NUR 155 Exam 2 V3 | NUR 155
Foundations of Nursing | Q&A with
Rationale (NUR155 Exam 2) | Galen
College of Nursing
1. A nurse is preparing to enter the room of a client who has a suspected diagnosis of
pulmonary tuberculosis. Which of the following items of personal protective equipment (PPE)
should the nurse don before entering?
A. A surgical mask
B. A face shield
C. An N95 respirator
D. Sterile gloves
Answer: C
Rationale: Tuberculosis is transmitted via airborne droplets that remain suspended in the
air. Therefore, the nurse must wear an N95 or higher-level respirator to filter out these
small particles. Standard surgical masks are insufficient for airborne precautions as they do
not provide the necessary filtration.
2. A nurse is caring for a client who is at risk for developing pressure injuries. Which of the
following interventions should the nurse include in the plan of care?
A. Massage reddened bony prominences daily.
,B. Reposition the client every 4 hours while in bed.
C. Apply a moisture barrier ointment to the skin if incontinent.
D. Use a donut-shaped cushion when the client is sitting in a chair.
Answer: C
Rationale: Maintaining skin integrity is crucial in preventing pressure injuries, and
moisture barrier ointments protect the skin from maceration caused by urine or stool.
Massaging reddened areas can cause further tissue damage and is contraindicated. Clients
should be repositioned at least every 2 hours to relieve pressure effectively.
3. During a physical assessment, the nurse notes that the client’s wound has a thick, yellow-
green drainage. How should the nurse document this type of exudate?
A. Serous drainage
B. Purulent drainage
C. Serosanguineous drainage
D. Sanguineous drainage
Answer: B
Rationale: Purulent drainage is thick and can be yellow, green, or brown, often indicating
the presence of an infection. Serous drainage is clear and watery, while sanguineous
drainage consists of bright red blood. Serosanguineous drainage is a mix of clear and blood-
tinged fluid, typically appearing pink.
, 4. A nurse is providing discharge teaching for a client who will be using a walker at home.
Which of the following instructions should the nurse include?
A. Use the walker to pull yourself up from a sitting position.
B. Advance the walker about 12 to 18 inches with each step.
C. Move the walker and the affected leg forward at the same time.
D. Keep your elbows bent at a 45-degree angle when holding the handgrips.
Answer: C
Rationale: When using a walker, the client should advance the walker and the affected
(weak) leg forward simultaneously to maintain balance. The walker should only be moved
about 6 to 8 inches forward to ensure stability. Clients should use the chair arms, not the
walker, to push themselves up into a standing position to prevent the walker from tipping.
5. A nurse is performing hand hygiene after caring for a client with Clostridium difficile (C.
diff). Which of the following actions is the most appropriate?
A. Wash hands with soap and water.
B. Use an alcohol-based hand sanitizer for 15 seconds.
C. Wipe hands with a chlorhexidine-impregnated cloth.
D. Rinse hands with hot water only.
Answer: A
Foundations of Nursing | Q&A with
Rationale (NUR155 Exam 2) | Galen
College of Nursing
1. A nurse is preparing to enter the room of a client who has a suspected diagnosis of
pulmonary tuberculosis. Which of the following items of personal protective equipment (PPE)
should the nurse don before entering?
A. A surgical mask
B. A face shield
C. An N95 respirator
D. Sterile gloves
Answer: C
Rationale: Tuberculosis is transmitted via airborne droplets that remain suspended in the
air. Therefore, the nurse must wear an N95 or higher-level respirator to filter out these
small particles. Standard surgical masks are insufficient for airborne precautions as they do
not provide the necessary filtration.
2. A nurse is caring for a client who is at risk for developing pressure injuries. Which of the
following interventions should the nurse include in the plan of care?
A. Massage reddened bony prominences daily.
,B. Reposition the client every 4 hours while in bed.
C. Apply a moisture barrier ointment to the skin if incontinent.
D. Use a donut-shaped cushion when the client is sitting in a chair.
Answer: C
Rationale: Maintaining skin integrity is crucial in preventing pressure injuries, and
moisture barrier ointments protect the skin from maceration caused by urine or stool.
Massaging reddened areas can cause further tissue damage and is contraindicated. Clients
should be repositioned at least every 2 hours to relieve pressure effectively.
3. During a physical assessment, the nurse notes that the client’s wound has a thick, yellow-
green drainage. How should the nurse document this type of exudate?
A. Serous drainage
B. Purulent drainage
C. Serosanguineous drainage
D. Sanguineous drainage
Answer: B
Rationale: Purulent drainage is thick and can be yellow, green, or brown, often indicating
the presence of an infection. Serous drainage is clear and watery, while sanguineous
drainage consists of bright red blood. Serosanguineous drainage is a mix of clear and blood-
tinged fluid, typically appearing pink.
, 4. A nurse is providing discharge teaching for a client who will be using a walker at home.
Which of the following instructions should the nurse include?
A. Use the walker to pull yourself up from a sitting position.
B. Advance the walker about 12 to 18 inches with each step.
C. Move the walker and the affected leg forward at the same time.
D. Keep your elbows bent at a 45-degree angle when holding the handgrips.
Answer: C
Rationale: When using a walker, the client should advance the walker and the affected
(weak) leg forward simultaneously to maintain balance. The walker should only be moved
about 6 to 8 inches forward to ensure stability. Clients should use the chair arms, not the
walker, to push themselves up into a standing position to prevent the walker from tipping.
5. A nurse is performing hand hygiene after caring for a client with Clostridium difficile (C.
diff). Which of the following actions is the most appropriate?
A. Wash hands with soap and water.
B. Use an alcohol-based hand sanitizer for 15 seconds.
C. Wipe hands with a chlorhexidine-impregnated cloth.
D. Rinse hands with hot water only.
Answer: A
