NR224 Exam 4 Actual Exam Style V1 | NR
224 Fundamentals - Skills | Chamberlain
1. When preparing to move a patient up in bed, what is the most important principle of body
mechanics for the nurse to follow?
A. Keep the knees straight while lifting
B. Twist at the waist to reach the patient
C. Keep the weight as close to the body as possible
D. Stand with feet together for a narrow base
Correct Answer: C
Expert Explanation: The nurse should keep the patient close to their center of gravity to
reduce strain on the back. Keeping the weight close to the body minimizes the force needed
to move the load. This principle helps prevent musculoskeletal injuries among nursing staff
during manual handling.
2. In which order should a nurse wash the body parts of a patient during a complete bed
bath?
A. Feet, legs, trunk, arms, face
B. Face, arms, trunk, legs, feet
C. Trunk, arms, face, feet, legs
D. Arms, face, legs, trunk, feet
,Correct Answer: B
Expert Explanation: The general rule for bathing is to move from the cleanest area to the
dirtiest area. Starting with the face prevents cross-contamination from other body parts.
Ending with the feet and perineal area ensures the water and cloth stay clean for as long as
possible.
3. A patient is using a walker for the first time. Which instruction should the nurse provide?
A. Move the walker first, then the weak leg, then the strong leg
B. Move the walker and the strong leg together
C. Step into the walker with the strong leg first
D. Lift the walker high off the ground with each step
Correct Answer: A
Expert Explanation: The walker should be moved forward about 6 inches first to provide
a stable base. The patient then moves the affected or weak leg into the walker followed by
the strong leg. This sequence ensures that the patient’s weight is always supported by
either the device or the strong limb.
4. On which side should a patient hold a cane for maximum support and stability?
A. On the weaker side
B. In the middle with both hands
C. On whichever side feels comfortable
, D. On the stronger side
Correct Answer: D
Expert Explanation: The cane should be held on the side opposite the injury or weakness.
This allows the cane to support the body’s weight while the weak leg is moving forward. It
mimics the natural motion of the arms during walking to maintain balance.
5. The nurse is assessing a patient’s risk for pressure injuries using the Braden Scale. Which
score would indicate the highest risk?
A. 9
B. 18
C. 15
D. 23
Correct Answer: A
Expert Explanation: The Braden Scale ranges from 6 to 23 points. A lower total score
indicates a higher risk for developing a pressure injury. A score of 9 is considered very high
risk and requires immediate preventive interventions.
6. A nurse observes a reddened area on a patient’s sacrum that does not blanch when
pressed. How should this be staged?
A. Stage 1 pressure injury
B. Stage 2 pressure injury
224 Fundamentals - Skills | Chamberlain
1. When preparing to move a patient up in bed, what is the most important principle of body
mechanics for the nurse to follow?
A. Keep the knees straight while lifting
B. Twist at the waist to reach the patient
C. Keep the weight as close to the body as possible
D. Stand with feet together for a narrow base
Correct Answer: C
Expert Explanation: The nurse should keep the patient close to their center of gravity to
reduce strain on the back. Keeping the weight close to the body minimizes the force needed
to move the load. This principle helps prevent musculoskeletal injuries among nursing staff
during manual handling.
2. In which order should a nurse wash the body parts of a patient during a complete bed
bath?
A. Feet, legs, trunk, arms, face
B. Face, arms, trunk, legs, feet
C. Trunk, arms, face, feet, legs
D. Arms, face, legs, trunk, feet
,Correct Answer: B
Expert Explanation: The general rule for bathing is to move from the cleanest area to the
dirtiest area. Starting with the face prevents cross-contamination from other body parts.
Ending with the feet and perineal area ensures the water and cloth stay clean for as long as
possible.
3. A patient is using a walker for the first time. Which instruction should the nurse provide?
A. Move the walker first, then the weak leg, then the strong leg
B. Move the walker and the strong leg together
C. Step into the walker with the strong leg first
D. Lift the walker high off the ground with each step
Correct Answer: A
Expert Explanation: The walker should be moved forward about 6 inches first to provide
a stable base. The patient then moves the affected or weak leg into the walker followed by
the strong leg. This sequence ensures that the patient’s weight is always supported by
either the device or the strong limb.
4. On which side should a patient hold a cane for maximum support and stability?
A. On the weaker side
B. In the middle with both hands
C. On whichever side feels comfortable
, D. On the stronger side
Correct Answer: D
Expert Explanation: The cane should be held on the side opposite the injury or weakness.
This allows the cane to support the body’s weight while the weak leg is moving forward. It
mimics the natural motion of the arms during walking to maintain balance.
5. The nurse is assessing a patient’s risk for pressure injuries using the Braden Scale. Which
score would indicate the highest risk?
A. 9
B. 18
C. 15
D. 23
Correct Answer: A
Expert Explanation: The Braden Scale ranges from 6 to 23 points. A lower total score
indicates a higher risk for developing a pressure injury. A score of 9 is considered very high
risk and requires immediate preventive interventions.
6. A nurse observes a reddened area on a patient’s sacrum that does not blanch when
pressed. How should this be staged?
A. Stage 1 pressure injury
B. Stage 2 pressure injury
