NUR 155 Final Exam V1 | NUR 155
Foundations of Nursing | Q&A with
Rationale (NUR155 Final Exam) | Galen
College of Nursing
1. A nurse is preparing to administer an intramuscular injection to an adult client. Which of
the following is the most appropriate site for a volume of 2.5 mL?
A. Ventrogluteal site
B. Deltoid muscle
C. Dorsum of the hand
D. Vastus lateralis (for infants only)
Answer: A
Rationale: The ventrogluteal site is the preferred and safest site for large volume
intramuscular injections in adults. It can accommodate up to 3 mL of medication and is free
of major nerves and blood vessels. The deltoid is limited to smaller volumes, typically 1 mL
or less.
2. When implementing standard precautions, which action should the nurse take?
A. Wear gloves only when the patient has a known infection.
B. Perform hand hygiene before and after every patient contact.
C. Recap needles immediately after use to prevent injury.
,D. Use a mask for all patient interactions within three feet.
Answer: B
Rationale: Hand hygiene is the single most important practice to prevent the transmission
of infections in the healthcare setting. Standard precautions apply to all patients, regardless
of their diagnosis or presumed infection status. Gloves and other PPE should be used
whenever contact with blood or body fluids is anticipated.
3. A client reports a pain level of 8 on a scale of 0 to 10. Which part of the nursing process is
the nurse performing when documenting this statement?
A. Planning
B. Implementation
C. Assessment
D. Evaluation
Answer: C
Rationale: Assessment is the first step of the nursing process and involves the systematic
collection of subjective and objective data. In this scenario, the client’s self-report of pain
level constitutes subjective data gathered during the assessment phase. Subsequent steps
like planning and implementation will depend on the accuracy of this initial assessment.
4. The nurse is caring for a patient with a diagnosis of orthostatic hypotension. Which
intervention is most critical for patient safety?
A. Encouraging the patient to drink more caffeine to raise blood pressure.
, B. Restricting fluid intake to 1000 mL per day.
C. Assisting the patient to dangle their legs at the bedside before standing.
D. Keeping the patient in a supine position at all times.
Answer: C
Rationale: Dangling the legs at the bedside allows the patient’s circulatory system to
adjust to postural changes gradually. This intervention helps prevent sudden drops in
blood pressure that can lead to dizziness or fainting upon standing. Ensuring the patient
moves slowly from a lying to a standing position is a standard safety protocol for
orthostatic hypotension.
5. Which of the following describes a ‘sentinel event’ according to The Joint Commission?
A. An expected side effect of a prescribed medication.
B. An unexpected occurrence involving death or serious physical injury.
C. A near-miss that did not reach the patient.
D. A routine follow-up appointment for a chronic condition.
Answer: B
Rationale: A sentinel event is defined as an unexpected occurrence involving death,
serious physical or psychological injury, or the risk thereof. These events require
immediate investigation and a root cause analysis to prevent recurrence. They are called
‘sentinel’ because they signal the need for immediate investigation and response.
Foundations of Nursing | Q&A with
Rationale (NUR155 Final Exam) | Galen
College of Nursing
1. A nurse is preparing to administer an intramuscular injection to an adult client. Which of
the following is the most appropriate site for a volume of 2.5 mL?
A. Ventrogluteal site
B. Deltoid muscle
C. Dorsum of the hand
D. Vastus lateralis (for infants only)
Answer: A
Rationale: The ventrogluteal site is the preferred and safest site for large volume
intramuscular injections in adults. It can accommodate up to 3 mL of medication and is free
of major nerves and blood vessels. The deltoid is limited to smaller volumes, typically 1 mL
or less.
2. When implementing standard precautions, which action should the nurse take?
A. Wear gloves only when the patient has a known infection.
B. Perform hand hygiene before and after every patient contact.
C. Recap needles immediately after use to prevent injury.
,D. Use a mask for all patient interactions within three feet.
Answer: B
Rationale: Hand hygiene is the single most important practice to prevent the transmission
of infections in the healthcare setting. Standard precautions apply to all patients, regardless
of their diagnosis or presumed infection status. Gloves and other PPE should be used
whenever contact with blood or body fluids is anticipated.
3. A client reports a pain level of 8 on a scale of 0 to 10. Which part of the nursing process is
the nurse performing when documenting this statement?
A. Planning
B. Implementation
C. Assessment
D. Evaluation
Answer: C
Rationale: Assessment is the first step of the nursing process and involves the systematic
collection of subjective and objective data. In this scenario, the client’s self-report of pain
level constitutes subjective data gathered during the assessment phase. Subsequent steps
like planning and implementation will depend on the accuracy of this initial assessment.
4. The nurse is caring for a patient with a diagnosis of orthostatic hypotension. Which
intervention is most critical for patient safety?
A. Encouraging the patient to drink more caffeine to raise blood pressure.
, B. Restricting fluid intake to 1000 mL per day.
C. Assisting the patient to dangle their legs at the bedside before standing.
D. Keeping the patient in a supine position at all times.
Answer: C
Rationale: Dangling the legs at the bedside allows the patient’s circulatory system to
adjust to postural changes gradually. This intervention helps prevent sudden drops in
blood pressure that can lead to dizziness or fainting upon standing. Ensuring the patient
moves slowly from a lying to a standing position is a standard safety protocol for
orthostatic hypotension.
5. Which of the following describes a ‘sentinel event’ according to The Joint Commission?
A. An expected side effect of a prescribed medication.
B. An unexpected occurrence involving death or serious physical injury.
C. A near-miss that did not reach the patient.
D. A routine follow-up appointment for a chronic condition.
Answer: B
Rationale: A sentinel event is defined as an unexpected occurrence involving death,
serious physical or psychological injury, or the risk thereof. These events require
immediate investigation and a root cause analysis to prevent recurrence. They are called
‘sentinel’ because they signal the need for immediate investigation and response.
