NUR 155 Final Exam V2 | NUR 155
Foundations of Nursing | Q&A with
Rationale (NUR155 Final Exam) | Galen
College of Nursing
1. A nurse is conducting a primary assessment of a patient who has just been admitted to the
unit. Which of the following data represents objective information?
A. The patient reports feeling dizzy when standing up.
B. The patient states their pain level is a 6 out of 10.
C. The nurse observes a 2 cm reddened area on the patient’s sacrum.
D. The patient expresses concern about being unable to pay for medications.
Answer: C
Rationale: Objective data consists of observable and measurable signs obtained through
physical examination and diagnostic testing. In this scenario, the nurse’s observation of a
skin abnormality is a factual, measurable finding. Subjective data, such as pain levels or
feelings of dizziness, are reports provided directly by the patient that cannot be
independently verified by the nurse’s senses.
2. When implementing the ‘R’ in the RACE mnemonic during a hospital fire, which action
should the nurse take first?
A. Rescue and remove all patients in immediate danger.
,B. Activate the fire alarm system.
C. Confine the fire by closing doors and windows.
D. Extinguish the fire using the nearest portable extinguisher.
Answer: A
Rationale: The RACE acronym stands for Rescue, Alarm, Confine, and Extinguish/Evacuate.
The priority in any fire situation is always the safety of the patients who are in the
immediate vicinity of the fire. Once patients are moved to a safe location, the nurse should
then proceed to activate the alarm and contain the fire.
3. A nurse is preparing to administer an oral medication to a patient. Which of the following
is the most reliable method for identifying the patient?
A. Ask the patient to state their full name and date of birth.
B. Check the room number against the medication administration record.
C. Verify the patient’s identity with a family member at the bedside.
D. Refer to the name printed on the patient’s water pitcher.
Answer: A
Rationale: Joint Commission standards require the use of at least two patient identifiers
before performing any procedure or administering medications. Asking the patient to state
their name and birth date allows for active verification against the medication
, administration record and the patient’s wristband. Room numbers and bedside items are
not acceptable identifiers because patients may be moved or items may be misplaced.
4. Which nursing intervention is most effective in preventing the development of pressure
injuries in a bedbound patient?
A. Massaging reddened bony prominences every shift.
B. Increasing the patient’s intake of clear liquids.
C. Placing a donut-shaped cushion under the patient’s sacrum.
D. Repositioning the patient at least every 2 hours.
Answer: D
Rationale: Frequent repositioning relieves pressure on bony prominences, which is the
primary cause of skin breakdown in immobilized patients. Massaging reddened areas is
contraindicated because it can cause further tissue damage to fragile capillaries. Donut
cushions should be avoided as they can actually impair circulation to the center of the area
being protected.
5. A nurse is documenting in a patient’s electronic health record. Which entry is the most
accurate and professional?
A. Patient seems to be having a good day today.
B. Patient drank an adequate amount of fluids during the shift.
C. Patient was very difficult and uncooperative during morning care.
Foundations of Nursing | Q&A with
Rationale (NUR155 Final Exam) | Galen
College of Nursing
1. A nurse is conducting a primary assessment of a patient who has just been admitted to the
unit. Which of the following data represents objective information?
A. The patient reports feeling dizzy when standing up.
B. The patient states their pain level is a 6 out of 10.
C. The nurse observes a 2 cm reddened area on the patient’s sacrum.
D. The patient expresses concern about being unable to pay for medications.
Answer: C
Rationale: Objective data consists of observable and measurable signs obtained through
physical examination and diagnostic testing. In this scenario, the nurse’s observation of a
skin abnormality is a factual, measurable finding. Subjective data, such as pain levels or
feelings of dizziness, are reports provided directly by the patient that cannot be
independently verified by the nurse’s senses.
2. When implementing the ‘R’ in the RACE mnemonic during a hospital fire, which action
should the nurse take first?
A. Rescue and remove all patients in immediate danger.
,B. Activate the fire alarm system.
C. Confine the fire by closing doors and windows.
D. Extinguish the fire using the nearest portable extinguisher.
Answer: A
Rationale: The RACE acronym stands for Rescue, Alarm, Confine, and Extinguish/Evacuate.
The priority in any fire situation is always the safety of the patients who are in the
immediate vicinity of the fire. Once patients are moved to a safe location, the nurse should
then proceed to activate the alarm and contain the fire.
3. A nurse is preparing to administer an oral medication to a patient. Which of the following
is the most reliable method for identifying the patient?
A. Ask the patient to state their full name and date of birth.
B. Check the room number against the medication administration record.
C. Verify the patient’s identity with a family member at the bedside.
D. Refer to the name printed on the patient’s water pitcher.
Answer: A
Rationale: Joint Commission standards require the use of at least two patient identifiers
before performing any procedure or administering medications. Asking the patient to state
their name and birth date allows for active verification against the medication
, administration record and the patient’s wristband. Room numbers and bedside items are
not acceptable identifiers because patients may be moved or items may be misplaced.
4. Which nursing intervention is most effective in preventing the development of pressure
injuries in a bedbound patient?
A. Massaging reddened bony prominences every shift.
B. Increasing the patient’s intake of clear liquids.
C. Placing a donut-shaped cushion under the patient’s sacrum.
D. Repositioning the patient at least every 2 hours.
Answer: D
Rationale: Frequent repositioning relieves pressure on bony prominences, which is the
primary cause of skin breakdown in immobilized patients. Massaging reddened areas is
contraindicated because it can cause further tissue damage to fragile capillaries. Donut
cushions should be avoided as they can actually impair circulation to the center of the area
being protected.
5. A nurse is documenting in a patient’s electronic health record. Which entry is the most
accurate and professional?
A. Patient seems to be having a good day today.
B. Patient drank an adequate amount of fluids during the shift.
C. Patient was very difficult and uncooperative during morning care.
