NUR 104/NUR104 Final Exam V2 | Foundations of
Nursing Q&A with Rationale | Fortis College
1. A nurse is conducting an admission assessment for an older adult client. Which of the
following findings should the nurse identify as a priority to report to the provider?
A. The client reports a sudden onset of confusion.
B. The client has a blood pressure of 138/88 mm Hg.
C. The client has a history of osteoarthritis.
D. The client uses a hearing aid in the left ear.
Correct Answer: A
Explanation: A sudden onset of confusion in an older adult is an acute change that may
indicate a serious underlying condition such as infection or hypoxia. The nurse must
prioritize physiological stability and safety when evaluating cognitive changes. This finding
requires immediate reporting to ensure prompt diagnosis and treatment by the healthcare
provider.
2. A nurse is caring for a client who is 2 days postoperative following abdominal surgery.
Which of the following actions should the nurse take to prevent pulmonary complications?
A. Instruct the client to use the incentive spirometer 10 times every hour while awake.
B. Administer pain medication only when the client rates pain at a 10/10.
C. Maintain the client in a supine position for the first 48 hours.
,D. Restrict fluid intake to 1,000 mL per day to prevent fluid overload.
Correct Answer: A
Explanation: Using an incentive spirometer promotes deep breathing and helps prevent
atelectasis and pneumonia in postoperative clients. Proper education on the frequency of
its use is a standard nursing intervention for surgical recovery. Encouraging the client to
perform this action regularly ensures maximal lung expansion and clear airways.
3. A nurse is preparing to administer an intramuscular injection to an adult client. Which of
the following sites is the safest for this procedure?
A. Dorsogluteal
B. Deltoid
C. Ventrogluteal
D. Vastus lateralis
Correct Answer: C
Explanation: The ventrogluteal site is considered the safest for intramuscular injections
because it is away from major nerves and blood vessels. It provides a large muscle mass
that can accommodate various medication volumes without significant risk of injury.
Recent evidence-based practice guidelines recommend this site over the dorsogluteal site
to avoid sciatic nerve damage.
,4. A nurse is providing discharge teaching to a client who will be self-administering insulin at
home. Which of the following statements by the client indicates an understanding of the
teaching?
A. I will rotate my injection sites within the same anatomical area.
B. I should reuse the same needle for up to three days.
C. I will massage the injection site for 2 minutes after the injection.
D. I will store my currently used insulin vial in the freezer.
Correct Answer: A
Explanation: Rotating injection sites within one anatomical area helps maintain consistent
absorption rates while preventing lipohypertrophy. This practice is essential for effective
glucose management and skin integrity in diabetic clients. The nurse should emphasize
that the client should avoid massaging the site as it can alter the absorption rate of the
insulin.
5. A nurse is assisting a client with limited mobility from the bed to a chair. Which of the
following actions should the nurse perform first?
A. Assess the client’s ability to assist with the transfer.
B. Position the chair at a 45-degree angle to the bed.
C. Place a gait belt around the client’s waist.
D. Lower the bed to its lowest position.
, Correct Answer: A
Explanation: Assessment is always the first step in the nursing process to ensure client
safety during any physical activity. By determining the client’s strength and balance, the
nurse can choose the appropriate equipment and level of assistance needed. Failure to
assess the client’s capacity could lead to an unsuccessful transfer and potential injury to
both the client and the nurse.
6. A nurse is teaching a group of newly licensed nurses about the use of standard precautions.
Which of the following scenarios requires the use of standard precautions?
A. Emptying a client’s urinary drainage bag.
B. Providing a bed bath to a client with intact skin.
C. Changing a sterile surgical dressing.
D. Administering oral medications to a client.
Correct Answer: A
Explanation: Standard precautions must be used whenever there is potential contact with
blood, body fluids, or secretions. Emptying a urinary drainage bag involves direct contact
with body fluids, necessitating the use of gloves and potentially other personal protective
equipment. These precautions are fundamental to preventing the transmission of
healthcare-associated infections.
Nursing Q&A with Rationale | Fortis College
1. A nurse is conducting an admission assessment for an older adult client. Which of the
following findings should the nurse identify as a priority to report to the provider?
A. The client reports a sudden onset of confusion.
B. The client has a blood pressure of 138/88 mm Hg.
C. The client has a history of osteoarthritis.
D. The client uses a hearing aid in the left ear.
Correct Answer: A
Explanation: A sudden onset of confusion in an older adult is an acute change that may
indicate a serious underlying condition such as infection or hypoxia. The nurse must
prioritize physiological stability and safety when evaluating cognitive changes. This finding
requires immediate reporting to ensure prompt diagnosis and treatment by the healthcare
provider.
2. A nurse is caring for a client who is 2 days postoperative following abdominal surgery.
Which of the following actions should the nurse take to prevent pulmonary complications?
A. Instruct the client to use the incentive spirometer 10 times every hour while awake.
B. Administer pain medication only when the client rates pain at a 10/10.
C. Maintain the client in a supine position for the first 48 hours.
,D. Restrict fluid intake to 1,000 mL per day to prevent fluid overload.
Correct Answer: A
Explanation: Using an incentive spirometer promotes deep breathing and helps prevent
atelectasis and pneumonia in postoperative clients. Proper education on the frequency of
its use is a standard nursing intervention for surgical recovery. Encouraging the client to
perform this action regularly ensures maximal lung expansion and clear airways.
3. A nurse is preparing to administer an intramuscular injection to an adult client. Which of
the following sites is the safest for this procedure?
A. Dorsogluteal
B. Deltoid
C. Ventrogluteal
D. Vastus lateralis
Correct Answer: C
Explanation: The ventrogluteal site is considered the safest for intramuscular injections
because it is away from major nerves and blood vessels. It provides a large muscle mass
that can accommodate various medication volumes without significant risk of injury.
Recent evidence-based practice guidelines recommend this site over the dorsogluteal site
to avoid sciatic nerve damage.
,4. A nurse is providing discharge teaching to a client who will be self-administering insulin at
home. Which of the following statements by the client indicates an understanding of the
teaching?
A. I will rotate my injection sites within the same anatomical area.
B. I should reuse the same needle for up to three days.
C. I will massage the injection site for 2 minutes after the injection.
D. I will store my currently used insulin vial in the freezer.
Correct Answer: A
Explanation: Rotating injection sites within one anatomical area helps maintain consistent
absorption rates while preventing lipohypertrophy. This practice is essential for effective
glucose management and skin integrity in diabetic clients. The nurse should emphasize
that the client should avoid massaging the site as it can alter the absorption rate of the
insulin.
5. A nurse is assisting a client with limited mobility from the bed to a chair. Which of the
following actions should the nurse perform first?
A. Assess the client’s ability to assist with the transfer.
B. Position the chair at a 45-degree angle to the bed.
C. Place a gait belt around the client’s waist.
D. Lower the bed to its lowest position.
, Correct Answer: A
Explanation: Assessment is always the first step in the nursing process to ensure client
safety during any physical activity. By determining the client’s strength and balance, the
nurse can choose the appropriate equipment and level of assistance needed. Failure to
assess the client’s capacity could lead to an unsuccessful transfer and potential injury to
both the client and the nurse.
6. A nurse is teaching a group of newly licensed nurses about the use of standard precautions.
Which of the following scenarios requires the use of standard precautions?
A. Emptying a client’s urinary drainage bag.
B. Providing a bed bath to a client with intact skin.
C. Changing a sterile surgical dressing.
D. Administering oral medications to a client.
Correct Answer: A
Explanation: Standard precautions must be used whenever there is potential contact with
blood, body fluids, or secretions. Emptying a urinary drainage bag involves direct contact
with body fluids, necessitating the use of gloves and potentially other personal protective
equipment. These precautions are fundamental to preventing the transmission of
healthcare-associated infections.
