NUR 104/NUR104 Exam 3 V3 | Foundations of
Nursing Q&A with Rationale | Fortis College
1. A nurse is preparing to administer a cleansing enema to a patient. In which position should
the nurse place the patient to ensure the best results?
A. Left Sims’ position with the right knee flexed
B. Right lateral position with the left leg flexed
C. Supine with the head of the bed elevated 30 degrees
D. High-Fowler’s position to utilize gravity
Correct Answer: A
Explanation: The left Sims’ position allows the enema solution to flow by gravity into the
sigmoid colon and rectum. This anatomical positioning facilitates the distribution of fluid
throughout the lower bowel. Placing the patient in other positions would hinder the flow
and decrease the effectiveness of the procedure.
2. Which clinical finding is most characteristic of a Stage 2 pressure injury?
A. Partial-thickness skin loss with a shallow, open ulcer and a red-pink wound bed
B. Full-thickness skin loss with visible adipose tissue
C. Non-blanchable erythema of intact skin
D. Purple or maroon localized area of discolored intact skin
Correct Answer: A
,Explanation: A Stage 2 pressure injury involves partial-thickness loss of the dermis and
presents as a shallow open ulcer. It may also present as an intact or open/ruptured serum-
filled blister without slough or bruising. This differs from Stage 1 which is non-blanchable
redness and Stage 3 which involves subcutaneous fat visibility.
3. A patient is prescribed oxygen via a nasal cannula at 4 L/min. Which nursing action is a
priority for this patient?
A. Ensure a humidification device is attached to the oxygen source
B. Apply petroleum jelly to the nares to prevent drying
C. Switch the patient to a non-rebreather mask for better delivery
D. Instruct the patient to breathe only through their nose
Correct Answer: A
Explanation: Oxygen therapy at flow rates higher than 4 L/min can have a drying effect on
the oral and nasal mucosa. Humidification is necessary to add moisture to the inspired air
and prevent irritation or bleeding. Petroleum jelly is oil-based and should be avoided due
to fire risks in the presence of oxygen.
4. The nurse is assessing a patient’s wound and notes the presence of thick, yellow-green
drainage. How should the nurse document this finding?
A. Serosanguineous drainage
B. Purulent drainage
C. Serous drainage
, D. Sanguineous drainage
Correct Answer: B
Explanation: Purulent drainage is thick and consists of white blood cells, dead tissue, and
bacteria, often indicating an infection. It can vary in color, appearing yellow, green, or
brown. Serous drainage is clear/watery, while sanguineous is bright red blood.
5. A patient reports difficulty urinating and a feeling of fullness in the lower abdomen. Which
nursing intervention should be performed first?
A. Perform a bladder scan to assess for residual urine
B. Insert an indwelling urinary catheter
C. Administer a prescribed diuretic
D. Encourage the patient to increase fluid intake
Correct Answer: A
Explanation: Assessment is the first step of the nursing process when a patient presents
with symptoms of urinary retention. A bladder scan provides an objective measurement of
the volume of urine remaining in the bladder. This non-invasive step guides further
interventions such as catheterization if necessary.
6. When teaching a patient about using an incentive spirometer, what instruction should the
nurse provide?
A. Exhale forcefully into the device as hard as possible
Nursing Q&A with Rationale | Fortis College
1. A nurse is preparing to administer a cleansing enema to a patient. In which position should
the nurse place the patient to ensure the best results?
A. Left Sims’ position with the right knee flexed
B. Right lateral position with the left leg flexed
C. Supine with the head of the bed elevated 30 degrees
D. High-Fowler’s position to utilize gravity
Correct Answer: A
Explanation: The left Sims’ position allows the enema solution to flow by gravity into the
sigmoid colon and rectum. This anatomical positioning facilitates the distribution of fluid
throughout the lower bowel. Placing the patient in other positions would hinder the flow
and decrease the effectiveness of the procedure.
2. Which clinical finding is most characteristic of a Stage 2 pressure injury?
A. Partial-thickness skin loss with a shallow, open ulcer and a red-pink wound bed
B. Full-thickness skin loss with visible adipose tissue
C. Non-blanchable erythema of intact skin
D. Purple or maroon localized area of discolored intact skin
Correct Answer: A
,Explanation: A Stage 2 pressure injury involves partial-thickness loss of the dermis and
presents as a shallow open ulcer. It may also present as an intact or open/ruptured serum-
filled blister without slough or bruising. This differs from Stage 1 which is non-blanchable
redness and Stage 3 which involves subcutaneous fat visibility.
3. A patient is prescribed oxygen via a nasal cannula at 4 L/min. Which nursing action is a
priority for this patient?
A. Ensure a humidification device is attached to the oxygen source
B. Apply petroleum jelly to the nares to prevent drying
C. Switch the patient to a non-rebreather mask for better delivery
D. Instruct the patient to breathe only through their nose
Correct Answer: A
Explanation: Oxygen therapy at flow rates higher than 4 L/min can have a drying effect on
the oral and nasal mucosa. Humidification is necessary to add moisture to the inspired air
and prevent irritation or bleeding. Petroleum jelly is oil-based and should be avoided due
to fire risks in the presence of oxygen.
4. The nurse is assessing a patient’s wound and notes the presence of thick, yellow-green
drainage. How should the nurse document this finding?
A. Serosanguineous drainage
B. Purulent drainage
C. Serous drainage
, D. Sanguineous drainage
Correct Answer: B
Explanation: Purulent drainage is thick and consists of white blood cells, dead tissue, and
bacteria, often indicating an infection. It can vary in color, appearing yellow, green, or
brown. Serous drainage is clear/watery, while sanguineous is bright red blood.
5. A patient reports difficulty urinating and a feeling of fullness in the lower abdomen. Which
nursing intervention should be performed first?
A. Perform a bladder scan to assess for residual urine
B. Insert an indwelling urinary catheter
C. Administer a prescribed diuretic
D. Encourage the patient to increase fluid intake
Correct Answer: A
Explanation: Assessment is the first step of the nursing process when a patient presents
with symptoms of urinary retention. A bladder scan provides an objective measurement of
the volume of urine remaining in the bladder. This non-invasive step guides further
interventions such as catheterization if necessary.
6. When teaching a patient about using an incentive spirometer, what instruction should the
nurse provide?
A. Exhale forcefully into the device as hard as possible
