Chamberlain University
1 MAXE · 422 RN
★ ★
C College of Nursing & Public Health
EST. 1889
EXTRAORDINARY CARE. EXTRAORDINARY NURSES.
NR224 Exam 1
F U N DA M E N TA LS O F N U RS I N G — E X A M 1 R E V I E W
INSTITUTION Chamberlain University PROGRAM Bachelor of Science in Nursing
COURSE CODE NR 224 COURSE TITLE Fundamentals of Nursing
ACADEMIC YEAR EXAM TITLE NR224 Exam 1
TOTAL QUESTIONS 90 Questions FORMAT Multiple Choice / Select All That
Apply — Select the Best Answer(s)
EXAMINATION INSTRUCTIONS
▸ Select the single best answer unless "Select all that apply" is specified.
▸ Questions have been randomized from the source material per Component 16.
▸ Topics covered: Vital Signs, Infection Control, Nursing Process, Critical Thinking, Safety, Nutrition, and
Physical Assessment.
▸ Correct answers and clinical rationales appear below each question for review.
▸ All nursing interventions reflect current evidence-based practice standards.
, FUNDAMENTALS OF NURSING — COMPREHENSIVE EXAM
Questions 1 – 90
REVIEW
1. A nurse is assessing a client for signs of infection. Which of the following are expected
findings upon assessment of an infection? (Select all that apply.)
A. Fever, chills, increased pulse and respiratory rate, malaise, fatigue, anorexia, nausea,
vomiting, abdominal cramping, diarrhea, enlarged lymph nodes
B. Decreased heart rate, hypothermia, and weight gain
C. Only localized edema and pain at the infection site
D. Bradycardia, bradypnea, and hypotension
CORRECT ANSWER A — Fever, chills, increased pulse and RR, malaise, fatigue, anorexia,
nausea, vomiting, abdominal cramping, diarrhea, enlarged lymph nodes
RATIONALE Systemic infection triggers a widespread inflammatory and immune response.
Expected findings include fever (pyrogens reset hypothalamic set point), chills
(rigors from muscular heat production), increased pulse and respiratory rate
(metabolic demand increases with temperature), malaise and fatigue (cytokine-
mediated), anorexia, nausea, vomiting, abdominal cramping, diarrhea (GI effects
of inflammatory mediators), and enlarged lymph nodes (lymphocyte proliferation
and antigen presentation). Localized infections may show only site-specific
findings, but systemic infections produce this broader constellation.
,2. A nurse is caring for an 82-year-old client in the emergency department who has an oral
body temperature of 38.3°C (101°F), pulse rate 114/min, and respiratory rate 22/min. He is
restless and his skin is warm. Which of the following interventions should the nurse take?
(Select all that apply.)
A. Obtain culture specimens before initiating antimicrobials
B. Restrict the client's oral fluid intake
C. Encourage the client to rest and limit activity
D. Allow the client to shiver to dispel excess heat
CORRECT ANSWER A, C, E — Obtain culture specimens before antimicrobials; Encourage rest
and limit activity; Assist with oral hygiene frequently
RATIONALE For a febrile patient: (A) Obtain cultures BEFORE starting antimicrobials —
antibiotics can sterilize cultures, making it impossible to identify the pathogen;
(C) Encourage rest — metabolic demands are already elevated from fever and
tachycardia, activity further increases oxygen consumption; (E) Frequent oral
hygiene — febrile patients have dry mucous membranes and are at risk for oral
complications. Do NOT restrict fluids (febrile patients need increased fluids to
replace insensible losses and prevent dehydration). Do NOT encourage shivering
(shivering increases metabolic heat production and raises temperature further).
, 3. A nurse is instructing an assistive personnel about caring for a client who has a low
platelet count as a result of chemotherapy. Which of the following instructions is the
priority for measuring vital signs for this client?
A. "Do not measure the client's temperature rectally."
B. "Count the client's radial pulse for 30 seconds and multiply it by 2."
C. "Do not let the client know you are counting her respirations."
D. "Let the client rest for 5 minutes before you measure her blood pressure."
CORRECT ANSWER A — "Do not measure the client's temperature rectally."
RATIONALE Thrombocytopenia (low platelet count) significantly increases bleeding risk.
Rectal temperature measurement is contraindicated because the rectal mucosa is
highly vascular and easily traumatized — inserting a thermometer could cause
rectal bleeding that may be difficult to control in a thrombocytopenic patient.
Alternative routes (oral, axillary, tympanic, temporal) should be used. While other
vital sign techniques are important (counting for full 60 seconds if irregular, not
letting the client alter breathing patterns, resting before BP), preventing
iatrogenic bleeding is the priority safety concern.
1 MAXE · 422 RN
★ ★
C College of Nursing & Public Health
EST. 1889
EXTRAORDINARY CARE. EXTRAORDINARY NURSES.
NR224 Exam 1
F U N DA M E N TA LS O F N U RS I N G — E X A M 1 R E V I E W
INSTITUTION Chamberlain University PROGRAM Bachelor of Science in Nursing
COURSE CODE NR 224 COURSE TITLE Fundamentals of Nursing
ACADEMIC YEAR EXAM TITLE NR224 Exam 1
TOTAL QUESTIONS 90 Questions FORMAT Multiple Choice / Select All That
Apply — Select the Best Answer(s)
EXAMINATION INSTRUCTIONS
▸ Select the single best answer unless "Select all that apply" is specified.
▸ Questions have been randomized from the source material per Component 16.
▸ Topics covered: Vital Signs, Infection Control, Nursing Process, Critical Thinking, Safety, Nutrition, and
Physical Assessment.
▸ Correct answers and clinical rationales appear below each question for review.
▸ All nursing interventions reflect current evidence-based practice standards.
, FUNDAMENTALS OF NURSING — COMPREHENSIVE EXAM
Questions 1 – 90
REVIEW
1. A nurse is assessing a client for signs of infection. Which of the following are expected
findings upon assessment of an infection? (Select all that apply.)
A. Fever, chills, increased pulse and respiratory rate, malaise, fatigue, anorexia, nausea,
vomiting, abdominal cramping, diarrhea, enlarged lymph nodes
B. Decreased heart rate, hypothermia, and weight gain
C. Only localized edema and pain at the infection site
D. Bradycardia, bradypnea, and hypotension
CORRECT ANSWER A — Fever, chills, increased pulse and RR, malaise, fatigue, anorexia,
nausea, vomiting, abdominal cramping, diarrhea, enlarged lymph nodes
RATIONALE Systemic infection triggers a widespread inflammatory and immune response.
Expected findings include fever (pyrogens reset hypothalamic set point), chills
(rigors from muscular heat production), increased pulse and respiratory rate
(metabolic demand increases with temperature), malaise and fatigue (cytokine-
mediated), anorexia, nausea, vomiting, abdominal cramping, diarrhea (GI effects
of inflammatory mediators), and enlarged lymph nodes (lymphocyte proliferation
and antigen presentation). Localized infections may show only site-specific
findings, but systemic infections produce this broader constellation.
,2. A nurse is caring for an 82-year-old client in the emergency department who has an oral
body temperature of 38.3°C (101°F), pulse rate 114/min, and respiratory rate 22/min. He is
restless and his skin is warm. Which of the following interventions should the nurse take?
(Select all that apply.)
A. Obtain culture specimens before initiating antimicrobials
B. Restrict the client's oral fluid intake
C. Encourage the client to rest and limit activity
D. Allow the client to shiver to dispel excess heat
CORRECT ANSWER A, C, E — Obtain culture specimens before antimicrobials; Encourage rest
and limit activity; Assist with oral hygiene frequently
RATIONALE For a febrile patient: (A) Obtain cultures BEFORE starting antimicrobials —
antibiotics can sterilize cultures, making it impossible to identify the pathogen;
(C) Encourage rest — metabolic demands are already elevated from fever and
tachycardia, activity further increases oxygen consumption; (E) Frequent oral
hygiene — febrile patients have dry mucous membranes and are at risk for oral
complications. Do NOT restrict fluids (febrile patients need increased fluids to
replace insensible losses and prevent dehydration). Do NOT encourage shivering
(shivering increases metabolic heat production and raises temperature further).
, 3. A nurse is instructing an assistive personnel about caring for a client who has a low
platelet count as a result of chemotherapy. Which of the following instructions is the
priority for measuring vital signs for this client?
A. "Do not measure the client's temperature rectally."
B. "Count the client's radial pulse for 30 seconds and multiply it by 2."
C. "Do not let the client know you are counting her respirations."
D. "Let the client rest for 5 minutes before you measure her blood pressure."
CORRECT ANSWER A — "Do not measure the client's temperature rectally."
RATIONALE Thrombocytopenia (low platelet count) significantly increases bleeding risk.
Rectal temperature measurement is contraindicated because the rectal mucosa is
highly vascular and easily traumatized — inserting a thermometer could cause
rectal bleeding that may be difficult to control in a thrombocytopenic patient.
Alternative routes (oral, axillary, tympanic, temporal) should be used. While other
vital sign techniques are important (counting for full 60 seconds if irregular, not
letting the client alter breathing patterns, resting before BP), preventing
iatrogenic bleeding is the priority safety concern.
