NUR 104/NUR104 Exam 4 V1 | Foundations of
Nursing Q&A with Rationale | Fortis College
1. A nurse is providing preoperative teaching to a client scheduled for surgery. The client asks
why they must remain NPO after midnight. Which response by the nurse is most appropriate?
A. To reduce the risk of developing a postoperative wound infection.
B. To ensure the stomach is empty for a clearer surgical view.
C. To prevent postoperative constipation and abdominal distension.
D. To prevent the risk of aspiration during anesthesia administration.
Correct Answer: D
Explanation: The primary reason for NPO status prior to surgery is to prevent the
aspiration of gastric contents into the lungs while the client is under anesthesia, which
suppresses protective airway reflexes. Aspiration can lead to severe pneumonia or
respiratory failure. The nurse must emphasize that even small amounts of liquid can pose a
significant risk.
2. When assessing a postoperative client, the nurse notes that the surgical dressing is
saturated with bright red blood. Which action should the nurse take first?
A. Reinforce the dressing with additional sterile gauze pads.
B. Remove the old dressing to inspect the incision site.
C. Notify the surgeon immediately about the active bleeding.
,D. Document the finding and reassess the client in one hour.
Correct Answer: A
Explanation: The initial nursing action for a saturated dressing in the immediate
postoperative period is to reinforce the dressing to promote clotting and prevent further
blood loss. The nurse should not remove the original surgical dressing as this may disturb
the wound and increase the risk of infection or further bleeding. After reinforcing the
dressing, the nurse should then assess vital signs and notify the surgical team.
3. A client is 2 days postoperative following abdominal surgery. The nurse notes that the
client has not yet had a bowel movement and bowel sounds are hypoactive. Which condition
does the nurse suspect?
A. Paralytic ileus
B. Fecal impaction
C. Bowel obstruction
D. Gastroenteritis
Correct Answer: A
Explanation: Paralytic ileus is a common postoperative complication characterized by a
temporary cessation of intestinal peristalsis, often due to abdominal surgery or anesthesia.
Symptoms include absent or hypoactive bowel sounds, abdominal distension, and lack of
bowel movements. The nurse should continue to monitor the client and encourage early
ambulation to stimulate gastric motility.
,4. The nurse is preparing to administer a cleansing enema to a client. In which position should
the nurse place the client to facilitate the flow of solution?
A. Right-side Sims’ position
B. Supine position with legs abducted
C. High-Fowler’s position
D. Left-side Sims’ position
Correct Answer: D
Explanation: The left-side Sims’ position allows the enema solution to flow by gravity into
the sigmoid colon and rectum due to the anatomical curvature of the large intestine.
Placing the client on the right side or in a supine position would hinder the effective
distribution of the fluid. This positioning also helps the client retain the fluid more
comfortably during the procedure.
5. A nurse is caring for a client with a Stage 2 pressure injury on the sacrum. Which
description best characterizes this type of wound?
A. Intact skin with non-blanchable redness over a bony prominence.
B. Partial-thickness loss of dermis presenting as a shallow open ulcer.
C. Full-thickness tissue loss with visible subcutaneous fat.
D. Full-thickness tissue loss with exposed bone, tendon, or muscle.
Correct Answer: B
, Explanation: A Stage 2 pressure injury is defined by partial-thickness loss of the dermis,
which may present as a shallow open ulcer with a red or pink wound bed, or as an intact or
ruptured serum-filled blister. This stage does not involve slough or bruising, which would
indicate a deeper injury. In contrast, Stage 1 involves intact skin with non-blanchable
redness, and Stage 3 involves subcutaneous fat visibility.
6. While performing a wound assessment, the nurse observes thick, yellow-green drainage on
the dressing. How should the nurse document this type of exudate?
A. Purulent
B. Sanguineous
C. Serosanguineous
D. Serous
Correct Answer: A
Explanation: Purulent drainage is thick and consists of white blood cells, liquefied dead
tissue debris, and both dead and living bacteria; it often indicates the presence of an
infection. It can vary in color, appearing yellow, green, or tan. Serous drainage is clear and
watery, while sanguineous is bloody and serosanguineous is a pale, pink, watery mixture.
7. A client has a Jackson-Pratt (JP) drain following a mastectomy. What is the priority nursing
action to ensure the drain functions effectively?
A. Keep the drain pinned to the client’s bedsheet.
B. Compress the bulb to maintain negative pressure.
Nursing Q&A with Rationale | Fortis College
1. A nurse is providing preoperative teaching to a client scheduled for surgery. The client asks
why they must remain NPO after midnight. Which response by the nurse is most appropriate?
A. To reduce the risk of developing a postoperative wound infection.
B. To ensure the stomach is empty for a clearer surgical view.
C. To prevent postoperative constipation and abdominal distension.
D. To prevent the risk of aspiration during anesthesia administration.
Correct Answer: D
Explanation: The primary reason for NPO status prior to surgery is to prevent the
aspiration of gastric contents into the lungs while the client is under anesthesia, which
suppresses protective airway reflexes. Aspiration can lead to severe pneumonia or
respiratory failure. The nurse must emphasize that even small amounts of liquid can pose a
significant risk.
2. When assessing a postoperative client, the nurse notes that the surgical dressing is
saturated with bright red blood. Which action should the nurse take first?
A. Reinforce the dressing with additional sterile gauze pads.
B. Remove the old dressing to inspect the incision site.
C. Notify the surgeon immediately about the active bleeding.
,D. Document the finding and reassess the client in one hour.
Correct Answer: A
Explanation: The initial nursing action for a saturated dressing in the immediate
postoperative period is to reinforce the dressing to promote clotting and prevent further
blood loss. The nurse should not remove the original surgical dressing as this may disturb
the wound and increase the risk of infection or further bleeding. After reinforcing the
dressing, the nurse should then assess vital signs and notify the surgical team.
3. A client is 2 days postoperative following abdominal surgery. The nurse notes that the
client has not yet had a bowel movement and bowel sounds are hypoactive. Which condition
does the nurse suspect?
A. Paralytic ileus
B. Fecal impaction
C. Bowel obstruction
D. Gastroenteritis
Correct Answer: A
Explanation: Paralytic ileus is a common postoperative complication characterized by a
temporary cessation of intestinal peristalsis, often due to abdominal surgery or anesthesia.
Symptoms include absent or hypoactive bowel sounds, abdominal distension, and lack of
bowel movements. The nurse should continue to monitor the client and encourage early
ambulation to stimulate gastric motility.
,4. The nurse is preparing to administer a cleansing enema to a client. In which position should
the nurse place the client to facilitate the flow of solution?
A. Right-side Sims’ position
B. Supine position with legs abducted
C. High-Fowler’s position
D. Left-side Sims’ position
Correct Answer: D
Explanation: The left-side Sims’ position allows the enema solution to flow by gravity into
the sigmoid colon and rectum due to the anatomical curvature of the large intestine.
Placing the client on the right side or in a supine position would hinder the effective
distribution of the fluid. This positioning also helps the client retain the fluid more
comfortably during the procedure.
5. A nurse is caring for a client with a Stage 2 pressure injury on the sacrum. Which
description best characterizes this type of wound?
A. Intact skin with non-blanchable redness over a bony prominence.
B. Partial-thickness loss of dermis presenting as a shallow open ulcer.
C. Full-thickness tissue loss with visible subcutaneous fat.
D. Full-thickness tissue loss with exposed bone, tendon, or muscle.
Correct Answer: B
, Explanation: A Stage 2 pressure injury is defined by partial-thickness loss of the dermis,
which may present as a shallow open ulcer with a red or pink wound bed, or as an intact or
ruptured serum-filled blister. This stage does not involve slough or bruising, which would
indicate a deeper injury. In contrast, Stage 1 involves intact skin with non-blanchable
redness, and Stage 3 involves subcutaneous fat visibility.
6. While performing a wound assessment, the nurse observes thick, yellow-green drainage on
the dressing. How should the nurse document this type of exudate?
A. Purulent
B. Sanguineous
C. Serosanguineous
D. Serous
Correct Answer: A
Explanation: Purulent drainage is thick and consists of white blood cells, liquefied dead
tissue debris, and both dead and living bacteria; it often indicates the presence of an
infection. It can vary in color, appearing yellow, green, or tan. Serous drainage is clear and
watery, while sanguineous is bloody and serosanguineous is a pale, pink, watery mixture.
7. A client has a Jackson-Pratt (JP) drain following a mastectomy. What is the priority nursing
action to ensure the drain functions effectively?
A. Keep the drain pinned to the client’s bedsheet.
B. Compress the bulb to maintain negative pressure.
