NR 224 Fundamentals of Nursing Exam 5 Practice 2026 |Chamberlain
College
1. When assessing a patient’s wound, the nurse notes clear, watery fluid. How
should the nurse document this type of drainage?
A. Serosanguineous
B. Purulent
C. Serous
D. Sanguineous
Answer: C
Rationale: Serous drainage is clear, watery plasma. Sanguineous is bright red,
serosanguineous is a mix of clear and red, and purulent is thick, yellow, green, or brown.
2. A nurse is caring for a patient who is at risk for developing pressure injuries.
Which tool should the nurse use to assess the patient’s risk level?
A. Glasgow Coma Scale
B. APGAR Score
C. Morse Fall Scale
D. Braden Scale
Answer: D
Rationale: The Braden Scale is the most commonly used tool for assessing pressure injury
risk, focusing on sensory perception, moisture, activity, mobility, nutrition, and
friction/shear.
,3. Which of the following is an early sign of hypoxia that the nurse should
monitor for?
A. Cyanosis
B. Restlessness
C. Bradycardia
D. Hypotension
Answer: B
Rationale: Restlessness, anxiety, and agitation are early signs of hypoxia. Cyanosis and
bradycardia are typically late signs.
4. A patient has a potassium level of 3.1 mEq/L. Which clinical manifestation
should the nurse expect to observe?
A. Hyperreflexia
B. Positive Trousseau’s sign
C. Muscle weakness and dysrhythmias
D. Peaked T waves on ECG
Answer: C
Rationale: Hypokalemia (low potassium) commonly causes muscle weakness, leg cramps,
and cardiac dysrhythmias. Peaked T waves are associated with hyperkalemia.
5. In the General Adaptation Syndrome (GAS), which stage involves the body’s
attempt to return to a state of homeostasis?
A. Alarm stage
B. Resistance stage
C. Exhaustion stage
D. Reaction stage
Answer: B
Rationale: In the resistance stage, the body stabilizes and responds in an attempt to
compensate for the stressor and return to normal function.
, 6. A postoperative patient has not voided for 8 hours. What is the nurse’s first
action?
A. Palpate the suprapubic area for bladder distension
B. Insert a straight catheter immediately
C. Increase the IV fluid rate
D. Notify the surgeon of possible renal failure
Answer: A
Rationale: The first step in assessment for urinary retention is to check for bladder
distension via palpation or a bladder scanner.
7. Which oxygen delivery device provides the most precise concentration of
oxygen?
A. Nasal cannula
B. Simple face mask
C. Venturi mask
D. Non-rebreather mask
Answer: C
Rationale: The Venturi mask is designed to deliver precise, high-flow concentrations of
oxygen by using different sized adapters.
8. A nurse is preparing to administer a bolus of 0.9% Normal Saline. This fluid is
classified as:
A. Hypotonic
B. Isotonic
C. Hypertonic
D. Colloid
Answer: B
Rationale: 0.9% Normal Saline has the same osmolality as body fluids, making it an
isotonic solution used for volume replacement.
College
1. When assessing a patient’s wound, the nurse notes clear, watery fluid. How
should the nurse document this type of drainage?
A. Serosanguineous
B. Purulent
C. Serous
D. Sanguineous
Answer: C
Rationale: Serous drainage is clear, watery plasma. Sanguineous is bright red,
serosanguineous is a mix of clear and red, and purulent is thick, yellow, green, or brown.
2. A nurse is caring for a patient who is at risk for developing pressure injuries.
Which tool should the nurse use to assess the patient’s risk level?
A. Glasgow Coma Scale
B. APGAR Score
C. Morse Fall Scale
D. Braden Scale
Answer: D
Rationale: The Braden Scale is the most commonly used tool for assessing pressure injury
risk, focusing on sensory perception, moisture, activity, mobility, nutrition, and
friction/shear.
,3. Which of the following is an early sign of hypoxia that the nurse should
monitor for?
A. Cyanosis
B. Restlessness
C. Bradycardia
D. Hypotension
Answer: B
Rationale: Restlessness, anxiety, and agitation are early signs of hypoxia. Cyanosis and
bradycardia are typically late signs.
4. A patient has a potassium level of 3.1 mEq/L. Which clinical manifestation
should the nurse expect to observe?
A. Hyperreflexia
B. Positive Trousseau’s sign
C. Muscle weakness and dysrhythmias
D. Peaked T waves on ECG
Answer: C
Rationale: Hypokalemia (low potassium) commonly causes muscle weakness, leg cramps,
and cardiac dysrhythmias. Peaked T waves are associated with hyperkalemia.
5. In the General Adaptation Syndrome (GAS), which stage involves the body’s
attempt to return to a state of homeostasis?
A. Alarm stage
B. Resistance stage
C. Exhaustion stage
D. Reaction stage
Answer: B
Rationale: In the resistance stage, the body stabilizes and responds in an attempt to
compensate for the stressor and return to normal function.
, 6. A postoperative patient has not voided for 8 hours. What is the nurse’s first
action?
A. Palpate the suprapubic area for bladder distension
B. Insert a straight catheter immediately
C. Increase the IV fluid rate
D. Notify the surgeon of possible renal failure
Answer: A
Rationale: The first step in assessment for urinary retention is to check for bladder
distension via palpation or a bladder scanner.
7. Which oxygen delivery device provides the most precise concentration of
oxygen?
A. Nasal cannula
B. Simple face mask
C. Venturi mask
D. Non-rebreather mask
Answer: C
Rationale: The Venturi mask is designed to deliver precise, high-flow concentrations of
oxygen by using different sized adapters.
8. A nurse is preparing to administer a bolus of 0.9% Normal Saline. This fluid is
classified as:
A. Hypotonic
B. Isotonic
C. Hypertonic
D. Colloid
Answer: B
Rationale: 0.9% Normal Saline has the same osmolality as body fluids, making it an
isotonic solution used for volume replacement.
