NR224 Exam 4 Actual Exam Style V2 | NR
224 Fundamentals - Skills | Chamberlain
1. When assessing a patient’s blood pressure, the nurse uses a cuff that is too small for the
patient’s arm. What effect will this have on the reading?
A. The blood pressure reading will be falsely low.
B. The blood pressure reading will be falsely high.
C. The systolic reading will be correct but diastolic will be low.
D. The reading will not be affected by cuff size.
Correct Answer: B
Expert Explanation: Using a blood pressure cuff that is too small or wrapped too loosely
will result in a falsely elevated blood pressure reading. This occurs because the cuff must
be inflated more to occlude the artery. Proper cuff sizing requires the width to be 40
percent of the arm circumference.
2. A nurse discovers a medication error was made during the previous shift. What is the
nurse’s first priority?
A. Assess the patient’s condition and vital signs.
B. Notify the healthcare provider of the error.
C. Complete an incident report immediately.
D. Contact the pharmacist to verify the dosage.
,Correct Answer: A
Expert Explanation: The first priority of the nurse when an error is discovered is always
the safety and assessment of the patient. The nurse must check for any adverse reactions or
changes in clinical status before taking administrative actions. Following the assessment,
the nurse should then notify the provider and complete an incident report per facility
policy.
3. Which action is essential for maintaining surgical asepsis when opening a sterile package?
A. Opening the first flap toward the nurse’s body.
B. Reaching over the sterile field to pick up instruments.
C. Touching only the outer 1-inch border of the sterile field.
D. Keeping the sterile field below the level of the waist.
Correct Answer: C
Expert Explanation: The outer 1-inch border of a sterile field is considered contaminated
and may be touched with clean hands. Sterile objects must always be kept above waist level
to remain within the line of sight and prevent contamination. Reaching over a sterile field
or opening the first flap toward the body are actions that break sterile technique.
4. The nurse is preparing to administer an intramuscular injection into the ventrogluteal site.
Which landmarks should the nurse use?
A. The acromion process and the axillary line.
B. The patella and the greater trochanter of the femur.
, C. The greater trochanter, anterior superior iliac spine, and iliac crest.
D. The posterior superior iliac spine and the gluteal fold.
Correct Answer: C
Expert Explanation: To locate the ventrogluteal site, the nurse places the palm over the
greater trochanter and the index finger on the anterior superior iliac spine. The middle
finger is extended toward the iliac crest to form a V-shaped triangle. This site is preferred
for IM injections because it is away from major nerves and blood vessels.
5. A patient who has been on prolonged bed rest attempts to stand up and reports feeling
dizzy and lightheaded. What is the nurse’s immediate action?
A. Measure the patient’s blood pressure while they are standing.
B. Encourage the patient to take deep breaths and keep standing.
C. Help the patient back to a sitting or lying position.
D. Call for a rapid response team to evaluate the patient.
Correct Answer: C
Expert Explanation: The patient is likely experiencing orthostatic hypotension, which is a
drop in blood pressure upon standing. The nurse’s immediate priority is to ensure patient
safety and prevent a fall by returning them to a supine or sitting position. Assessing the
blood pressure can be done once the patient is stable and safe.
224 Fundamentals - Skills | Chamberlain
1. When assessing a patient’s blood pressure, the nurse uses a cuff that is too small for the
patient’s arm. What effect will this have on the reading?
A. The blood pressure reading will be falsely low.
B. The blood pressure reading will be falsely high.
C. The systolic reading will be correct but diastolic will be low.
D. The reading will not be affected by cuff size.
Correct Answer: B
Expert Explanation: Using a blood pressure cuff that is too small or wrapped too loosely
will result in a falsely elevated blood pressure reading. This occurs because the cuff must
be inflated more to occlude the artery. Proper cuff sizing requires the width to be 40
percent of the arm circumference.
2. A nurse discovers a medication error was made during the previous shift. What is the
nurse’s first priority?
A. Assess the patient’s condition and vital signs.
B. Notify the healthcare provider of the error.
C. Complete an incident report immediately.
D. Contact the pharmacist to verify the dosage.
,Correct Answer: A
Expert Explanation: The first priority of the nurse when an error is discovered is always
the safety and assessment of the patient. The nurse must check for any adverse reactions or
changes in clinical status before taking administrative actions. Following the assessment,
the nurse should then notify the provider and complete an incident report per facility
policy.
3. Which action is essential for maintaining surgical asepsis when opening a sterile package?
A. Opening the first flap toward the nurse’s body.
B. Reaching over the sterile field to pick up instruments.
C. Touching only the outer 1-inch border of the sterile field.
D. Keeping the sterile field below the level of the waist.
Correct Answer: C
Expert Explanation: The outer 1-inch border of a sterile field is considered contaminated
and may be touched with clean hands. Sterile objects must always be kept above waist level
to remain within the line of sight and prevent contamination. Reaching over a sterile field
or opening the first flap toward the body are actions that break sterile technique.
4. The nurse is preparing to administer an intramuscular injection into the ventrogluteal site.
Which landmarks should the nurse use?
A. The acromion process and the axillary line.
B. The patella and the greater trochanter of the femur.
, C. The greater trochanter, anterior superior iliac spine, and iliac crest.
D. The posterior superior iliac spine and the gluteal fold.
Correct Answer: C
Expert Explanation: To locate the ventrogluteal site, the nurse places the palm over the
greater trochanter and the index finger on the anterior superior iliac spine. The middle
finger is extended toward the iliac crest to form a V-shaped triangle. This site is preferred
for IM injections because it is away from major nerves and blood vessels.
5. A patient who has been on prolonged bed rest attempts to stand up and reports feeling
dizzy and lightheaded. What is the nurse’s immediate action?
A. Measure the patient’s blood pressure while they are standing.
B. Encourage the patient to take deep breaths and keep standing.
C. Help the patient back to a sitting or lying position.
D. Call for a rapid response team to evaluate the patient.
Correct Answer: C
Expert Explanation: The patient is likely experiencing orthostatic hypotension, which is a
drop in blood pressure upon standing. The nurse’s immediate priority is to ensure patient
safety and prevent a fall by returning them to a supine or sitting position. Assessing the
blood pressure can be done once the patient is stable and safe.
