NUR 158 TEST #3 QUESTIONS AND CORRECT
ANSWERS (VERIFIED ANSWERS) PLUS RATIONALES
Q & A 2026|INSTANT DOWNLOAD PDF
1. A nurse is preparing to perform hand hygiene using alcohol-
based sanitizer. When is this method appropriate?
A. When hands are visibly soiled
B. After caring for a patient with Clostridium difficile
C. Before touching a patient
D. After exposure to blood
Answer: C. Before touching a patient
Rationale: Alcohol-based hand rub is appropriate when hands
are not visibly dirty and before patient contact to reduce
transmission of microorganisms.
2. Which isolation precaution is required for a patient with
pulmonary tuberculosis?
A. Contact precautions
B. Droplet precautions
C. Protective precautions
D. Airborne precautions
Answer: D. Airborne precautions
,Rationale: Tuberculosis spreads through airborne particles, so
the patient must be placed in a negative-pressure room and
staff must wear N95 respirators.
3. The nurse identifies which patient as being at highest risk
for falls?
A. 25-year-old with sprained ankle
B. 40-year-old with mild headache
C. 78-year-old receiving sedatives
D. 50-year-old with controlled hypertension
Answer: C. 78-year-old receiving sedatives
Rationale: Advanced age and sedative medications
significantly increase fall risk due to decreased alertness and
impaired mobility.
4. Which position should a patient be placed in to improve
oxygenation?
A. Supine
B. Sims
C. Fowler’s position
D. Trendelenburg
Answer: C. Fowler’s position
,Rationale: Fowler’s position (semi-sitting) expands lung
capacity and improves breathing by allowing greater lung
expansion.
5. The nurse is administering an intramuscular injection to an
adult. Which site is preferred?
A. Deltoid muscle
B. Ventrogluteal muscle
C. Abdomen
D. Dorsogluteal muscle
Answer: B. Ventrogluteal muscle
Rationale: The ventrogluteal site is safest because it avoids
major nerves and blood vessels.
6. A patient reports pain rated 8/10. What is the nurse’s first
action?
A. Notify the physician
B. Administer prescribed analgesic
C. Reassess in 30 minutes
D. Document the pain score
Answer: B. Administer prescribed analgesic
Rationale: When pain is severe and medication is prescribed,
prompt treatment is required.
, 7. Which vital sign change requires immediate nursing
intervention?
A. Pulse 78 bpm
B. Blood pressure 118/72 mmHg
C. Respiratory rate 30/min
D. Temperature 37°C
Answer: C. Respiratory rate 30/min
Rationale: A respiratory rate of 30/min indicates tachypnea,
which may signal respiratory distress.
8. The nurse is caring for a patient on bed rest. Which
intervention helps prevent pressure ulcers?
A. Repositioning every 2 hours
B. Limiting fluid intake
C. Applying heat to bony areas
D. Using tight bed sheets
Answer: A. Repositioning every 2 hours
Rationale: Regular repositioning relieves pressure on bony
prominences, preventing tissue damage.
9. Which patient statement indicates understanding of
infection prevention?
ANSWERS (VERIFIED ANSWERS) PLUS RATIONALES
Q & A 2026|INSTANT DOWNLOAD PDF
1. A nurse is preparing to perform hand hygiene using alcohol-
based sanitizer. When is this method appropriate?
A. When hands are visibly soiled
B. After caring for a patient with Clostridium difficile
C. Before touching a patient
D. After exposure to blood
Answer: C. Before touching a patient
Rationale: Alcohol-based hand rub is appropriate when hands
are not visibly dirty and before patient contact to reduce
transmission of microorganisms.
2. Which isolation precaution is required for a patient with
pulmonary tuberculosis?
A. Contact precautions
B. Droplet precautions
C. Protective precautions
D. Airborne precautions
Answer: D. Airborne precautions
,Rationale: Tuberculosis spreads through airborne particles, so
the patient must be placed in a negative-pressure room and
staff must wear N95 respirators.
3. The nurse identifies which patient as being at highest risk
for falls?
A. 25-year-old with sprained ankle
B. 40-year-old with mild headache
C. 78-year-old receiving sedatives
D. 50-year-old with controlled hypertension
Answer: C. 78-year-old receiving sedatives
Rationale: Advanced age and sedative medications
significantly increase fall risk due to decreased alertness and
impaired mobility.
4. Which position should a patient be placed in to improve
oxygenation?
A. Supine
B. Sims
C. Fowler’s position
D. Trendelenburg
Answer: C. Fowler’s position
,Rationale: Fowler’s position (semi-sitting) expands lung
capacity and improves breathing by allowing greater lung
expansion.
5. The nurse is administering an intramuscular injection to an
adult. Which site is preferred?
A. Deltoid muscle
B. Ventrogluteal muscle
C. Abdomen
D. Dorsogluteal muscle
Answer: B. Ventrogluteal muscle
Rationale: The ventrogluteal site is safest because it avoids
major nerves and blood vessels.
6. A patient reports pain rated 8/10. What is the nurse’s first
action?
A. Notify the physician
B. Administer prescribed analgesic
C. Reassess in 30 minutes
D. Document the pain score
Answer: B. Administer prescribed analgesic
Rationale: When pain is severe and medication is prescribed,
prompt treatment is required.
, 7. Which vital sign change requires immediate nursing
intervention?
A. Pulse 78 bpm
B. Blood pressure 118/72 mmHg
C. Respiratory rate 30/min
D. Temperature 37°C
Answer: C. Respiratory rate 30/min
Rationale: A respiratory rate of 30/min indicates tachypnea,
which may signal respiratory distress.
8. The nurse is caring for a patient on bed rest. Which
intervention helps prevent pressure ulcers?
A. Repositioning every 2 hours
B. Limiting fluid intake
C. Applying heat to bony areas
D. Using tight bed sheets
Answer: A. Repositioning every 2 hours
Rationale: Regular repositioning relieves pressure on bony
prominences, preventing tissue damage.
9. Which patient statement indicates understanding of
infection prevention?
