NR 224 Fundamentals of Nursing Exam 6 Study Guide 2026
|Chamberlain College
1. A patient with a history of COPD is receiving oxygen via a nasal cannula.
Which of the following flow rates is most appropriate to prevent suppression of
the respiratory drive?
A. 10-12 L/min
B. 6-8 L/min
C. 15 L/min
D. 1-2 L/min
Answer: D
Rationale: In patients with COPD, high concentrations of oxygen can suppress the hypoxic
drive to breathe; therefore, low flow rates (1-2 L/min) are typically recommended.
2. When assessing a patient for urinary retention, which finding would the nurse
expect to encounter?
A. Large amounts of dilute urine
B. Frequent small amounts of voiding or dribbling
C. Increased urgency with excessive output
D. Hematuria and dysuria
Answer: B
Rationale: Urinary retention often manifests as the inability to empty the bladder
completely, leading to overflow incontinence where small amounts of urine leak out
frequently.
,3. A nurse is preparing to administer an enema. In which position should the
patient be placed to facilitate the flow of solution into the sigmoid colon?
A. High-Fowler’s position
B. Right lateral position
C. Left-sided Sims’ position
D. Prone position
Answer: C
Rationale: The left-sided Sims’ position allows the enema solution to flow by gravity along
the natural curve of the sigmoid colon and rectum.
4. Which electrolyte imbalance is most closely associated with the development
of Trousseau’s sign and Chvostek’s sign?
A. Hypomagnesemia
B. Hyperkalemia
C. Hyponatremia
D. Hypocalcemia
Answer: D
Rationale: Hypocalcemia increases neuromuscular excitability, which can be
demonstrated through Chvostek’s sign (facial twitch) and Trousseau’s sign (carpal spasm).
5. A patient is diagnosed with fluid volume excess. Which clinical manifestation
should the nurse expect to find during the physical assessment?
A. Tachycardia and thread pulse
B. Poor skin turgor
C. Distended neck veins
D. Dry mucous membranes
Answer: C
Rationale: Fluid volume excess (hypervolemia) leads to increased intravascular volume,
commonly manifesting as distended neck veins (JVD) and peripheral edema.
, 6. What is the primary purpose of using the Z-track method when administering
an intramuscular injection?
A. To ensure the medication enters the vein
B. To prevent the medication from leaking into the subcutaneous tissue
C. To minimize pain during the needle insertion
D. To speed up the absorption rate of the drug
Answer: B
Rationale: The Z-track method seals the medication in the muscle tissue and prevents
irritation or staining of the subcutaneous layer by creating a zigzag path.
7. A nurse is caring for a patient with a Stage 2 pressure injury. How should this
wound be described in the documentation?
A. Partial-thickness loss of dermis presenting as a shallow open ulcer
B. Intact skin with non-blanchable redness
C. Full-thickness tissue loss with visible subcutaneous fat
D. Full-thickness tissue loss with exposed bone or tendon
Answer: A
Rationale: A Stage 2 pressure injury involves partial-thickness loss of the dermis and may
present as an abrasion, blister, or shallow crater.
8. When performing tracheostomy suctioning, what is the maximum amount of
time the nurse should apply suction?
A. 5 seconds
B. 1 minute
C. 20-30 seconds
D. 10-15 seconds
Answer: D
Rationale: Suctioning should be limited to 10-15 seconds to prevent hypoxia and trauma
to the tracheal mucosa.
|Chamberlain College
1. A patient with a history of COPD is receiving oxygen via a nasal cannula.
Which of the following flow rates is most appropriate to prevent suppression of
the respiratory drive?
A. 10-12 L/min
B. 6-8 L/min
C. 15 L/min
D. 1-2 L/min
Answer: D
Rationale: In patients with COPD, high concentrations of oxygen can suppress the hypoxic
drive to breathe; therefore, low flow rates (1-2 L/min) are typically recommended.
2. When assessing a patient for urinary retention, which finding would the nurse
expect to encounter?
A. Large amounts of dilute urine
B. Frequent small amounts of voiding or dribbling
C. Increased urgency with excessive output
D. Hematuria and dysuria
Answer: B
Rationale: Urinary retention often manifests as the inability to empty the bladder
completely, leading to overflow incontinence where small amounts of urine leak out
frequently.
,3. A nurse is preparing to administer an enema. In which position should the
patient be placed to facilitate the flow of solution into the sigmoid colon?
A. High-Fowler’s position
B. Right lateral position
C. Left-sided Sims’ position
D. Prone position
Answer: C
Rationale: The left-sided Sims’ position allows the enema solution to flow by gravity along
the natural curve of the sigmoid colon and rectum.
4. Which electrolyte imbalance is most closely associated with the development
of Trousseau’s sign and Chvostek’s sign?
A. Hypomagnesemia
B. Hyperkalemia
C. Hyponatremia
D. Hypocalcemia
Answer: D
Rationale: Hypocalcemia increases neuromuscular excitability, which can be
demonstrated through Chvostek’s sign (facial twitch) and Trousseau’s sign (carpal spasm).
5. A patient is diagnosed with fluid volume excess. Which clinical manifestation
should the nurse expect to find during the physical assessment?
A. Tachycardia and thread pulse
B. Poor skin turgor
C. Distended neck veins
D. Dry mucous membranes
Answer: C
Rationale: Fluid volume excess (hypervolemia) leads to increased intravascular volume,
commonly manifesting as distended neck veins (JVD) and peripheral edema.
, 6. What is the primary purpose of using the Z-track method when administering
an intramuscular injection?
A. To ensure the medication enters the vein
B. To prevent the medication from leaking into the subcutaneous tissue
C. To minimize pain during the needle insertion
D. To speed up the absorption rate of the drug
Answer: B
Rationale: The Z-track method seals the medication in the muscle tissue and prevents
irritation or staining of the subcutaneous layer by creating a zigzag path.
7. A nurse is caring for a patient with a Stage 2 pressure injury. How should this
wound be described in the documentation?
A. Partial-thickness loss of dermis presenting as a shallow open ulcer
B. Intact skin with non-blanchable redness
C. Full-thickness tissue loss with visible subcutaneous fat
D. Full-thickness tissue loss with exposed bone or tendon
Answer: A
Rationale: A Stage 2 pressure injury involves partial-thickness loss of the dermis and may
present as an abrasion, blister, or shallow crater.
8. When performing tracheostomy suctioning, what is the maximum amount of
time the nurse should apply suction?
A. 5 seconds
B. 1 minute
C. 20-30 seconds
D. 10-15 seconds
Answer: D
Rationale: Suctioning should be limited to 10-15 seconds to prevent hypoxia and trauma
to the tracheal mucosa.
