NUR 155 Exam 4 V2 | NUR 155
Foundations of Nursing | Q&A with
Rationale (NUR155 Exam 4) | Galen
College of Nursing
1. A nurse is documenting a patient’s progress using the SOAP format. Where should the
nurse record the patient’s statement, ‘I feel like I can’t catch my breath’?
A. Assessment
B. Objective
C. Subjective
D. Plan
Answer: C
Rationale: Subjective data consists of information provided by the patient that cannot be
measured by the nurse. The patient’s verbal expression of shortness of breath is a primary
source of subjective data. In the SOAP format, the ‘S’ stands for subjective, which is the
appropriate section for direct patient quotes regarding their symptoms.
2. When using the SBAR communication tool, which information does the nurse provide
during the ‘Background’ phase?
A. The immediate problem or reason for the call
B. Specific suggestions for patient care
,C. The nurse’s assessment of the current situation
D. The patient’s admitting diagnosis and medical history
Answer: D
Rationale: The Background portion of SBAR provides relevant clinical data related to the
current situation, such as the admission diagnosis and past history. This section helps the
receiver understand the context of the patient’s condition. It follows the Situation and
precedes the Assessment and Recommendation phases.
3. A nurse discovers a fire in a patient’s room. According to the RACE acronym, which action
should the nurse take first?
A. Activate the fire alarm
B. Confine the fire by closing doors
C. Extinguish the fire using a portable extinguisher
D. Rescue and remove the patient from immediate danger
Answer: D
Rationale: The RACE acronym stands for Rescue, Alarm, Confine, and Extinguish. The
priority is always the safety of the patient, so rescuing them from the immediate area of
danger is the first step. Once the patient is safe, the nurse then proceeds to activate the
alarm and contain the fire.
, 4. An older adult patient is at high risk for falls. Which nursing intervention is the most
effective for preventing falls in the hospital setting?
A. Placing the bed in the lowest position with wheels locked
B. Keeping all four side rails in the upright position
C. Applying a vest restraint during the night
D. Instructing the patient to wait for help before getting up
Answer: A
Rationale: Placing the bed in the lowest position minimizes the distance to the floor if a fall
occurs, and locking the wheels prevents the bed from moving during transfers. Using four
side rails is often considered a form of restraint and can increase the risk of injury if the
patient tries to climb over them. Providing a safe environment with a low, locked bed is a
standard evidence-based fall prevention strategy.
5. Which type of documentation entry is used to record a sudden change in a patient’s
condition and the nursing actions taken in response?
A. Flow sheet
B. Acuity record
C. Kardex
D. Narrative note
Answer: D
Foundations of Nursing | Q&A with
Rationale (NUR155 Exam 4) | Galen
College of Nursing
1. A nurse is documenting a patient’s progress using the SOAP format. Where should the
nurse record the patient’s statement, ‘I feel like I can’t catch my breath’?
A. Assessment
B. Objective
C. Subjective
D. Plan
Answer: C
Rationale: Subjective data consists of information provided by the patient that cannot be
measured by the nurse. The patient’s verbal expression of shortness of breath is a primary
source of subjective data. In the SOAP format, the ‘S’ stands for subjective, which is the
appropriate section for direct patient quotes regarding their symptoms.
2. When using the SBAR communication tool, which information does the nurse provide
during the ‘Background’ phase?
A. The immediate problem or reason for the call
B. Specific suggestions for patient care
,C. The nurse’s assessment of the current situation
D. The patient’s admitting diagnosis and medical history
Answer: D
Rationale: The Background portion of SBAR provides relevant clinical data related to the
current situation, such as the admission diagnosis and past history. This section helps the
receiver understand the context of the patient’s condition. It follows the Situation and
precedes the Assessment and Recommendation phases.
3. A nurse discovers a fire in a patient’s room. According to the RACE acronym, which action
should the nurse take first?
A. Activate the fire alarm
B. Confine the fire by closing doors
C. Extinguish the fire using a portable extinguisher
D. Rescue and remove the patient from immediate danger
Answer: D
Rationale: The RACE acronym stands for Rescue, Alarm, Confine, and Extinguish. The
priority is always the safety of the patient, so rescuing them from the immediate area of
danger is the first step. Once the patient is safe, the nurse then proceeds to activate the
alarm and contain the fire.
, 4. An older adult patient is at high risk for falls. Which nursing intervention is the most
effective for preventing falls in the hospital setting?
A. Placing the bed in the lowest position with wheels locked
B. Keeping all four side rails in the upright position
C. Applying a vest restraint during the night
D. Instructing the patient to wait for help before getting up
Answer: A
Rationale: Placing the bed in the lowest position minimizes the distance to the floor if a fall
occurs, and locking the wheels prevents the bed from moving during transfers. Using four
side rails is often considered a form of restraint and can increase the risk of injury if the
patient tries to climb over them. Providing a safe environment with a low, locked bed is a
standard evidence-based fall prevention strategy.
5. Which type of documentation entry is used to record a sudden change in a patient’s
condition and the nursing actions taken in response?
A. Flow sheet
B. Acuity record
C. Kardex
D. Narrative note
Answer: D
