NR 224 Fundamentals of Nursing Exam 8 Practice 2026 |Chamberlain
College
1. A nurse is caring for a client who is post-operative and reports sudden
shortness of breath and chest pain. Which action should the nurse take first?
A. Administer prescribed pain medication
B. Notify the rapid response team
C. Assess the client’s oxygen saturation
D. Perform a complete head-to-toe assessment
Answer: C
Rationale: According to the nursing process, assessment is the first step. Shortness of
breath and chest pain are signs of respiratory or cardiac distress, making oxygen saturation
the priority assessment.
2. Which of the following describes the ‘S’ in the SBAR communication tool?
A. Summary of the client’s medical history
B. Situation: a concise statement of the problem
C. Social status of the client
D. Suggestions for future care
Answer: B
Rationale: SBAR stands for Situation, Background, Assessment, and Recommendation. The
Situation component is a concise statement of the current problem.
,3. A nurse is preparing to administer an intramuscular injection to an adult
client. Which site is preferred for its lack of large nerves and blood vessels?
A. Dorsogluteal
B. Deltoid
C. Ventrogluteal
D. Vastus lateralis
Answer: C
Rationale: The ventrogluteal site is the preferred and safest site for IM injections in adults
because it is deep and away from major nerves and blood vessels.
4. When performing a sterile dressing change, which action by the nurse would
contaminate the sterile field?
A. Keeping sterile objects above the waist level
B. Turning one’s back to the sterile field to grab supplies
C. Opening the outermost flap of the sterile kit away from the body
D. Dropping sterile gauze onto the center of the field
Answer: B
Rationale: A sterile field is considered contaminated if it is out of visual range or if the
nurse turns their back to it.
5. A nurse is assessing a client with a potassium level of 3.2 mEq/L. Which
finding should the nurse expect?
A. Abdominal cramping and diarrhea
B. Positive Trousseau’s sign
C. Muscle weakness and cardiac dysrhythmias
D. Hyperactive deep tendon reflexes
Answer: C
Rationale: Hypokalemia (potassium < 3.5 mEq/L) typically manifests as muscle weakness,
leg cramps, and cardiac dysrhythmias.
, 6. Which of the following is a primary prevention nursing intervention?
A. Providing stroke rehabilitation to a client
B. Teaching a community group about the importance of influenza vaccinations
C. Conducting a screening for hypertension at a health fair
D. Monitoring blood glucose for a client with diabetes
Answer: B
Rationale: Primary prevention focuses on health promotion and protection against specific
diseases, such as immunizations.
7. A nurse is documenting in a client’s electronic health record. Which entry is
the most objective?
A. The client seems to be in a lot of pain.
B. The client refused breakfast and stated, ‘I feel nauseated.’
C. The client was very uncooperative during the physical exam.
D. The client appears to be sleeping soundly.
Answer: B
Rationale: Objective documentation describes facts, observations, or direct quotes without
interpretation or bias.
8. A client is diagnosed with Clostridium difficile (C. diff). Which type of isolation
precautions should the nurse implement?
A. Droplet precautions
B. Contact precautions
C. Standard precautions only
D. Airborne precautions
Answer: B
Rationale: C. difficile is transmitted via direct or indirect contact with contaminated
surfaces, requiring contact precautions and handwashing with soap and water.
College
1. A nurse is caring for a client who is post-operative and reports sudden
shortness of breath and chest pain. Which action should the nurse take first?
A. Administer prescribed pain medication
B. Notify the rapid response team
C. Assess the client’s oxygen saturation
D. Perform a complete head-to-toe assessment
Answer: C
Rationale: According to the nursing process, assessment is the first step. Shortness of
breath and chest pain are signs of respiratory or cardiac distress, making oxygen saturation
the priority assessment.
2. Which of the following describes the ‘S’ in the SBAR communication tool?
A. Summary of the client’s medical history
B. Situation: a concise statement of the problem
C. Social status of the client
D. Suggestions for future care
Answer: B
Rationale: SBAR stands for Situation, Background, Assessment, and Recommendation. The
Situation component is a concise statement of the current problem.
,3. A nurse is preparing to administer an intramuscular injection to an adult
client. Which site is preferred for its lack of large nerves and blood vessels?
A. Dorsogluteal
B. Deltoid
C. Ventrogluteal
D. Vastus lateralis
Answer: C
Rationale: The ventrogluteal site is the preferred and safest site for IM injections in adults
because it is deep and away from major nerves and blood vessels.
4. When performing a sterile dressing change, which action by the nurse would
contaminate the sterile field?
A. Keeping sterile objects above the waist level
B. Turning one’s back to the sterile field to grab supplies
C. Opening the outermost flap of the sterile kit away from the body
D. Dropping sterile gauze onto the center of the field
Answer: B
Rationale: A sterile field is considered contaminated if it is out of visual range or if the
nurse turns their back to it.
5. A nurse is assessing a client with a potassium level of 3.2 mEq/L. Which
finding should the nurse expect?
A. Abdominal cramping and diarrhea
B. Positive Trousseau’s sign
C. Muscle weakness and cardiac dysrhythmias
D. Hyperactive deep tendon reflexes
Answer: C
Rationale: Hypokalemia (potassium < 3.5 mEq/L) typically manifests as muscle weakness,
leg cramps, and cardiac dysrhythmias.
, 6. Which of the following is a primary prevention nursing intervention?
A. Providing stroke rehabilitation to a client
B. Teaching a community group about the importance of influenza vaccinations
C. Conducting a screening for hypertension at a health fair
D. Monitoring blood glucose for a client with diabetes
Answer: B
Rationale: Primary prevention focuses on health promotion and protection against specific
diseases, such as immunizations.
7. A nurse is documenting in a client’s electronic health record. Which entry is
the most objective?
A. The client seems to be in a lot of pain.
B. The client refused breakfast and stated, ‘I feel nauseated.’
C. The client was very uncooperative during the physical exam.
D. The client appears to be sleeping soundly.
Answer: B
Rationale: Objective documentation describes facts, observations, or direct quotes without
interpretation or bias.
8. A client is diagnosed with Clostridium difficile (C. diff). Which type of isolation
precautions should the nurse implement?
A. Droplet precautions
B. Contact precautions
C. Standard precautions only
D. Airborne precautions
Answer: B
Rationale: C. difficile is transmitted via direct or indirect contact with contaminated
surfaces, requiring contact precautions and handwashing with soap and water.
