NR 229 / NR229 Fundamentals – Skills (Military to BSN) Midterm
Practice Exam Version 1 – 2025200 Questions and Correct Answers
with Rationales
Exam Overview & Blueprint
The NR 229 Fundamentals – Skills course introduces students to the fundamental skills of
professional nursing. Key content areas covered in this midterm exam include:
- Infection Prevention & Control – Standard precautions, transmission‑based precautions, hand
hygiene, PPE donning/doffing, aseptic technique
- Safety & Mobility – Fall prevention, body mechanics, patient transfer techniques, range of
motion, positioning
- Hygiene & Comfort – Bed baths, oral care, perineal care, pressure injury prevention
- Vital Signs & Assessment – Temperature, pulse, respiration, blood pressure, pulse oximetry,
pain assessment, orthostatic hypotension
- Medication Administration – Rights of medication administration, dosage calculation, routes,
documentation
- Documentation & Delegation – Proper charting, SBAR, delegation guidelines, nursing process
- Clinical Procedures – Nasogastric tube insertion/verification, urinary catheterization, specimen
collection, sterile gloving, wound care, blood glucose monitoring
---
1. A nurse is preparing to perform oral care on an unconscious patient. What is the most
appropriate nursing action?
A. Place the patient in a supine position
B. Position the patient in a side-lying position
C. Use a large toothbrush to remove secretions
,D. Administer mouthwash via syringe
Answer: B
Rationale: Positioning the patient in a side-lying position allows secretions to drain from the
mouth and reduces the risk of aspiration. The supine position would increase aspiration risk; a
small, soft toothbrush should be used; and mouthwash should never be forcibly instilled into an
unconscious patient’s mouth.
---
2. Which of the following is a correct guideline for hand hygiene using alcohol‑based hand rub?
A. Use if hands are visibly soiled
B. Use before and after patient contact when hands are not visibly soiled
C. Use only at the end of your shift
D. Use after removing gloves only
Answer: B
Rationale: Alcohol‑based hand rub is appropriate when hands are not visibly dirty and should be
used before and after patient contact to prevent the spread of infection. If hands are visibly
soiled, soap and water must be used.
---
3. The nurse is documenting care given. Which documentation entry is most appropriate?
A. “Patient had a good day and ate well.”
,B. “Patient consumed 80% of lunch; no complaints of nausea.”
C. “Patient seems happy with the care provided.”
D. “Patient is doing fine.”
Answer: B
Rationale: Documentation should be objective, specific, and measurable. “Consumed 80% of
lunch” is factual and provides useful information. Subjective statements (“good day,” “seems
happy,” “doing fine”) are vague and lack clinical value.
---
4. A nurse is applying standard precautions. Which action is most important?
A. Wearing gloves for all patient contact
B. Performing hand hygiene before and after patient contact
C. Wearing a mask for every patient interaction
D. Using sterile gloves for routine vital signs
Answer: B
Rationale: Hand hygiene is the single most important measure for preventing the spread of
infection and is a core component of standard precautions. Gloves are not required for all
patient contact, and masks are not needed for routine interactions unless there is a risk of
splash or spray.
---
, 5. A patient is on contact precautions. Which personal protective equipment (PPE) must the
nurse wear when entering the room?
A. Gown and gloves
B. Mask and eye protection
C. N95 respirator
D. Gown, gloves, mask, and eye protection
Answer: A
Rationale: Contact precautions require the use of a gown and gloves. Gowns and gloves prevent
the transfer of microorganisms from the patient or environment to the healthcare worker and
vice versa. Droplet or airborne precautions require additional respiratory protection.
---
6. A patient has been in bed for several days and develops a reddened area over the sacrum
that does not blanch when pressure is applied. What stage of pressure injury is this?
A. Stage 1
B. Stage 2
C. Stage 3
D. Stage 4
Answer: A
Rationale: A Stage 1 pressure injury presents as intact skin with non‑blanchable redness, usually
over a bony prominence. Stage 2 involves partial‑thickness skin loss, Stage 3 full‑thickness skin
loss with subcutaneous fat visible, and Stage 4 exposes bone, tendon, or muscle.
Practice Exam Version 1 – 2025200 Questions and Correct Answers
with Rationales
Exam Overview & Blueprint
The NR 229 Fundamentals – Skills course introduces students to the fundamental skills of
professional nursing. Key content areas covered in this midterm exam include:
- Infection Prevention & Control – Standard precautions, transmission‑based precautions, hand
hygiene, PPE donning/doffing, aseptic technique
- Safety & Mobility – Fall prevention, body mechanics, patient transfer techniques, range of
motion, positioning
- Hygiene & Comfort – Bed baths, oral care, perineal care, pressure injury prevention
- Vital Signs & Assessment – Temperature, pulse, respiration, blood pressure, pulse oximetry,
pain assessment, orthostatic hypotension
- Medication Administration – Rights of medication administration, dosage calculation, routes,
documentation
- Documentation & Delegation – Proper charting, SBAR, delegation guidelines, nursing process
- Clinical Procedures – Nasogastric tube insertion/verification, urinary catheterization, specimen
collection, sterile gloving, wound care, blood glucose monitoring
---
1. A nurse is preparing to perform oral care on an unconscious patient. What is the most
appropriate nursing action?
A. Place the patient in a supine position
B. Position the patient in a side-lying position
C. Use a large toothbrush to remove secretions
,D. Administer mouthwash via syringe
Answer: B
Rationale: Positioning the patient in a side-lying position allows secretions to drain from the
mouth and reduces the risk of aspiration. The supine position would increase aspiration risk; a
small, soft toothbrush should be used; and mouthwash should never be forcibly instilled into an
unconscious patient’s mouth.
---
2. Which of the following is a correct guideline for hand hygiene using alcohol‑based hand rub?
A. Use if hands are visibly soiled
B. Use before and after patient contact when hands are not visibly soiled
C. Use only at the end of your shift
D. Use after removing gloves only
Answer: B
Rationale: Alcohol‑based hand rub is appropriate when hands are not visibly dirty and should be
used before and after patient contact to prevent the spread of infection. If hands are visibly
soiled, soap and water must be used.
---
3. The nurse is documenting care given. Which documentation entry is most appropriate?
A. “Patient had a good day and ate well.”
,B. “Patient consumed 80% of lunch; no complaints of nausea.”
C. “Patient seems happy with the care provided.”
D. “Patient is doing fine.”
Answer: B
Rationale: Documentation should be objective, specific, and measurable. “Consumed 80% of
lunch” is factual and provides useful information. Subjective statements (“good day,” “seems
happy,” “doing fine”) are vague and lack clinical value.
---
4. A nurse is applying standard precautions. Which action is most important?
A. Wearing gloves for all patient contact
B. Performing hand hygiene before and after patient contact
C. Wearing a mask for every patient interaction
D. Using sterile gloves for routine vital signs
Answer: B
Rationale: Hand hygiene is the single most important measure for preventing the spread of
infection and is a core component of standard precautions. Gloves are not required for all
patient contact, and masks are not needed for routine interactions unless there is a risk of
splash or spray.
---
, 5. A patient is on contact precautions. Which personal protective equipment (PPE) must the
nurse wear when entering the room?
A. Gown and gloves
B. Mask and eye protection
C. N95 respirator
D. Gown, gloves, mask, and eye protection
Answer: A
Rationale: Contact precautions require the use of a gown and gloves. Gowns and gloves prevent
the transfer of microorganisms from the patient or environment to the healthcare worker and
vice versa. Droplet or airborne precautions require additional respiratory protection.
---
6. A patient has been in bed for several days and develops a reddened area over the sacrum
that does not blanch when pressure is applied. What stage of pressure injury is this?
A. Stage 1
B. Stage 2
C. Stage 3
D. Stage 4
Answer: A
Rationale: A Stage 1 pressure injury presents as intact skin with non‑blanchable redness, usually
over a bony prominence. Stage 2 involves partial‑thickness skin loss, Stage 3 full‑thickness skin
loss with subcutaneous fat visible, and Stage 4 exposes bone, tendon, or muscle.
