NUR 155 Exam 2 V2 | NUR 155
Foundations of Nursing | Q&A with
Rationale (NUR155 Exam 2) | Galen
College of Nursing
1. A nurse is caring for a client who is diagnosed with Clostridioides difficile (C. diff). Which
hand hygiene method should the nurse use after providing direct care?
A. Antimicrobial soap and water
B. Chlorhexidine gluconate solution
C. Alcohol-based hand sanitizer
D. Sterile saline solution
Answer: A
Rationale: C. difficile is a spore-forming bacterium that is highly resistant to alcohol-based
rubs. Washing hands with soap and water provides the mechanical friction necessary to
remove the spores from the skin’s surface. This practice is essential in preventing the
cross-contamination of other clients in the healthcare setting.
2. A nurse is preparing to perform a sterile dressing change. Which action by the nurse
violates the principles of surgical asepsis?
A. Keeping the sterile field within the line of vision at all times
B. Maintaining a one-inch border around the edge of the sterile field
,C. Reaching over the sterile field to pick up a gauze pad
D. Holding sterile objects above the level of the waist
Answer: C
Rationale: Reaching over a sterile field creates a high risk of contamination from falling
microorganisms or clothing contact. A sterile object or field becomes contaminated by any
contact with non-sterile objects or by air currents. The nurse must always work around the
field to maintain its integrity throughout the procedure.
3. When assessing a client’s risk for pressure injuries, the nurse uses the Braden Scale. Which
score would indicate the highest risk for skin breakdown?
A. 14
B. 9
C. 18
D. 23
Answer: B
Rationale: The Braden Scale uses six subscales to evaluate sensory perception, moisture,
activity, mobility, nutrition, and friction. Lower scores on the Braden Scale indicate a higher
risk for developing a pressure injury. A score of 9 is considered very high risk, requiring
immediate and aggressive preventive interventions.
, 4. A client is discovered on the floor of their room during night rounds. After assessing the
client for injury, which action should the nurse take next?
A. Notify the healthcare provider and complete an incident report
B. Document the fall in the client’s medical record only
C. Administer pain medication to prevent discomfort
D. Place the client in four-point restraints
Answer: A
Rationale: Following an unexpected occurrence such as a fall, the nurse must ensure the
client’s immediate safety and then notify the provider. An incident or occurrence report
must be completed to assist in quality improvement and tracking trends. This report is a
confidential document and should not be mentioned directly in the medical record.
5. Which physical assessment finding is most characteristic of a Stage 2 pressure injury?
A. Non-blanchable erythema of intact skin
B. Full-thickness skin loss with visible adipose tissue
C. Full-thickness tissue loss with exposed bone or tendon
D. Partial-thickness loss of dermis presenting as a shallow open ulcer
Answer: D
Rationale: A Stage 2 pressure injury involves partial-thickness loss of the dermis and
presents as a shallow open ulcer with a red-pink wound bed without slough. It may also
Foundations of Nursing | Q&A with
Rationale (NUR155 Exam 2) | Galen
College of Nursing
1. A nurse is caring for a client who is diagnosed with Clostridioides difficile (C. diff). Which
hand hygiene method should the nurse use after providing direct care?
A. Antimicrobial soap and water
B. Chlorhexidine gluconate solution
C. Alcohol-based hand sanitizer
D. Sterile saline solution
Answer: A
Rationale: C. difficile is a spore-forming bacterium that is highly resistant to alcohol-based
rubs. Washing hands with soap and water provides the mechanical friction necessary to
remove the spores from the skin’s surface. This practice is essential in preventing the
cross-contamination of other clients in the healthcare setting.
2. A nurse is preparing to perform a sterile dressing change. Which action by the nurse
violates the principles of surgical asepsis?
A. Keeping the sterile field within the line of vision at all times
B. Maintaining a one-inch border around the edge of the sterile field
,C. Reaching over the sterile field to pick up a gauze pad
D. Holding sterile objects above the level of the waist
Answer: C
Rationale: Reaching over a sterile field creates a high risk of contamination from falling
microorganisms or clothing contact. A sterile object or field becomes contaminated by any
contact with non-sterile objects or by air currents. The nurse must always work around the
field to maintain its integrity throughout the procedure.
3. When assessing a client’s risk for pressure injuries, the nurse uses the Braden Scale. Which
score would indicate the highest risk for skin breakdown?
A. 14
B. 9
C. 18
D. 23
Answer: B
Rationale: The Braden Scale uses six subscales to evaluate sensory perception, moisture,
activity, mobility, nutrition, and friction. Lower scores on the Braden Scale indicate a higher
risk for developing a pressure injury. A score of 9 is considered very high risk, requiring
immediate and aggressive preventive interventions.
, 4. A client is discovered on the floor of their room during night rounds. After assessing the
client for injury, which action should the nurse take next?
A. Notify the healthcare provider and complete an incident report
B. Document the fall in the client’s medical record only
C. Administer pain medication to prevent discomfort
D. Place the client in four-point restraints
Answer: A
Rationale: Following an unexpected occurrence such as a fall, the nurse must ensure the
client’s immediate safety and then notify the provider. An incident or occurrence report
must be completed to assist in quality improvement and tracking trends. This report is a
confidential document and should not be mentioned directly in the medical record.
5. Which physical assessment finding is most characteristic of a Stage 2 pressure injury?
A. Non-blanchable erythema of intact skin
B. Full-thickness skin loss with visible adipose tissue
C. Full-thickness tissue loss with exposed bone or tendon
D. Partial-thickness loss of dermis presenting as a shallow open ulcer
Answer: D
Rationale: A Stage 2 pressure injury involves partial-thickness loss of the dermis and
presents as a shallow open ulcer with a red-pink wound bed without slough. It may also
