NR 224-FUNDAMENTALS SKILLS EXAM– QUESTIONS AND ANSWERS |
VERIFIED AND WELL DETAILED ANSWERS PLUS RATIONALES |
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1. A newly admitted client expresses anxiety about their upcoming diagnostic procedure
and states they do not understand what will happen. Which of the following actions should
the nurse take first?
A. Administer a prescribed anti-anxiety medication to calm the client before the procedure.
B. Inform the physician that the client is anxious and needs immediate reassurance.
C. Assess the client's specific knowledge gaps and concerns regarding the procedure.
D. Explain every step of the medical procedure in complex clinical detail to ensure full
transparency.
Prior to initiating interventions or notifying the provider, the nurse must assess the client's
specific understanding and fears to provide targeted education and emotional support.
Administering medication or explaining without knowing the source of anxiety is premature,
and notifying the provider is unnecessary before a thorough nursing assessment is completed.
2. While performing a routine physical assessment, a nurse notices a localized area of intact
skin with non-blanchable redness over the sacrum. How should the nurse document this
finding using standard staging categories?
A. Stage 1 pressure injury
B. Stage 2 pressure injury
C. Stage 3 pressure injury
D. Deep tissue injury
A Stage 1 pressure injury is characterized by intact skin with localized area of non-blanchable
erythema, typically over a bony prominence. A Stage 2 involves partial-thickness skin loss with
exposed dermis, a Stage 3 involves full-thickness skin loss, and a deep tissue injury presents as
persistent purple or dark red localized discoloration of intact or non-intact skin.
3. A nurse is preparing to administer a sublingual medication to an adult client. Which of
the following instructions is essential to provide to the client?
A. Swallow the tablet whole with a large glass of water immediately after placement.
B. Chew the tablet thoroughly before allowing it to dissolve under the tongue.
C. Place the medication under the tongue and allow it to dissolve completely without
swallowing saliva prematurely.
D. Place the medication between the cheek and the gum until it is fully absorbed.
Sublingual medications must be placed under the tongue where they dissolve and absorb
directly into the bloodstream through the mucous membranes. Swallowing the medication,
,chewing it, or placing it buccally changes the absorption rate and can render the drug
ineffective.
4. A nurse is caring for a client who is prescribed strict bed rest. Which of the following
nursing interventions is most effective in preventing deep vein thrombosis (DVT)?
A. Restricting oral fluid intake to prevent dependent edema formation
B. Applying sequential compression devices (SCDs) and encouraging active range-of-
motion exercises
C. Massaging the lower extremities vigorously every two hours to break up clots
D. Keeping the client's knees sharply flexed using pillows to promote comfort
SCDs and range-of-motion exercises promote venous return and prevent stasis, which is the
primary mechanism for DVT prevention in immobile clients. Fluid restriction increases blood
viscosity and clot risk, massage of lower extremities is contraindicated if a clot is suspected due
to the risk of dislodgement, and knee flexion impedes popliteal blood flow.
5. A client with a nasogastric (NG) tube connected to low intermittent suction reports
nausea and upper abdominal fullness. Which of the following actions should the nurse
perform first?
A. Irrigate the NG tube with sterile water to check for patency.
B. Administer a prescribed antiemetic medication.
C. Check the patency and suction equipment settings of the NG tube.
D. Advance the NG tube an additional 5 centimeters into the stomach.
When an NG tube client experiences nausea and fullness, the tube may be obstructed or the
suction may not be functioning correctly, leading to gastric distension. Checking equipment
and patency is the direct first step before irrigation, medication administration, or
repositioning.
6. A nurse is teaching a client how to use a metered-dose inhaler (MDI) without a spacer.
Which statement by the client indicates an understanding of the procedure?
A. "I will hold the inhaler two inches away from my open mouth before pressing down."
B. "I will exhale forcefully immediately after inhaling the medication."
C. "I will seal my lips tightly around the mouthpiece and breathe through my nose."
D. "I will wait at least five minutes between different puffs of the same medication."
Holding the MDI approximately 1 to 2 inches away from the open mouth allows the
aerosolized medication to slow down and mix with air, maximizing deposition into the lower
airways rather than catching on the back of the throat. Clients should hold their breath for 10
seconds after inhalation, breathe through the mouth, and wait about 1 minute between puffs
of the same drug.
, 7. A nurse enters a client's room and finds the client unresponsive, pulseless, and not
breathing. After calling for emergency assistance, what is the immediate next step in the
basic life support sequence?
A. Initiate chest compressions at a rate of 100 to 120 per minute.
B. Open the airway using the head-tilt, chin-lift maneuver and deliver two rescue breaths.
C. Retrieve the automated external defibrillator (AED) from the hallway.
D. Check the client's pupils for reactivity and constriction.
According to current resuscitation guidelines, for an adult in cardiac arrest, high-quality
chest compressions are prioritized over rescue breaths or other interventions. Compressions
should be started immediately at a rate of 100 to 120 per minute and a depth of at least 2
inches.
8. Which of the following laboratory values indicates that a client's wound healing process
may be significantly impaired due to nutritional deficits?
A. Serum sodium of 138 mEq/L
B. Serum albumin of 2.2 g/dL
C. White blood cell count of 7,000 /mm3
D. Hemoglobin of 14.5 g/dL
A low serum albumin level (normal is typically 3.5 to 5.0 g/dL) indicates poor nutritional
status and protein depletion, which severely impairs collagen synthesis, immune function, and
overall wound healing. The other laboratory values fall within normal or acceptable ranges.
9. A nurse is preparing to administer an intramuscular (IM) injection to an adult client into
the ventrogluteal site. Which anatomical landmarks should the nurse use to locate this site
accurately?
A. Greater trochanter, anterior superior iliac spine, and iliac crest
B. Acromion process and the axillary line
C. Middle third of the anterior thigh between the patella and groin
D. Umbilicus and the lateral abdominal wall
The ventrogluteal site is located by placing the heel of the hand on the client's greater
trochanter with the index finger pointing toward the anterior superior iliac spine and the
middle finger stretched back along the iliac crest. This site is free of major nerves and blood
vessels, making it the safest IM injection site for adults.
10. A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen via
nasal cannula at 4 L/min. The client reports shortness of breath and confusion. Which
physiological mechanism best explains the client's current status?
A. Hypoxic drive suppression leading to hypoventilation and carbon dioxide narcosis
B. Acute metabolic alkalosis caused by excessive oxygen administration
VERIFIED AND WELL DETAILED ANSWERS PLUS RATIONALES |
GUARANTEED PASS | LATEST EXAM UPDATE | EXAM PREP | STUDY
GUIDE | PRACTICE TEST| DOWNLOAD INSTANT PDF
1. A newly admitted client expresses anxiety about their upcoming diagnostic procedure
and states they do not understand what will happen. Which of the following actions should
the nurse take first?
A. Administer a prescribed anti-anxiety medication to calm the client before the procedure.
B. Inform the physician that the client is anxious and needs immediate reassurance.
C. Assess the client's specific knowledge gaps and concerns regarding the procedure.
D. Explain every step of the medical procedure in complex clinical detail to ensure full
transparency.
Prior to initiating interventions or notifying the provider, the nurse must assess the client's
specific understanding and fears to provide targeted education and emotional support.
Administering medication or explaining without knowing the source of anxiety is premature,
and notifying the provider is unnecessary before a thorough nursing assessment is completed.
2. While performing a routine physical assessment, a nurse notices a localized area of intact
skin with non-blanchable redness over the sacrum. How should the nurse document this
finding using standard staging categories?
A. Stage 1 pressure injury
B. Stage 2 pressure injury
C. Stage 3 pressure injury
D. Deep tissue injury
A Stage 1 pressure injury is characterized by intact skin with localized area of non-blanchable
erythema, typically over a bony prominence. A Stage 2 involves partial-thickness skin loss with
exposed dermis, a Stage 3 involves full-thickness skin loss, and a deep tissue injury presents as
persistent purple or dark red localized discoloration of intact or non-intact skin.
3. A nurse is preparing to administer a sublingual medication to an adult client. Which of
the following instructions is essential to provide to the client?
A. Swallow the tablet whole with a large glass of water immediately after placement.
B. Chew the tablet thoroughly before allowing it to dissolve under the tongue.
C. Place the medication under the tongue and allow it to dissolve completely without
swallowing saliva prematurely.
D. Place the medication between the cheek and the gum until it is fully absorbed.
Sublingual medications must be placed under the tongue where they dissolve and absorb
directly into the bloodstream through the mucous membranes. Swallowing the medication,
,chewing it, or placing it buccally changes the absorption rate and can render the drug
ineffective.
4. A nurse is caring for a client who is prescribed strict bed rest. Which of the following
nursing interventions is most effective in preventing deep vein thrombosis (DVT)?
A. Restricting oral fluid intake to prevent dependent edema formation
B. Applying sequential compression devices (SCDs) and encouraging active range-of-
motion exercises
C. Massaging the lower extremities vigorously every two hours to break up clots
D. Keeping the client's knees sharply flexed using pillows to promote comfort
SCDs and range-of-motion exercises promote venous return and prevent stasis, which is the
primary mechanism for DVT prevention in immobile clients. Fluid restriction increases blood
viscosity and clot risk, massage of lower extremities is contraindicated if a clot is suspected due
to the risk of dislodgement, and knee flexion impedes popliteal blood flow.
5. A client with a nasogastric (NG) tube connected to low intermittent suction reports
nausea and upper abdominal fullness. Which of the following actions should the nurse
perform first?
A. Irrigate the NG tube with sterile water to check for patency.
B. Administer a prescribed antiemetic medication.
C. Check the patency and suction equipment settings of the NG tube.
D. Advance the NG tube an additional 5 centimeters into the stomach.
When an NG tube client experiences nausea and fullness, the tube may be obstructed or the
suction may not be functioning correctly, leading to gastric distension. Checking equipment
and patency is the direct first step before irrigation, medication administration, or
repositioning.
6. A nurse is teaching a client how to use a metered-dose inhaler (MDI) without a spacer.
Which statement by the client indicates an understanding of the procedure?
A. "I will hold the inhaler two inches away from my open mouth before pressing down."
B. "I will exhale forcefully immediately after inhaling the medication."
C. "I will seal my lips tightly around the mouthpiece and breathe through my nose."
D. "I will wait at least five minutes between different puffs of the same medication."
Holding the MDI approximately 1 to 2 inches away from the open mouth allows the
aerosolized medication to slow down and mix with air, maximizing deposition into the lower
airways rather than catching on the back of the throat. Clients should hold their breath for 10
seconds after inhalation, breathe through the mouth, and wait about 1 minute between puffs
of the same drug.
, 7. A nurse enters a client's room and finds the client unresponsive, pulseless, and not
breathing. After calling for emergency assistance, what is the immediate next step in the
basic life support sequence?
A. Initiate chest compressions at a rate of 100 to 120 per minute.
B. Open the airway using the head-tilt, chin-lift maneuver and deliver two rescue breaths.
C. Retrieve the automated external defibrillator (AED) from the hallway.
D. Check the client's pupils for reactivity and constriction.
According to current resuscitation guidelines, for an adult in cardiac arrest, high-quality
chest compressions are prioritized over rescue breaths or other interventions. Compressions
should be started immediately at a rate of 100 to 120 per minute and a depth of at least 2
inches.
8. Which of the following laboratory values indicates that a client's wound healing process
may be significantly impaired due to nutritional deficits?
A. Serum sodium of 138 mEq/L
B. Serum albumin of 2.2 g/dL
C. White blood cell count of 7,000 /mm3
D. Hemoglobin of 14.5 g/dL
A low serum albumin level (normal is typically 3.5 to 5.0 g/dL) indicates poor nutritional
status and protein depletion, which severely impairs collagen synthesis, immune function, and
overall wound healing. The other laboratory values fall within normal or acceptable ranges.
9. A nurse is preparing to administer an intramuscular (IM) injection to an adult client into
the ventrogluteal site. Which anatomical landmarks should the nurse use to locate this site
accurately?
A. Greater trochanter, anterior superior iliac spine, and iliac crest
B. Acromion process and the axillary line
C. Middle third of the anterior thigh between the patella and groin
D. Umbilicus and the lateral abdominal wall
The ventrogluteal site is located by placing the heel of the hand on the client's greater
trochanter with the index finger pointing toward the anterior superior iliac spine and the
middle finger stretched back along the iliac crest. This site is free of major nerves and blood
vessels, making it the safest IM injection site for adults.
10. A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen via
nasal cannula at 4 L/min. The client reports shortness of breath and confusion. Which
physiological mechanism best explains the client's current status?
A. Hypoxic drive suppression leading to hypoventilation and carbon dioxide narcosis
B. Acute metabolic alkalosis caused by excessive oxygen administration
