NUR 104/NUR104 Exam 2 V3 | Foundations of
Nursing Q&A with Rationale | Fortis College
1. A nurse is assessing a client with a serum potassium level of 3.2 mEq/L. Which clinical
manifestation should the nurse expect to find?
A. Hyperactive bowel sounds
B. Peaked T waves on ECG
C. Muscle weakness and leg cramps
D. Strong, bounding pulses
Correct Answer: C
Explanation: Hypokalemia is defined as a serum potassium level below 3.5 mEq/L. This
electrolyte imbalance commonly causes muscle weakness, leg cramps, and cardiac
dysrhythmias. The nurse must monitor the client closely for respiratory distress and
cardiac arrest if levels continue to drop.
2. When interpreting arterial blood gas (ABG) results, the nurse notes a pH of 7.30 and a
PaCO2 of 52 mmHg. Which acid-base imbalance does this represent?
A. Metabolic Acidosis
B. Respiratory Acidosis
C. Respiratory Alkalosis
D. Metabolic Alkalosis
,Correct Answer: B
Explanation: The pH of 7.30 indicates acidosis because it is below the normal range of 7.35
to 7.45. An elevated PaCO2 level above 45 mmHg signifies that the primary cause is
respiratory in nature. This condition often results from hypoventilation where the lungs
are unable to remove enough carbon dioxide.
3. A nurse is preparing to perform hand hygiene. According to standard guidelines, how long
should the nurse scrub their hands with soap?
A. At least 5 seconds
B. Until the hands feel dry
C. Exactly 1 minute
D. At least 15 seconds
Correct Answer: D
Explanation: Proper hand hygiene requires vigorous scrubbing of all surfaces of the hands
for at least 15 to 20 seconds. This duration is necessary to mechanically remove transient
microorganisms from the skin. Consistent adherence to this practice is the single most
effective way to prevent the spread of healthcare-associated infections.
4. A client is admitted with a diagnosis of Clostridium difficile (C. diff). Which type of
precautions should the nurse implement?
A. Standard precautions only
B. Contact precautions
, C. Airborne precautions
D. Droplet precautions
Correct Answer: B
Explanation: Contact precautions are required for clients with known or suspected
infections transmitted by direct or indirect contact. Clostridium difficile is a spore-forming
bacterium that necessitates the use of gloves and gowns. Additionally, hand hygiene must
be performed with soap and water rather than alcohol-based rubs because spores are
resistant to alcohol.
5. The nurse is using the Braden Scale to assess a client’s risk for pressure injuries. Which
score would indicate the highest risk?
A. 23
B. 9
C. 15
D. 18
Correct Answer: B
Explanation: The Braden Scale evaluates six categories: sensory perception, moisture,
activity, mobility, nutrition, and friction/shear. A lower total score indicates a higher risk
for developing a pressure injury. A score of 9 is considered very high risk, requiring
immediate and aggressive preventive interventions.
Nursing Q&A with Rationale | Fortis College
1. A nurse is assessing a client with a serum potassium level of 3.2 mEq/L. Which clinical
manifestation should the nurse expect to find?
A. Hyperactive bowel sounds
B. Peaked T waves on ECG
C. Muscle weakness and leg cramps
D. Strong, bounding pulses
Correct Answer: C
Explanation: Hypokalemia is defined as a serum potassium level below 3.5 mEq/L. This
electrolyte imbalance commonly causes muscle weakness, leg cramps, and cardiac
dysrhythmias. The nurse must monitor the client closely for respiratory distress and
cardiac arrest if levels continue to drop.
2. When interpreting arterial blood gas (ABG) results, the nurse notes a pH of 7.30 and a
PaCO2 of 52 mmHg. Which acid-base imbalance does this represent?
A. Metabolic Acidosis
B. Respiratory Acidosis
C. Respiratory Alkalosis
D. Metabolic Alkalosis
,Correct Answer: B
Explanation: The pH of 7.30 indicates acidosis because it is below the normal range of 7.35
to 7.45. An elevated PaCO2 level above 45 mmHg signifies that the primary cause is
respiratory in nature. This condition often results from hypoventilation where the lungs
are unable to remove enough carbon dioxide.
3. A nurse is preparing to perform hand hygiene. According to standard guidelines, how long
should the nurse scrub their hands with soap?
A. At least 5 seconds
B. Until the hands feel dry
C. Exactly 1 minute
D. At least 15 seconds
Correct Answer: D
Explanation: Proper hand hygiene requires vigorous scrubbing of all surfaces of the hands
for at least 15 to 20 seconds. This duration is necessary to mechanically remove transient
microorganisms from the skin. Consistent adherence to this practice is the single most
effective way to prevent the spread of healthcare-associated infections.
4. A client is admitted with a diagnosis of Clostridium difficile (C. diff). Which type of
precautions should the nurse implement?
A. Standard precautions only
B. Contact precautions
, C. Airborne precautions
D. Droplet precautions
Correct Answer: B
Explanation: Contact precautions are required for clients with known or suspected
infections transmitted by direct or indirect contact. Clostridium difficile is a spore-forming
bacterium that necessitates the use of gloves and gowns. Additionally, hand hygiene must
be performed with soap and water rather than alcohol-based rubs because spores are
resistant to alcohol.
5. The nurse is using the Braden Scale to assess a client’s risk for pressure injuries. Which
score would indicate the highest risk?
A. 23
B. 9
C. 15
D. 18
Correct Answer: B
Explanation: The Braden Scale evaluates six categories: sensory perception, moisture,
activity, mobility, nutrition, and friction/shear. A lower total score indicates a higher risk
for developing a pressure injury. A score of 9 is considered very high risk, requiring
immediate and aggressive preventive interventions.
