NR 224 Fundamentals of Nursing – Skills
Review |questions with answers and
rationales
1. A nurse is preparing to insert an indwelling urinary catheter using sterile technique. After
donning sterile gloves, the nurse accidentally touches the bedrail with one gloved hand. What
should the nurse do next?
A. Continue the procedure using the uncontaminated glove only.
B. Clean the contaminated glove with antiseptic solution.
C. Remove the contaminated gloves and apply a new pair of sterile gloves.
D. Ask another nurse to complete the procedure.
Answer: C
Rationale: Touching a nonsterile surface contaminates the sterile glove. The nurse must replace
the contaminated gloves to maintain aseptic technique and reduce the risk of infection.
2. A nurse is preparing to administer oral medications. Which action should the nurse perform
first?
A. Explain the purpose of the medication.
B. Verify the patient's identity using two identifiers.
C. Offer the patient water.
D. Document medication administration.
Answer: B
Rationale: Correct patient identification is the first priority before administering any medication
and is one of the National Patient Safety Goals.
3. Which patient is at the greatest risk for developing a pressure injury?
A. A 24-year-old recovering from an appendectomy.
B. A 36-year-old with controlled asthma.
C. An 81-year-old who is bedridden following a stroke.
D. A 45-year-old recovering from a migraine.
,Answer: C
Rationale: Advanced age and immobility significantly increase the risk for pressure injuries due
to prolonged pressure over bony prominences.
4. A nurse is teaching a patient how to use an incentive spirometer. Which instruction is most
appropriate?
A. Blow forcefully into the mouthpiece.
B. Inhale slowly and deeply through the mouthpiece.
C. Exhale quickly through the mouthpiece.
D. Use the spirometer only when short of breath.
Answer: B
Rationale: Slow, deep inhalation expands the lungs and helps prevent atelectasis after surgery.
5. Which action by the nurse demonstrates proper hand hygiene?
A. Wear gloves instead of washing hands.
B. Use alcohol-based hand rub until hands are dry when hands are not visibly soiled.
C. Wash hands only before patient contact.
D. Rinse hands with water after using sanitizer.
Answer: B
Rationale: Alcohol-based hand rub is the preferred method when hands are not visibly soiled.
The hands should be rubbed until completely dry.
6. A nurse is transferring a patient from the bed to a wheelchair. Which action promotes patient
safety?
A. Keep the wheelchair unlocked during transfer.
B. Pull the patient by the arms.
C. Lock the wheelchair brakes before the transfer.
D. Leave the footrests down during transfer.
Answer: C
Rationale: Locking the wheelchair prevents movement and reduces the risk of falls during
transfer.
,7. A nurse is changing a sterile dressing. Which action contaminates the sterile field?
A. Keeping sterile items above waist level.
B. Opening the sterile package away from the body first.
C. Reaching over the sterile field.
D. Keeping the sterile field in sight at all times.
Answer: C
Rationale: Reaching over a sterile field contaminates it because microorganisms from clothing
or skin may fall onto the field.
8. A nurse is caring for a patient at high risk for falls. Which intervention is most appropriate?
A. Raise all four side rails.
B. Keep the bed in the lowest position with the call light within reach.
C. Encourage the patient to walk independently.
D. Apply wrist restraints.
Answer: B
Rationale: Keeping the bed low and the call light accessible are evidence-based strategies to
reduce fall risk.
9. A nurse is obtaining a blood pressure using a manual cuff. Which action can produce a falsely
elevated reading?
A. Supporting the patient's arm at heart level.
B. Using a cuff that is too small.
C. Allowing the patient to rest for 5 minutes.
D. Positioning the patient's feet flat on the floor.
Answer: B
Rationale: A cuff that is too small compresses the artery excessively, producing an inaccurately
high blood pressure reading.
10. A nurse is preparing to assist a patient with ambulation using a gait belt. Where should the
gait belt be placed?
, A. Around the patient's chest.
B. Around the patient's waist over clothing.
C. Around the patient's hips below the buttocks.
D. Around the patient's shoulders.
Answer: B
Rationale: The gait belt is secured snugly around the patient's waist to provide safe support
during ambulation.
11. Which finding requires immediate nursing intervention after opioid administration?
A. Heart rate of 86 beats/min.
B. Respiratory rate of 10 breaths/min.
C. Blood pressure of 128/74 mm Hg.
D. Temperature of 98.8°F (37.1°C).
Answer: B
Rationale: Respiratory depression is a serious adverse effect of opioids and requires immediate
assessment and intervention.
12. Before administering an enteral feeding through a nasogastric tube, the nurse should first:
A. Warm the formula in the microwave.
B. Verify tube placement according to agency policy.
C. Place the patient flat in bed.
D. Flush the tube with fruit juice.
Answer: B
Rationale: Tube placement must be verified before each feeding to prevent aspiration.
13. Which nursing action best prevents the spread of infection?
A. Wearing gloves for every patient interaction.
B. Performing hand hygiene before and after patient contact.
C. Wearing a surgical mask at all times.
D. Limiting patient visitors.
Answer: B
Review |questions with answers and
rationales
1. A nurse is preparing to insert an indwelling urinary catheter using sterile technique. After
donning sterile gloves, the nurse accidentally touches the bedrail with one gloved hand. What
should the nurse do next?
A. Continue the procedure using the uncontaminated glove only.
B. Clean the contaminated glove with antiseptic solution.
C. Remove the contaminated gloves and apply a new pair of sterile gloves.
D. Ask another nurse to complete the procedure.
Answer: C
Rationale: Touching a nonsterile surface contaminates the sterile glove. The nurse must replace
the contaminated gloves to maintain aseptic technique and reduce the risk of infection.
2. A nurse is preparing to administer oral medications. Which action should the nurse perform
first?
A. Explain the purpose of the medication.
B. Verify the patient's identity using two identifiers.
C. Offer the patient water.
D. Document medication administration.
Answer: B
Rationale: Correct patient identification is the first priority before administering any medication
and is one of the National Patient Safety Goals.
3. Which patient is at the greatest risk for developing a pressure injury?
A. A 24-year-old recovering from an appendectomy.
B. A 36-year-old with controlled asthma.
C. An 81-year-old who is bedridden following a stroke.
D. A 45-year-old recovering from a migraine.
,Answer: C
Rationale: Advanced age and immobility significantly increase the risk for pressure injuries due
to prolonged pressure over bony prominences.
4. A nurse is teaching a patient how to use an incentive spirometer. Which instruction is most
appropriate?
A. Blow forcefully into the mouthpiece.
B. Inhale slowly and deeply through the mouthpiece.
C. Exhale quickly through the mouthpiece.
D. Use the spirometer only when short of breath.
Answer: B
Rationale: Slow, deep inhalation expands the lungs and helps prevent atelectasis after surgery.
5. Which action by the nurse demonstrates proper hand hygiene?
A. Wear gloves instead of washing hands.
B. Use alcohol-based hand rub until hands are dry when hands are not visibly soiled.
C. Wash hands only before patient contact.
D. Rinse hands with water after using sanitizer.
Answer: B
Rationale: Alcohol-based hand rub is the preferred method when hands are not visibly soiled.
The hands should be rubbed until completely dry.
6. A nurse is transferring a patient from the bed to a wheelchair. Which action promotes patient
safety?
A. Keep the wheelchair unlocked during transfer.
B. Pull the patient by the arms.
C. Lock the wheelchair brakes before the transfer.
D. Leave the footrests down during transfer.
Answer: C
Rationale: Locking the wheelchair prevents movement and reduces the risk of falls during
transfer.
,7. A nurse is changing a sterile dressing. Which action contaminates the sterile field?
A. Keeping sterile items above waist level.
B. Opening the sterile package away from the body first.
C. Reaching over the sterile field.
D. Keeping the sterile field in sight at all times.
Answer: C
Rationale: Reaching over a sterile field contaminates it because microorganisms from clothing
or skin may fall onto the field.
8. A nurse is caring for a patient at high risk for falls. Which intervention is most appropriate?
A. Raise all four side rails.
B. Keep the bed in the lowest position with the call light within reach.
C. Encourage the patient to walk independently.
D. Apply wrist restraints.
Answer: B
Rationale: Keeping the bed low and the call light accessible are evidence-based strategies to
reduce fall risk.
9. A nurse is obtaining a blood pressure using a manual cuff. Which action can produce a falsely
elevated reading?
A. Supporting the patient's arm at heart level.
B. Using a cuff that is too small.
C. Allowing the patient to rest for 5 minutes.
D. Positioning the patient's feet flat on the floor.
Answer: B
Rationale: A cuff that is too small compresses the artery excessively, producing an inaccurately
high blood pressure reading.
10. A nurse is preparing to assist a patient with ambulation using a gait belt. Where should the
gait belt be placed?
, A. Around the patient's chest.
B. Around the patient's waist over clothing.
C. Around the patient's hips below the buttocks.
D. Around the patient's shoulders.
Answer: B
Rationale: The gait belt is secured snugly around the patient's waist to provide safe support
during ambulation.
11. Which finding requires immediate nursing intervention after opioid administration?
A. Heart rate of 86 beats/min.
B. Respiratory rate of 10 breaths/min.
C. Blood pressure of 128/74 mm Hg.
D. Temperature of 98.8°F (37.1°C).
Answer: B
Rationale: Respiratory depression is a serious adverse effect of opioids and requires immediate
assessment and intervention.
12. Before administering an enteral feeding through a nasogastric tube, the nurse should first:
A. Warm the formula in the microwave.
B. Verify tube placement according to agency policy.
C. Place the patient flat in bed.
D. Flush the tube with fruit juice.
Answer: B
Rationale: Tube placement must be verified before each feeding to prevent aspiration.
13. Which nursing action best prevents the spread of infection?
A. Wearing gloves for every patient interaction.
B. Performing hand hygiene before and after patient contact.
C. Wearing a surgical mask at all times.
D. Limiting patient visitors.
Answer: B
