anxiety, and tachycardia.
D. Clubbing of the fingers and toes.
Answer: C
Rationale: Restlessness and anxiety are often the earliest signs of hypoxia as the brain
reacts to decreasing oxygen levels. Tachycardia occurs as the heart attempts to compensate
by pumping more oxygenated blood to the tissues. Cyanosis and bradycardia are
considered late signs of respiratory distress.
5. A nurse is providing discharge teaching for a patient with a new ileostomy. Which
statement by the patient indicates a need for further teaching?
A. ‘I will empty my pouch when it is about one-third full.’
B. ‘I will take a laxative if I go more than two days without a bowel movement.’
C. ‘I will use a skin barrier to protect the skin around my stoma.’
D. ‘I should expect my stool to be liquid in consistency.’
Answer: B
Rationale: Patients with an ileostomy should never take laxatives because they are at high
risk for severe dehydration and electrolyte imbalances. The stool from an ileostomy is
naturally liquid or semi-liquid because it bypasses the large intestine where water is
