NRSG 100 Exam 3 V2 | NRSG 100
Fundamentals of Nursing | Actual Q&A
with Rationale (NRSG100 Exam 3) | Ivy
Tech
1. A nurse is assessing a client’s wound and notes a thick, yellow-green drainage. How should
the nurse document this finding?
A. Serous drainage
B. Purulent drainage
C. Sanguineous drainage
D. Serosanguineous drainage
Correct Answer: B
Purulent drainage is thick and indicates the presence of pus, which can vary in color from
yellow to green or brown. This type of drainage is often a clinical sign of infection within
the wound bed. Accurate documentation is essential for tracking the progression or
resolution of wound healing over time.
2. When performing a 24-hour urine collection, which action is most critical for the nurse to
implement?
A. Discard the first voided specimen and then start the clock.
B. Discard the last voided specimen at the end of the 24 hours.
,C. Keep the urine at room temperature throughout the collection period.
D. Ask the client to skip a void if they are feeling tired.
Correct Answer: A
The first voided specimen of a 24-hour collection is discarded because it represents urine
produced before the test period began. Following this first void, every subsequent drop of
urine must be collected and usually kept on ice or refrigerated to maintain chemical
stability. If any urine is accidentally discarded during the period, the entire test must be
restarted from the beginning.
3. A client is at risk for skin breakdown. Which Braden Scale score indicates the highest risk?
A. 12
B. 9
C. 18
D. 23
Correct Answer: B
The Braden Scale is a standardized tool used to assess a patient’s risk of developing
pressure ulcers, with scores ranging from 6 to 23. A lower total score indicates a higher
risk of skin breakdown, meaning a score of 9 places the patient in the ‘very high risk’
category. Nurses use this score to implement preventative measures such as frequent
turning and specialized support surfaces.
, 4. The nurse is preparing to administer a cleansing enema. In which position should the client
be placed?
A. High-Fowler’s position
B. Left lateral Sims’ position
C. Dorsal recumbent position
D. Prone position
Correct Answer: B
The left lateral Sims’ position allows the enema solution to flow by gravity into the
sigmoid colon and rectum more effectively. This position involves the client lying on the left
side with the right knee flexed toward the chest. Placing the patient correctly reduces
discomfort and improves the therapeutic outcome of the procedure.
5. Which dietary instruction is most appropriate for a client prescribed a clear liquid diet?
A. ‘You may have apple juice, gelatin, and tea.’
B. ‘You may have orange juice with pulp.’
C. ‘You may have vanilla pudding and milk.’
D. ‘You may have cream of mushroom soup.’
Correct Answer: A
A clear liquid diet consists of fluids that are transparent to light at room temperature and
leave minimal residue in the GI tract. Examples include apple juice, broth, plain gelatin, and
Fundamentals of Nursing | Actual Q&A
with Rationale (NRSG100 Exam 3) | Ivy
Tech
1. A nurse is assessing a client’s wound and notes a thick, yellow-green drainage. How should
the nurse document this finding?
A. Serous drainage
B. Purulent drainage
C. Sanguineous drainage
D. Serosanguineous drainage
Correct Answer: B
Purulent drainage is thick and indicates the presence of pus, which can vary in color from
yellow to green or brown. This type of drainage is often a clinical sign of infection within
the wound bed. Accurate documentation is essential for tracking the progression or
resolution of wound healing over time.
2. When performing a 24-hour urine collection, which action is most critical for the nurse to
implement?
A. Discard the first voided specimen and then start the clock.
B. Discard the last voided specimen at the end of the 24 hours.
,C. Keep the urine at room temperature throughout the collection period.
D. Ask the client to skip a void if they are feeling tired.
Correct Answer: A
The first voided specimen of a 24-hour collection is discarded because it represents urine
produced before the test period began. Following this first void, every subsequent drop of
urine must be collected and usually kept on ice or refrigerated to maintain chemical
stability. If any urine is accidentally discarded during the period, the entire test must be
restarted from the beginning.
3. A client is at risk for skin breakdown. Which Braden Scale score indicates the highest risk?
A. 12
B. 9
C. 18
D. 23
Correct Answer: B
The Braden Scale is a standardized tool used to assess a patient’s risk of developing
pressure ulcers, with scores ranging from 6 to 23. A lower total score indicates a higher
risk of skin breakdown, meaning a score of 9 places the patient in the ‘very high risk’
category. Nurses use this score to implement preventative measures such as frequent
turning and specialized support surfaces.
, 4. The nurse is preparing to administer a cleansing enema. In which position should the client
be placed?
A. High-Fowler’s position
B. Left lateral Sims’ position
C. Dorsal recumbent position
D. Prone position
Correct Answer: B
The left lateral Sims’ position allows the enema solution to flow by gravity into the
sigmoid colon and rectum more effectively. This position involves the client lying on the left
side with the right knee flexed toward the chest. Placing the patient correctly reduces
discomfort and improves the therapeutic outcome of the procedure.
5. Which dietary instruction is most appropriate for a client prescribed a clear liquid diet?
A. ‘You may have apple juice, gelatin, and tea.’
B. ‘You may have orange juice with pulp.’
C. ‘You may have vanilla pudding and milk.’
D. ‘You may have cream of mushroom soup.’
Correct Answer: A
A clear liquid diet consists of fluids that are transparent to light at room temperature and
leave minimal residue in the GI tract. Examples include apple juice, broth, plain gelatin, and
