NURS 103 FUNDAMENTALS OF
NURSING WEEK 4 COMPREHENSIVE
QUIZ 2026 | WCU
1. A nurse is assessing a patient with a Stage 2 pressure injury. Which characteristic should
the nurse expect to find?
A. Full-thickness skin loss with visible adipose tissue
B. Non-blanchable erythema of intact skin
C. Full-thickness tissue loss with exposed bone or muscle
D. Partial-thickness loss of dermis presenting as a shallow open ulcer with a red-pink
wound bed
Answer: D
Conceptual Explanation: A Stage 2 pressure injury involves partial-thickness loss of the
dermis. Stage 1 is non-blanchable erythema, Stage 3 involves subcutaneous fat, and Stage 4
involves exposed bone/muscle.
,2. When assessing orthostatic hypotension, the nurse finds a patient’s blood pressure drops
from 140/90 mmHg (supine) to 110/70 mmHg (standing). What is the priority nursing action?
A. Encourage the patient to drink more fluids immediately
B. Assist the patient back to a sitting or supine position
C. Document the findings as a normal age-related change
D. Administer a prescribed antihypertensive medication
Answer: B
Conceptual Explanation: The priority is patient safety. A significant drop (20 mmHg
systolic or 10 mmHg diastolic) indicates orthostatic hypotension, which increases fall risk.
Returning the patient to a safe position is the immediate action.
3. The nurse is providing oral care to an unconscious patient. Which position is most
appropriate to prevent aspiration?
A. High-Fowler’s position
B. Side-lying (Sims) position with the head turned toward the side
C. Supine with the head of the bed flat
D. Trendelenburg position
Answer: B
Conceptual Explanation: The side-lying position allows secretions to drain out of the
mouth by gravity rather than being aspirated into the lungs.
, 4. Which assessment finding is an early sign of hypoxia?
A. Cyanosis of the mucous membranes
B. Restlessness and anxiety
C. Bradycardia and bradypnea
D. Clubbing of the fingers
Answer: B
Conceptual Explanation: Restlessness, anxiety, and agitation are early clinical
manifestations of hypoxia. Cyanosis and bradycardia are late signs.
5. A nurse notes a ‘pulse deficit’ while assessing a patient. How is this calculated?
A. The difference between the systolic and diastolic blood pressure
B. The difference between the carotid and femoral pulses
C. The time delay between the S1 and S2 heart sounds
D. The difference between the apical and radial pulse rates
Answer: D
Conceptual Explanation: A pulse deficit occurs when the heart contracts but the pulse
does not reach the periphery. It is calculated by subtracting the radial rate from the apical
rate simultaneously.
6. A patient has a Braden Scale score of 10. How should the nurse interpret this result?
A. The patient is at low risk for pressure injuries
NURSING WEEK 4 COMPREHENSIVE
QUIZ 2026 | WCU
1. A nurse is assessing a patient with a Stage 2 pressure injury. Which characteristic should
the nurse expect to find?
A. Full-thickness skin loss with visible adipose tissue
B. Non-blanchable erythema of intact skin
C. Full-thickness tissue loss with exposed bone or muscle
D. Partial-thickness loss of dermis presenting as a shallow open ulcer with a red-pink
wound bed
Answer: D
Conceptual Explanation: A Stage 2 pressure injury involves partial-thickness loss of the
dermis. Stage 1 is non-blanchable erythema, Stage 3 involves subcutaneous fat, and Stage 4
involves exposed bone/muscle.
,2. When assessing orthostatic hypotension, the nurse finds a patient’s blood pressure drops
from 140/90 mmHg (supine) to 110/70 mmHg (standing). What is the priority nursing action?
A. Encourage the patient to drink more fluids immediately
B. Assist the patient back to a sitting or supine position
C. Document the findings as a normal age-related change
D. Administer a prescribed antihypertensive medication
Answer: B
Conceptual Explanation: The priority is patient safety. A significant drop (20 mmHg
systolic or 10 mmHg diastolic) indicates orthostatic hypotension, which increases fall risk.
Returning the patient to a safe position is the immediate action.
3. The nurse is providing oral care to an unconscious patient. Which position is most
appropriate to prevent aspiration?
A. High-Fowler’s position
B. Side-lying (Sims) position with the head turned toward the side
C. Supine with the head of the bed flat
D. Trendelenburg position
Answer: B
Conceptual Explanation: The side-lying position allows secretions to drain out of the
mouth by gravity rather than being aspirated into the lungs.
, 4. Which assessment finding is an early sign of hypoxia?
A. Cyanosis of the mucous membranes
B. Restlessness and anxiety
C. Bradycardia and bradypnea
D. Clubbing of the fingers
Answer: B
Conceptual Explanation: Restlessness, anxiety, and agitation are early clinical
manifestations of hypoxia. Cyanosis and bradycardia are late signs.
5. A nurse notes a ‘pulse deficit’ while assessing a patient. How is this calculated?
A. The difference between the systolic and diastolic blood pressure
B. The difference between the carotid and femoral pulses
C. The time delay between the S1 and S2 heart sounds
D. The difference between the apical and radial pulse rates
Answer: D
Conceptual Explanation: A pulse deficit occurs when the heart contracts but the pulse
does not reach the periphery. It is calculated by subtracting the radial rate from the apical
rate simultaneously.
6. A patient has a Braden Scale score of 10. How should the nurse interpret this result?
A. The patient is at low risk for pressure injuries
