PNR 106/PNR106 Final Exam V3 | Foundations of
Nursing Q&A with Rationale | Fortis College
1. A nurse is performing an admission assessment on a client. Which of the following findings
should the nurse categorize as objective data?
A. Client reports feeling dizzy when standing.
B. Client states their pain level is 7 on a scale of 0 to 10.
C. Client expresses anxiety about the upcoming surgery.
D. Client’s blood pressure is 150/92 mmHg.
Correct Answer: D
Explanation: Objective data are observable and measurable signs obtained through
physical examination and laboratory tests. Blood pressure is a quantifiable measurement
that can be verified by another healthcare professional. Subjective data, such as pain levels
or feelings of dizziness, are based on the client’s personal perceptions and cannot be
directly measured by the nurse.
2. A nurse is caring for a client who is at risk for pressure injuries. Which of the following
interventions should the nurse include in the plan of care?
A. Apply a moisture barrier ointment to the skin of an incontinent client.
B. Reposition the client every 4 hours while they are in bed.
C. Massage reddened bony prominences to improve circulation.
,D. Keep the head of the bed elevated at 45 degrees at all times.
Correct Answer: A
Explanation: Applying a moisture barrier helps protect the skin from breakdown caused
by exposure to urine or feces. Massaging reddened areas is contraindicated as it can cause
further tissue damage to already fragile capillaries. Clients should be repositioned at least
every 2 hours to prevent prolonged pressure on one area, rather than every 4 hours.
3. A nurse is preparing to administer an intramuscular injection to an adult client. Which of
the following sites is the safest for this procedure?
A. Dorsogluteal
B. Deltoid
C. Ventrogluteal
D. Vastus lateralis
Correct Answer: C
Explanation: The ventrogluteal site is considered the safest for intramuscular injections
because it is away from major nerves and blood vessels. The dorsogluteal site is no longer
recommended due to the high risk of injury to the sciatic nerve. While the deltoid and
vastus lateralis are common sites, the ventrogluteal is preferred for larger volumes and
consistency in safety.
, 4. Which step of the nursing process involves comparing the client’s current status with the
established goals?
A. Assessment
B. Evaluation
C. Implementation
D. Diagnosis
Correct Answer: B
Explanation: Evaluation is the final step of the nursing process where the nurse
determines if the client’s goals have been met, partially met, or not met. This step allows
the nurse to decide whether to continue, modify, or terminate the plan of care based on the
client’s progress. Assessment occurs at the beginning, while implementation involves
carrying out the planned nursing actions.
5. A nurse is caring for a client who has a prescription for a clear liquid diet. Which of the
following items should the nurse offer the client?
A. Vanilla pudding
B. Orange juice with pulp
C. Cream of chicken soup
D. Apple juice
Correct Answer: D
Nursing Q&A with Rationale | Fortis College
1. A nurse is performing an admission assessment on a client. Which of the following findings
should the nurse categorize as objective data?
A. Client reports feeling dizzy when standing.
B. Client states their pain level is 7 on a scale of 0 to 10.
C. Client expresses anxiety about the upcoming surgery.
D. Client’s blood pressure is 150/92 mmHg.
Correct Answer: D
Explanation: Objective data are observable and measurable signs obtained through
physical examination and laboratory tests. Blood pressure is a quantifiable measurement
that can be verified by another healthcare professional. Subjective data, such as pain levels
or feelings of dizziness, are based on the client’s personal perceptions and cannot be
directly measured by the nurse.
2. A nurse is caring for a client who is at risk for pressure injuries. Which of the following
interventions should the nurse include in the plan of care?
A. Apply a moisture barrier ointment to the skin of an incontinent client.
B. Reposition the client every 4 hours while they are in bed.
C. Massage reddened bony prominences to improve circulation.
,D. Keep the head of the bed elevated at 45 degrees at all times.
Correct Answer: A
Explanation: Applying a moisture barrier helps protect the skin from breakdown caused
by exposure to urine or feces. Massaging reddened areas is contraindicated as it can cause
further tissue damage to already fragile capillaries. Clients should be repositioned at least
every 2 hours to prevent prolonged pressure on one area, rather than every 4 hours.
3. A nurse is preparing to administer an intramuscular injection to an adult client. Which of
the following sites is the safest for this procedure?
A. Dorsogluteal
B. Deltoid
C. Ventrogluteal
D. Vastus lateralis
Correct Answer: C
Explanation: The ventrogluteal site is considered the safest for intramuscular injections
because it is away from major nerves and blood vessels. The dorsogluteal site is no longer
recommended due to the high risk of injury to the sciatic nerve. While the deltoid and
vastus lateralis are common sites, the ventrogluteal is preferred for larger volumes and
consistency in safety.
, 4. Which step of the nursing process involves comparing the client’s current status with the
established goals?
A. Assessment
B. Evaluation
C. Implementation
D. Diagnosis
Correct Answer: B
Explanation: Evaluation is the final step of the nursing process where the nurse
determines if the client’s goals have been met, partially met, or not met. This step allows
the nurse to decide whether to continue, modify, or terminate the plan of care based on the
client’s progress. Assessment occurs at the beginning, while implementation involves
carrying out the planned nursing actions.
5. A nurse is caring for a client who has a prescription for a clear liquid diet. Which of the
following items should the nurse offer the client?
A. Vanilla pudding
B. Orange juice with pulp
C. Cream of chicken soup
D. Apple juice
Correct Answer: D
