NR 224 Fundamentals Exam 2026:
Weeks 3-5 Review with 250
Questions & Rationales, Exams of
Nursing
which is the desirable expected outcome for the client - ANSWER//the client
will be free of signs and symptoms of infection by discharge A 47-year-old
client comes to the clinic for a Papanicolaou (Pap) smear. She tells the nurse
that she has been experiencing hot flashes and that her periods have been
occurring at longer, less regular intervals, with a scanty flow. What does the
nurse conclude is the most likely cause of these changes? -
ANSWER//perimenopause which findings occur with orthostatic hypotension?
select all that apply reflex tachycardia feeling of faintness increased cardiac
output increased diastolic pressure decreased systolic pressure -
ANSWER//feeling of faintness decreased systolic pressure The registered RN
asks a client to rate their pain on a scale from 0 to 10, then instructs the
nursing student to perform a physical assessment. which steps by the nursing
student would be included in a physical assessment for pain? select all that
apply palpating for tenderness observing nonverbal cues inspecting any areas
of discomfort noticing if the pain is localized or radiates noticing if the client
gives nonverbal signs of pain - ANSWER//palpating for tenderness observing
nonverbal cues inspecting any areas of discomfort noticing if the pain is
localized or radiates noticing if the client gives nonverbal signs of pain which
statement demonstrates an understanding of a computer-based client
information system - ANSWER//client information is immediately available
when this system is used which information would the registered nurse
provide to a student nurse about the importance of nursing documentation for
risk management? SATA a nurses documentation is the evidence of care the
client receives nurses notes would not be given to an attorney in the event of
a lawsuit the nurse would note assessments and significant changes in the
clients health incase an occurrence report is filed, nurses would enter the
report in the client's chart the nurse would always document the primary
health care providers responses whenever they are contact - ANSWER//a
nurses documentation is the evidence of care the client receives the nurse
would note assessments and significant changes in the clients health the
nurse would always document the primary health care providers responses
whenever they are contact which record may the nurse use to document
information specific to the clients health in a story-like fashion? acuity record
source record hand off reports narrative documentation - ANSWER//narrative
documentation which written statement by the nurse while documenting
factual records indicates the nurse needs additional training? the client seems
restless the client states, " I am worried." The client's pulse rate is 90 beats
per min the client has a body temp of 39C (102.2 F) - ANSWER//the client
seems restless The nurse documents data that was gathered during an
assessment in the clients medical record. Which action would the nurse take
,to to ensure that the data is meaningful to other healthcare providers? -
ANSWER//record object data using accurate terminology which technique
would the nurse use to don the second glove during the sterile technique? -
ANSWER//insert gloved fingers under cuff of second glove and life glove, then
insert ungloved hand into glove which technique would the nurse use to
maintain surgical asepsis? - ANSWER//change the sterile field after sterile
water has spilled on it which piece of equipment would the nurse make sure is
sterile while providing care for a client? - ANSWER//suction catheter which
action would the nurse take to maintain sterility when performing a dressing
change? - ANSWER//remove the sterile drape from the package by lifting it by
the corners which basic principles of surgical asepsis must the nurse consider
when changing the dressings of a child with severe burns? SATA a paper field
must remain dry to be considered sterile sterile items must be held below the
waist to be sterile a 1 inch border around a sterile field is considered
contaminated sterile objects in contact with clean objects are considered
contaminated a fenestrated drape is not considered sterile - ANSWER//a
paper field must remain dry to be considered sterile a 1 inch border around a
sterile field is considered contaminated sterile objects in contact with clean
objects are considered contaminated
Infection - ANSWER//is the invasion of a susceptible host by pathogens or
microorganisms, resulting in disease. Entry and multiplication of organisms
result in disease Colonization - ANSWER//occurs when a microorganism
invades the host but does not cause infection Communicable Disease -
ANSWER//is the infectious disease transmitted from one person to another. If
pathogens multiply and cause clinical signs and symptoms.... - ANSWER//the
infection is symptomatic If clinical signs and symptoms are not present.. -
ANSWER//the illness is asymptomatic ***Most important technique to use in
preventing and controlling transmission of infection is.... - ANSWER//HAND
HYGIENE! ***Chain of Infection - ANSWER//1)Infectious agent or pathogen
2)Reservoir or source for pathogen growth 3)Portal of exit 4)Mode of
transmission 5)Portal of entry 6)Susceptible host Direct contact -
ANSWER//Person to person OR Person to source Indirect contact -
ANSWER//Person to inanimate object Droplet contact - ANSWER//Coughing,
Sneezing, Talking (Lg particle only 3 ft) Airborne - ANSWER//Droplet nuclei or
residue suspended in air or carried on dust particles Vehicles -
ANSWER//Food, water, drugs and solutions, blood, fomites Vector -
ANSWER//-External transfer -Internal Transmission (parasitic) Mosquito,
louse, flea, tick Immunocompromised - ANSWER//means having an impaired
immune system. Virulence - ANSWER//is the ability to produce disease
Aerobic Bacteria - ANSWER//require oxygen for survival and for multiplication
sufficient to cause disease. Anaerobic - ANSWER//thrive where little or no
free oxygen is available. Bacteriostasis - ANSWER//prevention of growth and
reproduction of bacteria. Bactericidal - ANSWER//destructive to bacteria
Normal flora - ANSWER//helps to resist infection by releasing antibacterial
substances and inhibiting multiplication of pathogenic microorganisms Factors
influencing infection prevention and control... - ANSWER//Age Nutritional
status Stress Disease process Treatments or conditions that compromise the
immune response Health Care Associated Infection (HAI's) (Nosocomial) -
ANSWER//Results from delivery of health services in a health care facility
, Patients at greater risk of HAI... - ANSWER//Multiple illnesses Older adults
Poorly nourished Lowered resistance to infection Critical illness invasive
treatment devices Major sites for HAI's... - ANSWER//Surgical or traumatic
wounds Urinary and respiratory tracts Bloodstream More complex condition of
the patient... - ANSWER//Less people should be taking care of them
***Medical Asepsis - ANSWER//Controlling Pathogen Hand hygiene "Clean
procedure" Common on home, ECF, assisted living Standard precautions
(CDC) ***Sterile Asepsis - ANSWER//Killing or eliminating pathogen Scrub
(Surgical) PPE Sterile handling Common in hospital ***Principles of Surgical
Asepsis - ANSWER//1. A sterile object remains sterile only when touched by
another sterile object. 2. Only sterile objects may be placed on a sterile field. 3.
A sterile object or field out of the range of vision or an object held below a
person's waist is contaminated. 4. A sterile object or field becomes
contaminated by prolonged exposure to air. 5. When a sterile surface comes
in contact with a wet, contaminated surface, the sterile object or field becomes
contaminated by capillary action. 6. Fluid flows in the direction of gravity. 7.
The edges of a sterile field or container are considered to be contaminated.
Disinfection - ANSWER//a process that eliminates many or all microorganisms,
with the exception of bacterial spores, from inanimate objects Sterilization -
ANSWER//the complete elimination or destruction of all microorganisms,
including spores ***Isolation Considerations - ANSWER//Psychological
implications Isolation environment Personal protective equipment Specimen
collection Bagging of trash or linen Patient transport Infection Assessment -
ANSWER//Review of past disease travel history Immunizations and
vaccinations Status of defense mechanisms Patient susceptibility
Medications/therapies Clinical appearance Signs and symptoms of infection
NEG cultures Vital signs are used to... - ANSWER//Monitor patient's condition
•Identify problems •Evaluate response to intervention Vital Signs -
ANSWER//Indicators of bodily functions that reflect health status of the patient
Order of Vitals ALWAYS.... - ANSWER//T, P, R, BP, O2 & pain Temperature -
ANSWER//36-38C(96.8-100.4) Temp -Tympanic - ANSWER//37 C or 98.6F
Temp - Oral - ANSWER//37ºC 98.6ºF Temp- Rectal - ANSWER//37.5ºC
99.5ºF Pulse - ANSWER//60 to 100 beats/ minute Respiratory Rate -
ANSWER//12 to 20 breaths/ minute (Quality?) labored, with ease etc. Blood
Pressure - ANSWER//120/80 Pulse Pressure - ANSWER//30 to 50 mmHg
SpO2 - ANSWER//95 to 100% Contraindications - ANSWER//Modifying vitals/
technique to help the patient. Change Rectal -Temp - ANSWER//Can alert the
vagus nerve or cause bowel movement. Core temp - ANSWER//from deep
tissues Surface temp - ANSWER//from outer side Factors affecting body
temp.... - ANSWER//Age Exercise ; increase Hormonal level Circadian
rhythm ; natural vital drop Environment Temperature alterations ; disease
process Signs of Fever - ANSWER//Hot, dry, flushed skin Headache Thirst
Loss of appetite (anorexia) Malaise Dangerous signs of fever -
ANSWER//Rapid heart rate Dehydration Decreased urinary output Seizures
Antipyretics - ANSWER//Medication to relieve fever Apical pulse.. -
ANSWER//Chest / stehoscope Peripheral Pulse.. - ANSWER//is palpated, two
fingers on wrist Characters of a pulse.. - ANSWER//Rate• how fast or slow
Rhythm• un even, un constant Strength• strong or weak Equality• how witty or
fritty the beat is Comparison Apical to Radial Adult heart is .. - ANSWER//60
to 100 beats/min Factors influencing Pulse Rate - ANSWER//exercise drugs
Weeks 3-5 Review with 250
Questions & Rationales, Exams of
Nursing
which is the desirable expected outcome for the client - ANSWER//the client
will be free of signs and symptoms of infection by discharge A 47-year-old
client comes to the clinic for a Papanicolaou (Pap) smear. She tells the nurse
that she has been experiencing hot flashes and that her periods have been
occurring at longer, less regular intervals, with a scanty flow. What does the
nurse conclude is the most likely cause of these changes? -
ANSWER//perimenopause which findings occur with orthostatic hypotension?
select all that apply reflex tachycardia feeling of faintness increased cardiac
output increased diastolic pressure decreased systolic pressure -
ANSWER//feeling of faintness decreased systolic pressure The registered RN
asks a client to rate their pain on a scale from 0 to 10, then instructs the
nursing student to perform a physical assessment. which steps by the nursing
student would be included in a physical assessment for pain? select all that
apply palpating for tenderness observing nonverbal cues inspecting any areas
of discomfort noticing if the pain is localized or radiates noticing if the client
gives nonverbal signs of pain - ANSWER//palpating for tenderness observing
nonverbal cues inspecting any areas of discomfort noticing if the pain is
localized or radiates noticing if the client gives nonverbal signs of pain which
statement demonstrates an understanding of a computer-based client
information system - ANSWER//client information is immediately available
when this system is used which information would the registered nurse
provide to a student nurse about the importance of nursing documentation for
risk management? SATA a nurses documentation is the evidence of care the
client receives nurses notes would not be given to an attorney in the event of
a lawsuit the nurse would note assessments and significant changes in the
clients health incase an occurrence report is filed, nurses would enter the
report in the client's chart the nurse would always document the primary
health care providers responses whenever they are contact - ANSWER//a
nurses documentation is the evidence of care the client receives the nurse
would note assessments and significant changes in the clients health the
nurse would always document the primary health care providers responses
whenever they are contact which record may the nurse use to document
information specific to the clients health in a story-like fashion? acuity record
source record hand off reports narrative documentation - ANSWER//narrative
documentation which written statement by the nurse while documenting
factual records indicates the nurse needs additional training? the client seems
restless the client states, " I am worried." The client's pulse rate is 90 beats
per min the client has a body temp of 39C (102.2 F) - ANSWER//the client
seems restless The nurse documents data that was gathered during an
assessment in the clients medical record. Which action would the nurse take
,to to ensure that the data is meaningful to other healthcare providers? -
ANSWER//record object data using accurate terminology which technique
would the nurse use to don the second glove during the sterile technique? -
ANSWER//insert gloved fingers under cuff of second glove and life glove, then
insert ungloved hand into glove which technique would the nurse use to
maintain surgical asepsis? - ANSWER//change the sterile field after sterile
water has spilled on it which piece of equipment would the nurse make sure is
sterile while providing care for a client? - ANSWER//suction catheter which
action would the nurse take to maintain sterility when performing a dressing
change? - ANSWER//remove the sterile drape from the package by lifting it by
the corners which basic principles of surgical asepsis must the nurse consider
when changing the dressings of a child with severe burns? SATA a paper field
must remain dry to be considered sterile sterile items must be held below the
waist to be sterile a 1 inch border around a sterile field is considered
contaminated sterile objects in contact with clean objects are considered
contaminated a fenestrated drape is not considered sterile - ANSWER//a
paper field must remain dry to be considered sterile a 1 inch border around a
sterile field is considered contaminated sterile objects in contact with clean
objects are considered contaminated
Infection - ANSWER//is the invasion of a susceptible host by pathogens or
microorganisms, resulting in disease. Entry and multiplication of organisms
result in disease Colonization - ANSWER//occurs when a microorganism
invades the host but does not cause infection Communicable Disease -
ANSWER//is the infectious disease transmitted from one person to another. If
pathogens multiply and cause clinical signs and symptoms.... - ANSWER//the
infection is symptomatic If clinical signs and symptoms are not present.. -
ANSWER//the illness is asymptomatic ***Most important technique to use in
preventing and controlling transmission of infection is.... - ANSWER//HAND
HYGIENE! ***Chain of Infection - ANSWER//1)Infectious agent or pathogen
2)Reservoir or source for pathogen growth 3)Portal of exit 4)Mode of
transmission 5)Portal of entry 6)Susceptible host Direct contact -
ANSWER//Person to person OR Person to source Indirect contact -
ANSWER//Person to inanimate object Droplet contact - ANSWER//Coughing,
Sneezing, Talking (Lg particle only 3 ft) Airborne - ANSWER//Droplet nuclei or
residue suspended in air or carried on dust particles Vehicles -
ANSWER//Food, water, drugs and solutions, blood, fomites Vector -
ANSWER//-External transfer -Internal Transmission (parasitic) Mosquito,
louse, flea, tick Immunocompromised - ANSWER//means having an impaired
immune system. Virulence - ANSWER//is the ability to produce disease
Aerobic Bacteria - ANSWER//require oxygen for survival and for multiplication
sufficient to cause disease. Anaerobic - ANSWER//thrive where little or no
free oxygen is available. Bacteriostasis - ANSWER//prevention of growth and
reproduction of bacteria. Bactericidal - ANSWER//destructive to bacteria
Normal flora - ANSWER//helps to resist infection by releasing antibacterial
substances and inhibiting multiplication of pathogenic microorganisms Factors
influencing infection prevention and control... - ANSWER//Age Nutritional
status Stress Disease process Treatments or conditions that compromise the
immune response Health Care Associated Infection (HAI's) (Nosocomial) -
ANSWER//Results from delivery of health services in a health care facility
, Patients at greater risk of HAI... - ANSWER//Multiple illnesses Older adults
Poorly nourished Lowered resistance to infection Critical illness invasive
treatment devices Major sites for HAI's... - ANSWER//Surgical or traumatic
wounds Urinary and respiratory tracts Bloodstream More complex condition of
the patient... - ANSWER//Less people should be taking care of them
***Medical Asepsis - ANSWER//Controlling Pathogen Hand hygiene "Clean
procedure" Common on home, ECF, assisted living Standard precautions
(CDC) ***Sterile Asepsis - ANSWER//Killing or eliminating pathogen Scrub
(Surgical) PPE Sterile handling Common in hospital ***Principles of Surgical
Asepsis - ANSWER//1. A sterile object remains sterile only when touched by
another sterile object. 2. Only sterile objects may be placed on a sterile field. 3.
A sterile object or field out of the range of vision or an object held below a
person's waist is contaminated. 4. A sterile object or field becomes
contaminated by prolonged exposure to air. 5. When a sterile surface comes
in contact with a wet, contaminated surface, the sterile object or field becomes
contaminated by capillary action. 6. Fluid flows in the direction of gravity. 7.
The edges of a sterile field or container are considered to be contaminated.
Disinfection - ANSWER//a process that eliminates many or all microorganisms,
with the exception of bacterial spores, from inanimate objects Sterilization -
ANSWER//the complete elimination or destruction of all microorganisms,
including spores ***Isolation Considerations - ANSWER//Psychological
implications Isolation environment Personal protective equipment Specimen
collection Bagging of trash or linen Patient transport Infection Assessment -
ANSWER//Review of past disease travel history Immunizations and
vaccinations Status of defense mechanisms Patient susceptibility
Medications/therapies Clinical appearance Signs and symptoms of infection
NEG cultures Vital signs are used to... - ANSWER//Monitor patient's condition
•Identify problems •Evaluate response to intervention Vital Signs -
ANSWER//Indicators of bodily functions that reflect health status of the patient
Order of Vitals ALWAYS.... - ANSWER//T, P, R, BP, O2 & pain Temperature -
ANSWER//36-38C(96.8-100.4) Temp -Tympanic - ANSWER//37 C or 98.6F
Temp - Oral - ANSWER//37ºC 98.6ºF Temp- Rectal - ANSWER//37.5ºC
99.5ºF Pulse - ANSWER//60 to 100 beats/ minute Respiratory Rate -
ANSWER//12 to 20 breaths/ minute (Quality?) labored, with ease etc. Blood
Pressure - ANSWER//120/80 Pulse Pressure - ANSWER//30 to 50 mmHg
SpO2 - ANSWER//95 to 100% Contraindications - ANSWER//Modifying vitals/
technique to help the patient. Change Rectal -Temp - ANSWER//Can alert the
vagus nerve or cause bowel movement. Core temp - ANSWER//from deep
tissues Surface temp - ANSWER//from outer side Factors affecting body
temp.... - ANSWER//Age Exercise ; increase Hormonal level Circadian
rhythm ; natural vital drop Environment Temperature alterations ; disease
process Signs of Fever - ANSWER//Hot, dry, flushed skin Headache Thirst
Loss of appetite (anorexia) Malaise Dangerous signs of fever -
ANSWER//Rapid heart rate Dehydration Decreased urinary output Seizures
Antipyretics - ANSWER//Medication to relieve fever Apical pulse.. -
ANSWER//Chest / stehoscope Peripheral Pulse.. - ANSWER//is palpated, two
fingers on wrist Characters of a pulse.. - ANSWER//Rate• how fast or slow
Rhythm• un even, un constant Strength• strong or weak Equality• how witty or
fritty the beat is Comparison Apical to Radial Adult heart is .. - ANSWER//60
to 100 beats/min Factors influencing Pulse Rate - ANSWER//exercise drugs
