NSG 300/NSG300 Exam 3 V1 | Foundations
of Nursing Q&A with Rationale | Grand
Canyon University
1. When transferring a patient from a bed to a wheelchair, which action by the nurse best
demonstrates proper body mechanics?
A. Bending at the waist to reach the patient’s arm.
B. Twisting the torso while moving the patient.
C. Flexing the knees and keeping the feet wide apart.
D. Lifting the patient using the small muscles of the back.
Correct Answer: C
Expert Explanation: Proper body mechanics involve using the large muscle groups of the
legs rather than the back. Keeping the feet wide apart provides a stable base of support and
lowers the center of gravity. This practice significantly reduces the risk of work-related
musculoskeletal injuries for the healthcare provider.
2. Which assessment finding is the most reliable indicator of a patient’s risk for developing a
pressure injury?
A. A Braden Scale score of 20.
B. The presence of pink, intact skin.
C. A Braden Scale score of 12.
,D. Patient reporting mild discomfort when sitting.
Correct Answer: C
Expert Explanation: The Braden Scale is a standardized tool used to predict pressure sore
risk based on six subscales. A lower total score indicates a higher risk for developing a
pressure injury, with 12 representing a high risk. Nurses must use this score to implement
targeted preventive interventions such as frequent repositioning.
3. A nurse identifies a wound that has partial-thickness loss of dermis presenting as a shallow
open ulcer with a red-pink wound bed. How should this be staged?
A. Stage 1
B. Stage 4
C. Stage 3
D. Stage 2
Correct Answer: D
Expert Explanation: A Stage 2 pressure injury is characterized by partial-thickness skin
loss involving the epidermis or dermis. It often presents as a shallow open ulcer or a
ruptured/intact serum-filled blister. Unlike Stage 3 or 4, there is no visible adipose tissue
or deeper structures like muscle or bone.
4. A patient’s surgical wound has thick, yellow drainage. How should the nurse document this
finding?
A. Serous drainage
, B. Sanguineous drainage
C. Serosanguineous drainage
D. Purulent drainage
Correct Answer: D
Expert Explanation: Purulent drainage is thick and consists of white blood cells, dead
tissue, and bacteria, often appearing yellow, green, or brown. It is a common sign of
infection in a wound bed and should be reported to the provider immediately.
Documenting the color, odor, and consistency helps track the progression or resolution of
an infection.
5. Which intervention is the priority for a patient who has just experienced wound
evisceration?
A. Apply a tight abdominal binder to hold the wound together.
B. Gently push the protruding organs back into the abdominal cavity.
C. Cover the area with sterile gauze soaked in sterile normal saline.
D. Leave the wound open to air to prevent bacterial trapped moisture.
Correct Answer: C
Expert Explanation: Wound evisceration is a medical emergency where internal organs
protrude through an opened incision. The nurse must immediately cover the exposed
organs with sterile dressings moistened with sterile normal saline to prevent drying and
of Nursing Q&A with Rationale | Grand
Canyon University
1. When transferring a patient from a bed to a wheelchair, which action by the nurse best
demonstrates proper body mechanics?
A. Bending at the waist to reach the patient’s arm.
B. Twisting the torso while moving the patient.
C. Flexing the knees and keeping the feet wide apart.
D. Lifting the patient using the small muscles of the back.
Correct Answer: C
Expert Explanation: Proper body mechanics involve using the large muscle groups of the
legs rather than the back. Keeping the feet wide apart provides a stable base of support and
lowers the center of gravity. This practice significantly reduces the risk of work-related
musculoskeletal injuries for the healthcare provider.
2. Which assessment finding is the most reliable indicator of a patient’s risk for developing a
pressure injury?
A. A Braden Scale score of 20.
B. The presence of pink, intact skin.
C. A Braden Scale score of 12.
,D. Patient reporting mild discomfort when sitting.
Correct Answer: C
Expert Explanation: The Braden Scale is a standardized tool used to predict pressure sore
risk based on six subscales. A lower total score indicates a higher risk for developing a
pressure injury, with 12 representing a high risk. Nurses must use this score to implement
targeted preventive interventions such as frequent repositioning.
3. A nurse identifies a wound that has partial-thickness loss of dermis presenting as a shallow
open ulcer with a red-pink wound bed. How should this be staged?
A. Stage 1
B. Stage 4
C. Stage 3
D. Stage 2
Correct Answer: D
Expert Explanation: A Stage 2 pressure injury is characterized by partial-thickness skin
loss involving the epidermis or dermis. It often presents as a shallow open ulcer or a
ruptured/intact serum-filled blister. Unlike Stage 3 or 4, there is no visible adipose tissue
or deeper structures like muscle or bone.
4. A patient’s surgical wound has thick, yellow drainage. How should the nurse document this
finding?
A. Serous drainage
, B. Sanguineous drainage
C. Serosanguineous drainage
D. Purulent drainage
Correct Answer: D
Expert Explanation: Purulent drainage is thick and consists of white blood cells, dead
tissue, and bacteria, often appearing yellow, green, or brown. It is a common sign of
infection in a wound bed and should be reported to the provider immediately.
Documenting the color, odor, and consistency helps track the progression or resolution of
an infection.
5. Which intervention is the priority for a patient who has just experienced wound
evisceration?
A. Apply a tight abdominal binder to hold the wound together.
B. Gently push the protruding organs back into the abdominal cavity.
C. Cover the area with sterile gauze soaked in sterile normal saline.
D. Leave the wound open to air to prevent bacterial trapped moisture.
Correct Answer: C
Expert Explanation: Wound evisceration is a medical emergency where internal organs
protrude through an opened incision. The nurse must immediately cover the exposed
organs with sterile dressings moistened with sterile normal saline to prevent drying and
