NUR 155 Exam 4 V1 | NUR 155
Foundations of Nursing | Q&A with
Rationale (NUR155 Exam 4) | Galen
College of Nursing
1. A nurse is caring for a patient who has been bedridden for one week. Which assessment
finding should the nurse prioritize as a potential complication of immobility?
A. Diminished breath sounds in the lung bases
B. Increased urinary output
C. Increased appetite
D. Decreased heart rate
Answer: A
Rationale: Diminished breath sounds often indicate atelectasis, which is a common
respiratory complication of immobility. The lack of deep breathing and movement leads to
the collapse of alveoli and pooling of secretions. The nurse must prioritize this finding to
prevent pneumonia through interventions like incentive spirometry and frequent
repositioning.
2. During a skin assessment, the nurse notes a localized area of intact skin with non-
blanchable erythema over the patient’s sacrum. How should the nurse document this
finding?
A. Stage 2 pressure injury
,B. Deep tissue pressure injury
C. Stage 1 pressure injury
D. Unstageable pressure injury
Answer: C
Rationale: A Stage 1 pressure injury is characterized by intact skin with a localized area of
non-blanchable erythema. This stage indicates that the underlying tissue is under stress
but the epidermis has not yet broken down. The nurse should implement pressure-
relieving measures immediately, such as turning the patient every two hours, to prevent
further damage.
3. Which nursing action is most important to prevent a catheter-associated urinary tract
infection (CAUTI) in a patient with an indwelling urinary catheter?
A. Cleaning the perineal area with antiseptic daily
B. Keeping the drainage bag below the level of the bladder
C. Changing the catheter every week
D. Irrigating the catheter every 8 hours
Answer: B
Rationale: Maintaining the drainage bag below the level of the bladder prevents the
backflow of contaminated urine into the bladder. Backflow is a significant risk factor for
developing a CAUTI because it introduces bacteria into a sterile environment. Standard
, practice also involves maintaining a closed drainage system and performing routine
perineal care with soap and water.
4. A patient is receiving continuous enteral feedings via a nasogastric tube. Which action
should the nurse take to minimize the risk of aspiration?
A. Check gastric residual volumes every 24 hours
B. Keep the head of the bed flat during feeding
C. Elevate the head of the bed to at least 30 to 45 degrees
D. Administer feeding at room temperature
Answer: C
Rationale: Elevating the head of the bed (HOB) to 30-45 degrees uses gravity to keep the
formula in the stomach and reduces the risk of pulmonary aspiration. Aspiration is a life-
threatening complication of enteral nutrition that requires diligent monitoring of the
patient’s respiratory status. The nurse should maintain this position during the feeding and
for at least 30 to 60 minutes after a bolus feeding.
5. A nurse is teaching a patient about increasing dietary fiber to manage chronic constipation.
Which food choice indicates that the teaching was effective?
A. Whole-grain cereal
B. Fruit juice without pulp
C. White bread
Foundations of Nursing | Q&A with
Rationale (NUR155 Exam 4) | Galen
College of Nursing
1. A nurse is caring for a patient who has been bedridden for one week. Which assessment
finding should the nurse prioritize as a potential complication of immobility?
A. Diminished breath sounds in the lung bases
B. Increased urinary output
C. Increased appetite
D. Decreased heart rate
Answer: A
Rationale: Diminished breath sounds often indicate atelectasis, which is a common
respiratory complication of immobility. The lack of deep breathing and movement leads to
the collapse of alveoli and pooling of secretions. The nurse must prioritize this finding to
prevent pneumonia through interventions like incentive spirometry and frequent
repositioning.
2. During a skin assessment, the nurse notes a localized area of intact skin with non-
blanchable erythema over the patient’s sacrum. How should the nurse document this
finding?
A. Stage 2 pressure injury
,B. Deep tissue pressure injury
C. Stage 1 pressure injury
D. Unstageable pressure injury
Answer: C
Rationale: A Stage 1 pressure injury is characterized by intact skin with a localized area of
non-blanchable erythema. This stage indicates that the underlying tissue is under stress
but the epidermis has not yet broken down. The nurse should implement pressure-
relieving measures immediately, such as turning the patient every two hours, to prevent
further damage.
3. Which nursing action is most important to prevent a catheter-associated urinary tract
infection (CAUTI) in a patient with an indwelling urinary catheter?
A. Cleaning the perineal area with antiseptic daily
B. Keeping the drainage bag below the level of the bladder
C. Changing the catheter every week
D. Irrigating the catheter every 8 hours
Answer: B
Rationale: Maintaining the drainage bag below the level of the bladder prevents the
backflow of contaminated urine into the bladder. Backflow is a significant risk factor for
developing a CAUTI because it introduces bacteria into a sterile environment. Standard
, practice also involves maintaining a closed drainage system and performing routine
perineal care with soap and water.
4. A patient is receiving continuous enteral feedings via a nasogastric tube. Which action
should the nurse take to minimize the risk of aspiration?
A. Check gastric residual volumes every 24 hours
B. Keep the head of the bed flat during feeding
C. Elevate the head of the bed to at least 30 to 45 degrees
D. Administer feeding at room temperature
Answer: C
Rationale: Elevating the head of the bed (HOB) to 30-45 degrees uses gravity to keep the
formula in the stomach and reduces the risk of pulmonary aspiration. Aspiration is a life-
threatening complication of enteral nutrition that requires diligent monitoring of the
patient’s respiratory status. The nurse should maintain this position during the feeding and
for at least 30 to 60 minutes after a bolus feeding.
5. A nurse is teaching a patient about increasing dietary fiber to manage chronic constipation.
Which food choice indicates that the teaching was effective?
A. Whole-grain cereal
B. Fruit juice without pulp
C. White bread
