NUR 155 COMPREHENSIVE
FOUNDATIONS EXAM (EXAMS 2, 3, AND
4) QUESTIONS AND ANSWERS
1. A nurse is caring for a patient who is at high risk for falls. Which of the following is the
priority nursing intervention?
A. Place the bed in the highest position to prevent the patient from getting up.
B. Ensure the call light is within reach and the patient knows how to use it.
C. Apply a vest restraint to keep the patient in the chair.
D. Keep all four side rails up at all times.
Answer: B
Conceptual Explanation: Safety priorities start with the least restrictive measures.
Keeping the call light in reach is a standard safety intervention. High bed positions and four
side rails are safety hazards, and restraints are a last resort.
2. The nurse is preparing to administer an intramuscular (IM) injection to a 6-month-old
infant. Which site is most appropriate?
A. Dorsogluteal
B. Deltoid
,C. Vastus Lateralis
D. Ventrogluteal
Answer: C
Conceptual Explanation: The vastus lateralis is the preferred site for IM injections in
infants because it is the most developed muscle at that age.
3. When measuring blood pressure, the nurse uses a cuff that is too small for the patient’s
arm. What effect will this have on the reading?
A. The reading will be falsely low.
B. The diastolic will be correct but the systolic will be high.
C. The reading will be unaffected.
D. The reading will be falsely high.
Answer: D
Conceptual Explanation: A blood pressure cuff that is too small (too narrow) will result in
a falsely high blood pressure reading.
4. A nurse is caring for a patient with Clostridium difficile (C. diff). Which infection control
measure is mandatory for this patient?
A. Wash hands with soap and water after leaving the room.
B. Wear an N95 respirator when entering the room.
C. Use alcohol-based hand sanitizer after every contact.
, D. Maintain the patient in a negative-pressure room.
Answer: A
Conceptual Explanation: C. diff spores are resistant to alcohol-based sanitizers; therefore,
mechanical washing with soap and water is required to remove them from hands.
5. The nurse notices a patient’s surgical wound has eviscerated. What is the immediate
priority action?
A. Push the organs back into the abdominal cavity gently.
B. Call the family to provide emotional support.
C. Place the patient in a high-Fowler’s position.
D. Cover the protruding organs with sterile gauze moistened with sterile normal saline.
Answer: D
Conceptual Explanation: Evisceration is a medical emergency. The nurse must cover the
organs with sterile, saline-soaked dressings to keep them moist and prevent infection while
waiting for the surgical team.
6. A patient has a potassium level of 6.2 mEq/L. Which of the following is the nurse’s priority
assessment?
A. Bowel sounds
B. Cardiac rhythm
C. Deep tendon reflexes
FOUNDATIONS EXAM (EXAMS 2, 3, AND
4) QUESTIONS AND ANSWERS
1. A nurse is caring for a patient who is at high risk for falls. Which of the following is the
priority nursing intervention?
A. Place the bed in the highest position to prevent the patient from getting up.
B. Ensure the call light is within reach and the patient knows how to use it.
C. Apply a vest restraint to keep the patient in the chair.
D. Keep all four side rails up at all times.
Answer: B
Conceptual Explanation: Safety priorities start with the least restrictive measures.
Keeping the call light in reach is a standard safety intervention. High bed positions and four
side rails are safety hazards, and restraints are a last resort.
2. The nurse is preparing to administer an intramuscular (IM) injection to a 6-month-old
infant. Which site is most appropriate?
A. Dorsogluteal
B. Deltoid
,C. Vastus Lateralis
D. Ventrogluteal
Answer: C
Conceptual Explanation: The vastus lateralis is the preferred site for IM injections in
infants because it is the most developed muscle at that age.
3. When measuring blood pressure, the nurse uses a cuff that is too small for the patient’s
arm. What effect will this have on the reading?
A. The reading will be falsely low.
B. The diastolic will be correct but the systolic will be high.
C. The reading will be unaffected.
D. The reading will be falsely high.
Answer: D
Conceptual Explanation: A blood pressure cuff that is too small (too narrow) will result in
a falsely high blood pressure reading.
4. A nurse is caring for a patient with Clostridium difficile (C. diff). Which infection control
measure is mandatory for this patient?
A. Wash hands with soap and water after leaving the room.
B. Wear an N95 respirator when entering the room.
C. Use alcohol-based hand sanitizer after every contact.
, D. Maintain the patient in a negative-pressure room.
Answer: A
Conceptual Explanation: C. diff spores are resistant to alcohol-based sanitizers; therefore,
mechanical washing with soap and water is required to remove them from hands.
5. The nurse notices a patient’s surgical wound has eviscerated. What is the immediate
priority action?
A. Push the organs back into the abdominal cavity gently.
B. Call the family to provide emotional support.
C. Place the patient in a high-Fowler’s position.
D. Cover the protruding organs with sterile gauze moistened with sterile normal saline.
Answer: D
Conceptual Explanation: Evisceration is a medical emergency. The nurse must cover the
organs with sterile, saline-soaked dressings to keep them moist and prevent infection while
waiting for the surgical team.
6. A patient has a potassium level of 6.2 mEq/L. Which of the following is the nurse’s priority
assessment?
A. Bowel sounds
B. Cardiac rhythm
C. Deep tendon reflexes
