NUR 155 Exam 4 V3 | 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 is experiencing dyspnea and has an oxygen saturation of
88%. Which oxygen delivery device should the nurse anticipate using to deliver a precise
concentration of oxygen?
A. Nasal Cannula
B. Simple Face Mask
C. Non-rebreather mask
D. Venturi Mask
Answer: D
Rationale: The Venturi mask is the most accurate device for delivering a specific oxygen
concentration because it uses calibrated valves to mix room air with oxygen. This device is
particularly beneficial for patients with COPD who require titrated oxygen therapy to avoid
suppressing their respiratory drive. Other masks like the simple face mask provide variable
concentrations based on the patient’s breathing pattern.
2. While performing a sterile dressing change, the nurse notices that a drop of sterile water
has fallen onto the sterile field. Which action should the nurse take next?
A. Continue the procedure if the water is sterile.
,B. Spray the area with an antimicrobial solution.
C. Blot the water with a sterile gauze pad.
D. Consider the field contaminated and start over with new supplies.
Answer: D
Rationale: When a sterile surface comes into contact with moisture, it is considered
contaminated due to capillary action that can wick microorganisms through the barrier.
The nurse must maintain strict surgical asepsis to prevent healthcare-associated infections.
Consequently, the only safe action is to discard the current setup and begin the process
again with a new sterile kit.
3. A nurse is preparing to administer a tap water enema to a client. Which position should the
nurse assist the client into for this procedure?
A. High-Fowler’s position
B. Prone position
C. Lithotomy position
D. Left Sims’ position
Answer: D
Rationale: The Left Sims’ position allows the enema solution to flow downward by gravity
into the sigmoid colon and rectum. This position involves the client lying on the left side
, with the right knee flexed toward the chest. It provides the best access to the rectal area
while promoting comfort and safety for the patient.
4. A nurse is monitoring a client’s urinary output and notes the output is 25 mL per hour for
the last two hours. What is the nurse’s priority action?
A. Document the finding as normal.
B. Increase the IV fluid rate immediately.
C. Notify the healthcare provider of the low output.
D. Encourage the client to drink more water.
Answer: C
Rationale: A minimum urinary output of 30 mL per hour is generally considered the
threshold for adequate renal perfusion. An output consistently below this level may
indicate dehydration, decreased cardiac output, or renal failure. The nurse must report this
finding promptly so that the underlying cause can be addressed through medical
intervention.
5. Which of the following findings is an early sign of hypoxia in a client with a respiratory
disorder?
A. Cyanosis
B. Bradypnea
C. Bradycardia
Foundations of Nursing | Q&A with
Rationale (NUR155 Exam 4) | Galen
College of Nursing
1. A nurse is caring for a patient who is experiencing dyspnea and has an oxygen saturation of
88%. Which oxygen delivery device should the nurse anticipate using to deliver a precise
concentration of oxygen?
A. Nasal Cannula
B. Simple Face Mask
C. Non-rebreather mask
D. Venturi Mask
Answer: D
Rationale: The Venturi mask is the most accurate device for delivering a specific oxygen
concentration because it uses calibrated valves to mix room air with oxygen. This device is
particularly beneficial for patients with COPD who require titrated oxygen therapy to avoid
suppressing their respiratory drive. Other masks like the simple face mask provide variable
concentrations based on the patient’s breathing pattern.
2. While performing a sterile dressing change, the nurse notices that a drop of sterile water
has fallen onto the sterile field. Which action should the nurse take next?
A. Continue the procedure if the water is sterile.
,B. Spray the area with an antimicrobial solution.
C. Blot the water with a sterile gauze pad.
D. Consider the field contaminated and start over with new supplies.
Answer: D
Rationale: When a sterile surface comes into contact with moisture, it is considered
contaminated due to capillary action that can wick microorganisms through the barrier.
The nurse must maintain strict surgical asepsis to prevent healthcare-associated infections.
Consequently, the only safe action is to discard the current setup and begin the process
again with a new sterile kit.
3. A nurse is preparing to administer a tap water enema to a client. Which position should the
nurse assist the client into for this procedure?
A. High-Fowler’s position
B. Prone position
C. Lithotomy position
D. Left Sims’ position
Answer: D
Rationale: The Left Sims’ position allows the enema solution to flow downward by gravity
into the sigmoid colon and rectum. This position involves the client lying on the left side
, with the right knee flexed toward the chest. It provides the best access to the rectal area
while promoting comfort and safety for the patient.
4. A nurse is monitoring a client’s urinary output and notes the output is 25 mL per hour for
the last two hours. What is the nurse’s priority action?
A. Document the finding as normal.
B. Increase the IV fluid rate immediately.
C. Notify the healthcare provider of the low output.
D. Encourage the client to drink more water.
Answer: C
Rationale: A minimum urinary output of 30 mL per hour is generally considered the
threshold for adequate renal perfusion. An output consistently below this level may
indicate dehydration, decreased cardiac output, or renal failure. The nurse must report this
finding promptly so that the underlying cause can be addressed through medical
intervention.
5. Which of the following findings is an early sign of hypoxia in a client with a respiratory
disorder?
A. Cyanosis
B. Bradypnea
C. Bradycardia
