NU NUR 340 Module 4 (pdf) | 2026/2027 | Nursing Care of Adults and
Older Adults II Q&A | Nursing
1. A graduate nursing student is studying the concept of tissue integrity.
Which of the following best defines this concept?
A) The ability of the skin and mucous membranes to remain intact and
protect the body
B) The process of wound healing by primary intention
C) The function of the immune system in fighting infection
D) The body's response to surgical stress
Correct Answer: The ability of the skin and mucous membranes to remain
intact and protect the body
Rationale: Tissue integrity refers to the state of structurally intact skin and
mucous membranes, which serve as the body's first line of defense against
infection and injury. Compromised tissue integrity increases the risk of
infection, fluid loss, and delayed healing, making it a critical concept in adult
health nursing.
2. An advanced practice nurse is evaluating a patient's oxygenation status.
Which of the following is the most sensitive indicator of adequate
oxygenation?
A) Respiratory rate
B) Oxygen saturation (SpO2)
C) Arterial blood gas (ABG) analysis
D) Skin color
Correct Answer: Arterial blood gas (ABG) analysis
,Rationale: ABG analysis provides the most accurate and comprehensive
assessment of oxygenation, ventilation, and acid-base status by measuring
PaO2, PaCO2, pH, and bicarbonate. SpO2 is a useful non-invasive screening
tool, but ABG analysis is the gold standard for evaluating oxygenation.
3. A nurse is assessing a patient's perfusion status. Which of the following
findings indicates adequate peripheral perfusion?
A) Cool, pale extremities
B) Capillary refill time of 2 seconds
C) Weak, thready peripheral pulses
D) Dependent rubor in the lower extremities
Correct Answer: Capillary refill time of 2 seconds
Rationale: Normal capillary refill time is less than 2 seconds, indicating
adequate peripheral perfusion. Cool, pale extremities, weak pulses, and
dependent rubor are signs of compromised perfusion and potential
peripheral arterial disease.
4. A nurse is caring for a patient with impaired tissue integrity. Which of the
following is the priority nursing intervention?
A) Administering prescribed analgesics
B) Applying a moisture-retentive dressing
C) Assessing the wound for signs of infection
D) Repositioning the patient every 2 hours
Correct Answer: Assessing the wound for signs of infection
Rationale: Assessment is the first step of the nursing process. The priority is
to assess the wound for signs of infection, such as increased redness,
,warmth, purulent drainage, or odor, to guide appropriate interventions and
prevent complications.
5. A patient is scheduled for a major abdominal surgery. The nurse
understands that the primary goal of preoperative teaching is to:
A) Ensure the patient understands the surgical procedure
B) Reduce the patient's anxiety and promote a positive outcome
C) Obtain informed consent for the procedure
D) Administer preoperative medications
Correct Answer: Reduce the patient's anxiety and promote a positive
outcome
Rationale: Preoperative teaching aims to reduce anxiety, promote
understanding, and enhance postoperative recovery. Providing information
about what to expect before, during, and after surgery empowers the patient
and can lead to better outcomes.
6. A nurse is assessing a postoperative patient for complications. Which of
the following findings is most indicative of a wound infection?
A) Serous drainage and well-approximated wound edges
B) Purulent drainage and increasing erythema
C) Mild edema and bruising around the incision
D) Pain that is relieved by prescribed analgesics
Correct Answer: Purulent drainage and increasing erythema
Rationale: Purulent drainage and increasing erythema are classic signs of a
wound infection. Serous drainage, well-approximated edges, mild edema,
, and pain that is relieved by medication are expected findings in a healing
wound.
7. A nurse is providing discharge teaching to a patient who has undergone a
major surgery. Which of the following instructions is most important to
prevent postoperative complications?
A) "Ambulate as soon as possible to prevent deep vein thrombosis."
B) "Keep the surgical wound dry for the first 24-48 hours."
C) "Report any signs of infection, such as fever or increased redness."
D) "All of the above."
Correct Answer: "All of the above."
Rationale: Early ambulation, proper wound care, and monitoring for signs of
infection are all essential components of postoperative care to prevent
complications such as DVT, wound infection, and delayed healing.
8. A nurse is caring for a patient with impaired mobility. Which of the
following interventions is most effective in preventing pressure ulcers?
A) Using a donut-shaped cushion for seating
B) Repositioning the patient every 2 hours
C) Massaging bony prominences daily
D) Keeping the skin moist to prevent cracking
Correct Answer: Repositioning the patient every 2 hours
Rationale: Repositioning every 2 hours is the most effective intervention to
relieve pressure on bony prominences and prevent pressure ulcers. Donut-
shaped cushions can impair circulation, massage can cause tissue damage,
and moist skin increases the risk of breakdown.
Older Adults II Q&A | Nursing
1. A graduate nursing student is studying the concept of tissue integrity.
Which of the following best defines this concept?
A) The ability of the skin and mucous membranes to remain intact and
protect the body
B) The process of wound healing by primary intention
C) The function of the immune system in fighting infection
D) The body's response to surgical stress
Correct Answer: The ability of the skin and mucous membranes to remain
intact and protect the body
Rationale: Tissue integrity refers to the state of structurally intact skin and
mucous membranes, which serve as the body's first line of defense against
infection and injury. Compromised tissue integrity increases the risk of
infection, fluid loss, and delayed healing, making it a critical concept in adult
health nursing.
2. An advanced practice nurse is evaluating a patient's oxygenation status.
Which of the following is the most sensitive indicator of adequate
oxygenation?
A) Respiratory rate
B) Oxygen saturation (SpO2)
C) Arterial blood gas (ABG) analysis
D) Skin color
Correct Answer: Arterial blood gas (ABG) analysis
,Rationale: ABG analysis provides the most accurate and comprehensive
assessment of oxygenation, ventilation, and acid-base status by measuring
PaO2, PaCO2, pH, and bicarbonate. SpO2 is a useful non-invasive screening
tool, but ABG analysis is the gold standard for evaluating oxygenation.
3. A nurse is assessing a patient's perfusion status. Which of the following
findings indicates adequate peripheral perfusion?
A) Cool, pale extremities
B) Capillary refill time of 2 seconds
C) Weak, thready peripheral pulses
D) Dependent rubor in the lower extremities
Correct Answer: Capillary refill time of 2 seconds
Rationale: Normal capillary refill time is less than 2 seconds, indicating
adequate peripheral perfusion. Cool, pale extremities, weak pulses, and
dependent rubor are signs of compromised perfusion and potential
peripheral arterial disease.
4. A nurse is caring for a patient with impaired tissue integrity. Which of the
following is the priority nursing intervention?
A) Administering prescribed analgesics
B) Applying a moisture-retentive dressing
C) Assessing the wound for signs of infection
D) Repositioning the patient every 2 hours
Correct Answer: Assessing the wound for signs of infection
Rationale: Assessment is the first step of the nursing process. The priority is
to assess the wound for signs of infection, such as increased redness,
,warmth, purulent drainage, or odor, to guide appropriate interventions and
prevent complications.
5. A patient is scheduled for a major abdominal surgery. The nurse
understands that the primary goal of preoperative teaching is to:
A) Ensure the patient understands the surgical procedure
B) Reduce the patient's anxiety and promote a positive outcome
C) Obtain informed consent for the procedure
D) Administer preoperative medications
Correct Answer: Reduce the patient's anxiety and promote a positive
outcome
Rationale: Preoperative teaching aims to reduce anxiety, promote
understanding, and enhance postoperative recovery. Providing information
about what to expect before, during, and after surgery empowers the patient
and can lead to better outcomes.
6. A nurse is assessing a postoperative patient for complications. Which of
the following findings is most indicative of a wound infection?
A) Serous drainage and well-approximated wound edges
B) Purulent drainage and increasing erythema
C) Mild edema and bruising around the incision
D) Pain that is relieved by prescribed analgesics
Correct Answer: Purulent drainage and increasing erythema
Rationale: Purulent drainage and increasing erythema are classic signs of a
wound infection. Serous drainage, well-approximated edges, mild edema,
, and pain that is relieved by medication are expected findings in a healing
wound.
7. A nurse is providing discharge teaching to a patient who has undergone a
major surgery. Which of the following instructions is most important to
prevent postoperative complications?
A) "Ambulate as soon as possible to prevent deep vein thrombosis."
B) "Keep the surgical wound dry for the first 24-48 hours."
C) "Report any signs of infection, such as fever or increased redness."
D) "All of the above."
Correct Answer: "All of the above."
Rationale: Early ambulation, proper wound care, and monitoring for signs of
infection are all essential components of postoperative care to prevent
complications such as DVT, wound infection, and delayed healing.
8. A nurse is caring for a patient with impaired mobility. Which of the
following interventions is most effective in preventing pressure ulcers?
A) Using a donut-shaped cushion for seating
B) Repositioning the patient every 2 hours
C) Massaging bony prominences daily
D) Keeping the skin moist to prevent cracking
Correct Answer: Repositioning the patient every 2 hours
Rationale: Repositioning every 2 hours is the most effective intervention to
relieve pressure on bony prominences and prevent pressure ulcers. Donut-
shaped cushions can impair circulation, massage can cause tissue damage,
and moist skin increases the risk of breakdown.
