NUR 104/NUR104 Exam 3 V1 | Foundations of
Nursing Q&A with Rationale | Fortis College
1. A nurse is caring for a client who is prescribed a clear liquid diet. Which of the following
food items should the nurse offer?
A. Vanilla pudding
B. Cream of mushroom soup
C. Orange juice with pulp
D. Apple juice
Correct Answer: D
Explanation: Apple juice is considered a clear liquid because it is transparent at room
temperature. A clear liquid diet is designed to provide fluid and electrolytes with minimal
digestion required. Items like pudding, orange juice with pulp, and cream soups are
classified as full liquids.
2. Which assessment finding should the nurse identify as a manifestation of fluid volume
excess?
A. Tachycardia and flat neck veins
B. Crackles upon lung auscultation
C. Dry mucous membranes
D. Increased urine specific gravity
,Correct Answer: B
Explanation: Crackles in the lungs indicate that fluid is leaking into the alveoli, which is a
classic sign of fluid volume excess. This condition often results in weight gain, edema, and
bounding pulses. The nurse must monitor respiratory status closely to ensure the patient
does not develop pulmonary edema.
3. A nurse is assessing a pressure injury and finds full-thickness skin loss with visible
subcutaneous fat, but no muscle or bone is exposed. How should this be staged?
A. Stage 3
B. Stage 2
C. Stage 1
D. Stage 4
Correct Answer: A
Explanation: Stage 3 pressure injuries involve full-thickness skin loss that extends into the
subcutaneous tissue layer. Slough may be present, but it does not obscure the depth of
tissue loss. This differs from Stage 4, where muscle, tendon, or bone would be visible or
directly palpable.
4. When performing tracheostomy care, which action should the nurse take first?
A. Hyperoxygenate the client
B. Remove the old dressing
, C. Clean the inner cannula
D. Suction the tracheostomy tube
Correct Answer: A
Explanation: Hyperoxygenation is the priority action before suctioning or cleaning a
tracheostomy to prevent hypoxia. Providing 100% oxygen helps maintain stable oxygen
saturation levels during the procedure. The nurse should use the manual resuscitation bag
or increase the ventilator settings as per protocol.
5. A nurse is caring for a client with a new colostomy. The stoma appears beefy red and
moist. Which action is appropriate?
A. Document the finding as normal
B. Apply a cold compress to the stoma
C. Notify the surgeon immediately
D. Clean the area with alcohol swabs
Correct Answer: A
Explanation: A healthy stoma should appear beefy red, moist, and shiny. This indicates
adequate blood supply to the intestinal tissue. If the stoma were pale, dusky, or black, it
would indicate ischemia and require immediate medical intervention.
6. Which of the following is an example of objective data?
A. The client reports a pain level of 7 out of 10
Nursing Q&A with Rationale | Fortis College
1. A nurse is caring for a client who is prescribed a clear liquid diet. Which of the following
food items should the nurse offer?
A. Vanilla pudding
B. Cream of mushroom soup
C. Orange juice with pulp
D. Apple juice
Correct Answer: D
Explanation: Apple juice is considered a clear liquid because it is transparent at room
temperature. A clear liquid diet is designed to provide fluid and electrolytes with minimal
digestion required. Items like pudding, orange juice with pulp, and cream soups are
classified as full liquids.
2. Which assessment finding should the nurse identify as a manifestation of fluid volume
excess?
A. Tachycardia and flat neck veins
B. Crackles upon lung auscultation
C. Dry mucous membranes
D. Increased urine specific gravity
,Correct Answer: B
Explanation: Crackles in the lungs indicate that fluid is leaking into the alveoli, which is a
classic sign of fluid volume excess. This condition often results in weight gain, edema, and
bounding pulses. The nurse must monitor respiratory status closely to ensure the patient
does not develop pulmonary edema.
3. A nurse is assessing a pressure injury and finds full-thickness skin loss with visible
subcutaneous fat, but no muscle or bone is exposed. How should this be staged?
A. Stage 3
B. Stage 2
C. Stage 1
D. Stage 4
Correct Answer: A
Explanation: Stage 3 pressure injuries involve full-thickness skin loss that extends into the
subcutaneous tissue layer. Slough may be present, but it does not obscure the depth of
tissue loss. This differs from Stage 4, where muscle, tendon, or bone would be visible or
directly palpable.
4. When performing tracheostomy care, which action should the nurse take first?
A. Hyperoxygenate the client
B. Remove the old dressing
, C. Clean the inner cannula
D. Suction the tracheostomy tube
Correct Answer: A
Explanation: Hyperoxygenation is the priority action before suctioning or cleaning a
tracheostomy to prevent hypoxia. Providing 100% oxygen helps maintain stable oxygen
saturation levels during the procedure. The nurse should use the manual resuscitation bag
or increase the ventilator settings as per protocol.
5. A nurse is caring for a client with a new colostomy. The stoma appears beefy red and
moist. Which action is appropriate?
A. Document the finding as normal
B. Apply a cold compress to the stoma
C. Notify the surgeon immediately
D. Clean the area with alcohol swabs
Correct Answer: A
Explanation: A healthy stoma should appear beefy red, moist, and shiny. This indicates
adequate blood supply to the intestinal tissue. If the stoma were pale, dusky, or black, it
would indicate ischemia and require immediate medical intervention.
6. Which of the following is an example of objective data?
A. The client reports a pain level of 7 out of 10
