Exam 3: NUR 101/ NUR101 (Latest 2025/
2026 Update) Health Assessment |
Questions with Verified Answers &
Rationale | Grade A| 100% Correct -Fortis.
Question:
The nurse is collecting data from several clients at the clinic. Which client
i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,-
does the nurse determine is most likely receive the Zostavax vaccine for
i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,-
the prevention of shingles?
i,- i,- i,-
A. 24-year old client that will be traveling out of the country
i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,-
B. 6-month-old infant having surgery to repair a cleft lip
i,- i,- i,- i,- i,- i,- i,- i,- i,-
C. 62-year-old client that had a mild case of shingles 4 years previously
i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,-
D. 38-year-old pregnant client that has gestational diabetes?
i,- i,- i,- i,- i,- i,- i,-
Answer:
C. 62-year-old client that had a mild case of shingles 4 years previously
i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,-
Explanation: The Centers for Disease Control and Prevention (CDC)
i,- i,- i,- i,- i,- i,- i,- i,- i,-
recommends that anyone 60 years of age or older receive the shingles
i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,-
vaccine, even if they have had a previous case of shingles to prevent
i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,-
reoccurrence of the virus. The other clients are not at greater risk for the
i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,-
development of shingles. i,- i,-
,Question:
The nurse is preparing to perform wound care for a client. What action
i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,-
should the nurse prioritize before changing the dressing?
i,- i,- i,- i,- i,- i,- i,-
A. put on gloves
i,- i,- i,-
B. wash hands thoroughly
i,- i,- i,-
C. slowly remove the soiled dressing
i,- i,- i,- i,- i,-
D. observe the dressing for the amount, type, and odor of drainage?
i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,-
Answer:
B. wash hands thoroughly
i,- i,- i,-
Explanation: The first thing the nurse must do is wash hands. Putting on
i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,-
gloves, removing the dressing, and observing the drainage are all parts of
i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,-
the dressing change procedure that come after hand washing.
i,- i,- i,- i,- i,- i,- i,- i,-
Question:
The nurse is reinforcing education to parents of an infant about burn
i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,-
prevention. Which instructions should be reinforced regarding burns from
i,- i,- i,- i,- i,- i,- i,- i,- i,-
tap water?
i,-
A. Set the water-heater temperature at 130° F (54.4° C) or less.
i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,-
B. Run the hot water first, then adjust the temperature with cold water.
i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,-
C. Before putting the infant in the tub, test the water with a hand.
i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,-
D. Supervise an infant in the bathroom, only leaving the infant for a few
i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,-
seconds if needed.? i,- i,-
,Answer:
C. Before putting the infant in the tub, test the water with a hand.
i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,-
Explanation: Instruct the parents to fill the tub with water first, then test all
i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,-
of the water in the tub with a hand for hot spots. The cold water should
i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,-
be run first and then adjusted with hot water. Water heaters should be set
i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,-
at 120° F (48.9° C). Never leave a infant alone in the bathroom, even for a
i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,-
second.
Question:
When planning care for a client with burns on the upper torso, which
i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,-
nursing diagnosis should take the highest priority?
i,- i,- i,- i,- i,- i,-
A. Ineffective airway clearance related to edema of the respiratory
i,- i,- i,- i,- i,- i,- i,- i,- i,- i,-
passages
B. Impaired physical mobility related to the disease process
i,- i,- i,- i,- i,- i,- i,- i,-
C. Impaired skin integrity related to disease process
i,- i,- i,- i,- i,- i,- i,-
D. Risk for infection related to breaks in the skin?
i,- i,- i,- i,- i,- i,- i,- i,- i,-
Answer:
A. Ineffective airway clearance related to edema of the respiratory
i,- i,- i,- i,- i,- i,- i,- i,- i,- i,-
passages
Explanation: When caring for a client with upper torso burns, the nurse's
i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,-
primary goal is to maintain respiratory integrity. Therefore, Ineffective
i,- i,- i,- i,- i,- i,- i,- i,- i,-
airway clearance related to edema of the respiratory passages should take
i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,-
the highest priority. Impaired physical mobility related to the disease
i,- i,- i,- i,- i,- i,- i,- i,- i,- i,-
, process is not appropriate because burns are not a disease. Impaired skin
i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,-
integrity related to disease process is not the priority and Risk for
i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,-
infection related to breaks in the skin may be appropriate, but they do not
i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,-
command a higher priority than Ineffective airway clearance because they
i,- i,- i,- i,- i,- i,- i,- i,- i,- i,-
do not reflect immediately life-threatening problems.
i,- i,- i,- i,- i,-
Question:
A client with atopic dermatitis is prescribed medication for
i,- i,- i,- i,- i,- i,- i,- i,- i,-
photochemotherapy. After administering medication for i,- i,- i,- i,- i,-
photochemotherapy, the nurse determines that the client understands the i,- i,- i,- i,- i,- i,- i,- i,- i,-
instructions based on which client statements? Select all that apply.
i,- i,- i,- i,- i,- i,- i,- i,- i,-
A. "I must protect my skin and eyes from natural sunlight for 12 hours
i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,-
after taking this medication."
i,- i,- i,-
B. "I will need to wear wraparound ultraviolet-protective sunglasses both
i,- i,- i,- i,- i,- i,- i,- i,- i,- i,-
indoors and outdoors, from the moment I take the medication until
i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,-
nightfall on the treatment day." i,- i,- i,- i,-
C. "I will need to wear protective-wear wraparound ultraviolet-protective
i,- i,- i,- i,- i,- i,- i,- i,- i,-
sunglasses after dark if I am under fluorescent lighting."
i,- i,- i,- i,- i,- i,- i,- i,-
D. "As long as I am inside behind a window glass I will not need to wear
i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,-
my protective glasses."
i,- i,-
E. "I will need to wear broad-spectrum sunscreen if I am outside."?
i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,-
Answer:
A. "I must protect my skin and eyes from natural sunlight for 12 hours
i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,-
after taking this medication."
i,- i,- i,-
B. "I will need to wear wraparound ultraviolet-protective sunglasses both
i,- i,- i,- i,- i,- i,- i,- i,- i,- i,-
indoors and outdoors, from the moment I take the medication until
i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,-
nightfall on the treatment day." i,- i,- i,- i,-
2026 Update) Health Assessment |
Questions with Verified Answers &
Rationale | Grade A| 100% Correct -Fortis.
Question:
The nurse is collecting data from several clients at the clinic. Which client
i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,-
does the nurse determine is most likely receive the Zostavax vaccine for
i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,-
the prevention of shingles?
i,- i,- i,-
A. 24-year old client that will be traveling out of the country
i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,-
B. 6-month-old infant having surgery to repair a cleft lip
i,- i,- i,- i,- i,- i,- i,- i,- i,-
C. 62-year-old client that had a mild case of shingles 4 years previously
i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,-
D. 38-year-old pregnant client that has gestational diabetes?
i,- i,- i,- i,- i,- i,- i,-
Answer:
C. 62-year-old client that had a mild case of shingles 4 years previously
i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,-
Explanation: The Centers for Disease Control and Prevention (CDC)
i,- i,- i,- i,- i,- i,- i,- i,- i,-
recommends that anyone 60 years of age or older receive the shingles
i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,-
vaccine, even if they have had a previous case of shingles to prevent
i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,-
reoccurrence of the virus. The other clients are not at greater risk for the
i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,-
development of shingles. i,- i,-
,Question:
The nurse is preparing to perform wound care for a client. What action
i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,-
should the nurse prioritize before changing the dressing?
i,- i,- i,- i,- i,- i,- i,-
A. put on gloves
i,- i,- i,-
B. wash hands thoroughly
i,- i,- i,-
C. slowly remove the soiled dressing
i,- i,- i,- i,- i,-
D. observe the dressing for the amount, type, and odor of drainage?
i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,-
Answer:
B. wash hands thoroughly
i,- i,- i,-
Explanation: The first thing the nurse must do is wash hands. Putting on
i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,-
gloves, removing the dressing, and observing the drainage are all parts of
i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,-
the dressing change procedure that come after hand washing.
i,- i,- i,- i,- i,- i,- i,- i,-
Question:
The nurse is reinforcing education to parents of an infant about burn
i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,-
prevention. Which instructions should be reinforced regarding burns from
i,- i,- i,- i,- i,- i,- i,- i,- i,-
tap water?
i,-
A. Set the water-heater temperature at 130° F (54.4° C) or less.
i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,-
B. Run the hot water first, then adjust the temperature with cold water.
i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,-
C. Before putting the infant in the tub, test the water with a hand.
i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,-
D. Supervise an infant in the bathroom, only leaving the infant for a few
i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,-
seconds if needed.? i,- i,-
,Answer:
C. Before putting the infant in the tub, test the water with a hand.
i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,-
Explanation: Instruct the parents to fill the tub with water first, then test all
i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,-
of the water in the tub with a hand for hot spots. The cold water should
i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,-
be run first and then adjusted with hot water. Water heaters should be set
i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,-
at 120° F (48.9° C). Never leave a infant alone in the bathroom, even for a
i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,-
second.
Question:
When planning care for a client with burns on the upper torso, which
i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,-
nursing diagnosis should take the highest priority?
i,- i,- i,- i,- i,- i,-
A. Ineffective airway clearance related to edema of the respiratory
i,- i,- i,- i,- i,- i,- i,- i,- i,- i,-
passages
B. Impaired physical mobility related to the disease process
i,- i,- i,- i,- i,- i,- i,- i,-
C. Impaired skin integrity related to disease process
i,- i,- i,- i,- i,- i,- i,-
D. Risk for infection related to breaks in the skin?
i,- i,- i,- i,- i,- i,- i,- i,- i,-
Answer:
A. Ineffective airway clearance related to edema of the respiratory
i,- i,- i,- i,- i,- i,- i,- i,- i,- i,-
passages
Explanation: When caring for a client with upper torso burns, the nurse's
i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,-
primary goal is to maintain respiratory integrity. Therefore, Ineffective
i,- i,- i,- i,- i,- i,- i,- i,- i,-
airway clearance related to edema of the respiratory passages should take
i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,-
the highest priority. Impaired physical mobility related to the disease
i,- i,- i,- i,- i,- i,- i,- i,- i,- i,-
, process is not appropriate because burns are not a disease. Impaired skin
i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,-
integrity related to disease process is not the priority and Risk for
i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,-
infection related to breaks in the skin may be appropriate, but they do not
i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,-
command a higher priority than Ineffective airway clearance because they
i,- i,- i,- i,- i,- i,- i,- i,- i,- i,-
do not reflect immediately life-threatening problems.
i,- i,- i,- i,- i,-
Question:
A client with atopic dermatitis is prescribed medication for
i,- i,- i,- i,- i,- i,- i,- i,- i,-
photochemotherapy. After administering medication for i,- i,- i,- i,- i,-
photochemotherapy, the nurse determines that the client understands the i,- i,- i,- i,- i,- i,- i,- i,- i,-
instructions based on which client statements? Select all that apply.
i,- i,- i,- i,- i,- i,- i,- i,- i,-
A. "I must protect my skin and eyes from natural sunlight for 12 hours
i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,-
after taking this medication."
i,- i,- i,-
B. "I will need to wear wraparound ultraviolet-protective sunglasses both
i,- i,- i,- i,- i,- i,- i,- i,- i,- i,-
indoors and outdoors, from the moment I take the medication until
i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,-
nightfall on the treatment day." i,- i,- i,- i,-
C. "I will need to wear protective-wear wraparound ultraviolet-protective
i,- i,- i,- i,- i,- i,- i,- i,- i,-
sunglasses after dark if I am under fluorescent lighting."
i,- i,- i,- i,- i,- i,- i,- i,-
D. "As long as I am inside behind a window glass I will not need to wear
i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,-
my protective glasses."
i,- i,-
E. "I will need to wear broad-spectrum sunscreen if I am outside."?
i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,-
Answer:
A. "I must protect my skin and eyes from natural sunlight for 12 hours
i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,-
after taking this medication."
i,- i,- i,-
B. "I will need to wear wraparound ultraviolet-protective sunglasses both
i,- i,- i,- i,- i,- i,- i,- i,- i,- i,-
indoors and outdoors, from the moment I take the medication until
i,- i,- i,- i,- i,- i,- i,- i,- i,- i,- i,-
nightfall on the treatment day." i,- i,- i,- i,-
