NR224 Exam 4 Actual Exam Style V3 | NR
224 Fundamentals - Skills | Chamberlain
1. A nurse observes a patient’s peripheral IV site is cool to the touch, pale, and significantly
swollen. What is the nurse’s priority action?
A. Apply a warm compress to the site to increase circulation.
B. Stop the infusion and remove the intravenous catheter.
C. Flush the line with 10 mL of normal saline to check for patency.
D. Decrease the infusion rate and document the findings.
Correct Answer: B
Expert Explanation: The assessment findings of coolness, pallor, and edema indicate
infiltration of the IV fluid into the surrounding tissue. The priority intervention is to
immediately stop the infusion and remove the catheter to prevent further tissue damage.
Following removal, the nurse should assess the site, elevate the limb, and apply a compress
as per facility protocol.
2. When administering a cleansing enema, the patient reports severe abdominal cramping.
Which action should the nurse take next?
A. Stop the procedure and notify the healthcare provider immediately.
B. Encourage the patient to take deep breaths and continue at the same rate.
C. Lower the enema container to slow the rate of fluid flow.
,D. Advance the rectal tube an additional two inches into the colon.
Correct Answer: C
Expert Explanation: Abdominal cramping during an enema often indicates that the fluid is
being administered too quickly or is too cold. By lowering the container, the nurse reduces
the hydrostatic pressure, which slows the flow and typically alleviates the cramping. This
allows the patient to tolerate the procedure better without having to stop it entirely unless
the pain persists.
3. A nurse is preparing to perform tracheostomy suctioning for a patient with thick
secretions. What is the maximum duration for each suction pass?
A. 10 to 15 seconds
B. 5 seconds
C. 20 to 25 seconds
D. 30 seconds
Correct Answer: A
Expert Explanation: Suctioning should never exceed 10 to 15 seconds per pass to
minimize the risk of hypoxia and mucosal damage. The nurse must allow the patient to
recover and re-oxygenate between passes to maintain stable vital signs. Prolonged
suctioning can lead to severe complications such as bradycardia and cardiac arrest.
,4. A patient receiving a blood transfusion begins to complain of a headache, lower back pain,
and exhibits a temperature increase of 2 degrees F. What is the nurse’s first action?
A. Stop the transfusion immediately and disconnect the tubing.
B. Administer an antipyretic as ordered by the physician.
C. Slow the transfusion to a keep-vein-open rate.
D. Re-check the patient’s identification against the blood bag.
Correct Answer: A
Expert Explanation: The patient’s symptoms are indicative of an acute hemolytic reaction,
which is a medical emergency. The nurse must stop the blood flow immediately and
disconnect the entire administration set to prevent any further exposure to the
incompatible blood. Normal saline should then be infused through new tubing to maintain
vascular access while the provider is notified.
5. The nurse is assessing a patient with a Stage 3 pressure injury. Which characteristic is
expected for this stage?
A. Non-blanchable erythema of intact skin.
B. Partial-thickness loss of dermis with a red-pink wound bed.
C. Full-thickness skin loss with visible subcutaneous fat.
D. Full-thickness tissue loss with exposed bone or tendon.
Correct Answer: C
, Expert Explanation: A Stage 3 pressure injury involves full-thickness skin loss where
subcutaneous fat may be visible, but bone, tendon, or muscle are not exposed. Slough or
eschar may be present but does not obscure the depth of tissue loss. This differs from Stage
4, where the injury extends to the muscle or bone.
6. While inserting an indwelling urinary catheter in a male patient, the nurse meets
resistance. What is the most appropriate nursing intervention?
A. Force the catheter past the resistance into the bladder.
B. Remove the catheter and attempt to insert a smaller size.
C. Ask the patient to take deep breaths and apply gentle pressure.
D. Stop the procedure and call for a urology consult.
Correct Answer: C
Expert Explanation: Resistance in male patients is often caused by the external sphincter
or an enlarged prostate. Instructing the patient to take deep breaths or bear down slightly
can help relax the sphincter, and applying gentle, steady pressure often allows the catheter
to pass. If resistance remains firm, the nurse should stop to avoid trauma and notify the
provider.
7. Which assessment finding indicates that a patient’s chest tube is functioning correctly with
a water-seal drainage system?
A. Continuous bubbling in the water-seal chamber.
B. The fluid level in the water-seal chamber fluctuates with respirations.
224 Fundamentals - Skills | Chamberlain
1. A nurse observes a patient’s peripheral IV site is cool to the touch, pale, and significantly
swollen. What is the nurse’s priority action?
A. Apply a warm compress to the site to increase circulation.
B. Stop the infusion and remove the intravenous catheter.
C. Flush the line with 10 mL of normal saline to check for patency.
D. Decrease the infusion rate and document the findings.
Correct Answer: B
Expert Explanation: The assessment findings of coolness, pallor, and edema indicate
infiltration of the IV fluid into the surrounding tissue. The priority intervention is to
immediately stop the infusion and remove the catheter to prevent further tissue damage.
Following removal, the nurse should assess the site, elevate the limb, and apply a compress
as per facility protocol.
2. When administering a cleansing enema, the patient reports severe abdominal cramping.
Which action should the nurse take next?
A. Stop the procedure and notify the healthcare provider immediately.
B. Encourage the patient to take deep breaths and continue at the same rate.
C. Lower the enema container to slow the rate of fluid flow.
,D. Advance the rectal tube an additional two inches into the colon.
Correct Answer: C
Expert Explanation: Abdominal cramping during an enema often indicates that the fluid is
being administered too quickly or is too cold. By lowering the container, the nurse reduces
the hydrostatic pressure, which slows the flow and typically alleviates the cramping. This
allows the patient to tolerate the procedure better without having to stop it entirely unless
the pain persists.
3. A nurse is preparing to perform tracheostomy suctioning for a patient with thick
secretions. What is the maximum duration for each suction pass?
A. 10 to 15 seconds
B. 5 seconds
C. 20 to 25 seconds
D. 30 seconds
Correct Answer: A
Expert Explanation: Suctioning should never exceed 10 to 15 seconds per pass to
minimize the risk of hypoxia and mucosal damage. The nurse must allow the patient to
recover and re-oxygenate between passes to maintain stable vital signs. Prolonged
suctioning can lead to severe complications such as bradycardia and cardiac arrest.
,4. A patient receiving a blood transfusion begins to complain of a headache, lower back pain,
and exhibits a temperature increase of 2 degrees F. What is the nurse’s first action?
A. Stop the transfusion immediately and disconnect the tubing.
B. Administer an antipyretic as ordered by the physician.
C. Slow the transfusion to a keep-vein-open rate.
D. Re-check the patient’s identification against the blood bag.
Correct Answer: A
Expert Explanation: The patient’s symptoms are indicative of an acute hemolytic reaction,
which is a medical emergency. The nurse must stop the blood flow immediately and
disconnect the entire administration set to prevent any further exposure to the
incompatible blood. Normal saline should then be infused through new tubing to maintain
vascular access while the provider is notified.
5. The nurse is assessing a patient with a Stage 3 pressure injury. Which characteristic is
expected for this stage?
A. Non-blanchable erythema of intact skin.
B. Partial-thickness loss of dermis with a red-pink wound bed.
C. Full-thickness skin loss with visible subcutaneous fat.
D. Full-thickness tissue loss with exposed bone or tendon.
Correct Answer: C
, Expert Explanation: A Stage 3 pressure injury involves full-thickness skin loss where
subcutaneous fat may be visible, but bone, tendon, or muscle are not exposed. Slough or
eschar may be present but does not obscure the depth of tissue loss. This differs from Stage
4, where the injury extends to the muscle or bone.
6. While inserting an indwelling urinary catheter in a male patient, the nurse meets
resistance. What is the most appropriate nursing intervention?
A. Force the catheter past the resistance into the bladder.
B. Remove the catheter and attempt to insert a smaller size.
C. Ask the patient to take deep breaths and apply gentle pressure.
D. Stop the procedure and call for a urology consult.
Correct Answer: C
Expert Explanation: Resistance in male patients is often caused by the external sphincter
or an enlarged prostate. Instructing the patient to take deep breaths or bear down slightly
can help relax the sphincter, and applying gentle, steady pressure often allows the catheter
to pass. If resistance remains firm, the nurse should stop to avoid trauma and notify the
provider.
7. Which assessment finding indicates that a patient’s chest tube is functioning correctly with
a water-seal drainage system?
A. Continuous bubbling in the water-seal chamber.
B. The fluid level in the water-seal chamber fluctuates with respirations.
