NUR 104/NUR104 Exam 4 V3 | Foundations of
Nursing Q&A with Rationale | Fortis College
1. A nurse is caring for a patient who has developed a stage 3 pressure injury. Which
characteristic should the nurse expect to observe during the assessment?
A. Full-thickness skin loss with visible subcutaneous fat
B. Partial-thickness skin loss with a exposed dermis
C. Non-blanchable erythema of intact skin
D. Full-thickness skin loss with exposed bone or muscle
Correct Answer: A
Explanation: A stage 3 pressure injury involves full-thickness skin loss where adipose (fat)
is visible in the ulcer. It does not extend through the underlying fascia to the bone or
muscle, which would be a stage 4 injury. Proper documentation of the wound bed and
surrounding tissue is essential for tracking healing progress.
2. The nurse is preparing to administer oxygen via a nasal cannula to a patient with a
respiratory rate of 24/min. What is the maximum recommended flow rate for this delivery
device?
A. 6 L/min
B. 2 L/min
C. 10 L/min
,D. 15 L/min
Correct Answer: A
Explanation: A nasal cannula is typically used for flow rates ranging from 1 to 6 liters per
minute. Flow rates above 6 L/min are often ineffective because of the anatomical dead
space and can cause drying of the nasal mucosa. If the patient requires higher
concentrations of oxygen, a simple face mask or non-rebreather mask should be
considered.
3. During a pre-operative assessment, a patient expresses fear about the surgery. Which
action should the nurse take first?
A. Administer the prescribed sedative medication immediately
B. Reassure the patient that the surgeon is highly skilled
C. Listen to the patient’s concerns and encourage expression of feelings
D. Explain the technical details of the surgical procedure
Correct Answer: C
Explanation: Active listening and encouraging the expression of feelings is the therapeutic
first step in addressing patient anxiety. This allows the nurse to identify specific fears and
provide appropriate emotional support or clarification. Providing technical details or false
reassurance often ignores the underlying emotional needs of the patient.
, 4. A nurse is monitoring a patient for signs of hypokalemia. Which of the following findings is
most indicative of this electrolyte imbalance?
A. Peaked T waves on the EKG
B. Hyperactive bowel sounds
C. Positive Chvostek’s sign
D. Muscle weakness and leg cramps
Correct Answer: D
Explanation: Hypokalemia, or low serum potassium, often manifests as muscle weakness,
fatigue, and leg cramps due to the role of potassium in muscle contraction. Cardiovascular
changes can also occur, such as the presence of U waves or flattened T waves on an EKG.
Chvostek’s sign is associated with hypocalcemia, not hypokalemia.
5. Which intervention is a priority for a patient who is experiencing a wound evisceration
following abdominal surgery?
A. Attempt to gently push the organs back into the abdominal cavity
B. Apply a dry, sterile pressure dressing to the site
C. Place the patient in a high-Fowler’s position to ease breathing
D. Cover the protruding organs with sterile towels moistened with sterile normal saline
Correct Answer: D
Nursing Q&A with Rationale | Fortis College
1. A nurse is caring for a patient who has developed a stage 3 pressure injury. Which
characteristic should the nurse expect to observe during the assessment?
A. Full-thickness skin loss with visible subcutaneous fat
B. Partial-thickness skin loss with a exposed dermis
C. Non-blanchable erythema of intact skin
D. Full-thickness skin loss with exposed bone or muscle
Correct Answer: A
Explanation: A stage 3 pressure injury involves full-thickness skin loss where adipose (fat)
is visible in the ulcer. It does not extend through the underlying fascia to the bone or
muscle, which would be a stage 4 injury. Proper documentation of the wound bed and
surrounding tissue is essential for tracking healing progress.
2. The nurse is preparing to administer oxygen via a nasal cannula to a patient with a
respiratory rate of 24/min. What is the maximum recommended flow rate for this delivery
device?
A. 6 L/min
B. 2 L/min
C. 10 L/min
,D. 15 L/min
Correct Answer: A
Explanation: A nasal cannula is typically used for flow rates ranging from 1 to 6 liters per
minute. Flow rates above 6 L/min are often ineffective because of the anatomical dead
space and can cause drying of the nasal mucosa. If the patient requires higher
concentrations of oxygen, a simple face mask or non-rebreather mask should be
considered.
3. During a pre-operative assessment, a patient expresses fear about the surgery. Which
action should the nurse take first?
A. Administer the prescribed sedative medication immediately
B. Reassure the patient that the surgeon is highly skilled
C. Listen to the patient’s concerns and encourage expression of feelings
D. Explain the technical details of the surgical procedure
Correct Answer: C
Explanation: Active listening and encouraging the expression of feelings is the therapeutic
first step in addressing patient anxiety. This allows the nurse to identify specific fears and
provide appropriate emotional support or clarification. Providing technical details or false
reassurance often ignores the underlying emotional needs of the patient.
, 4. A nurse is monitoring a patient for signs of hypokalemia. Which of the following findings is
most indicative of this electrolyte imbalance?
A. Peaked T waves on the EKG
B. Hyperactive bowel sounds
C. Positive Chvostek’s sign
D. Muscle weakness and leg cramps
Correct Answer: D
Explanation: Hypokalemia, or low serum potassium, often manifests as muscle weakness,
fatigue, and leg cramps due to the role of potassium in muscle contraction. Cardiovascular
changes can also occur, such as the presence of U waves or flattened T waves on an EKG.
Chvostek’s sign is associated with hypocalcemia, not hypokalemia.
5. Which intervention is a priority for a patient who is experiencing a wound evisceration
following abdominal surgery?
A. Attempt to gently push the organs back into the abdominal cavity
B. Apply a dry, sterile pressure dressing to the site
C. Place the patient in a high-Fowler’s position to ease breathing
D. Cover the protruding organs with sterile towels moistened with sterile normal saline
Correct Answer: D
