NUR 104/NUR104 Exam 3 V3 | Foundations
of Nursing Q&A with Rationale | Fortis
College
1. A nurse is caring for a patient who is at high risk for skin breakdown. Which of the
following assessment tools is most appropriate for the nurse to utilize?
A. Braden Scale
B. Glasgow Coma Scale
C. Morse Fall Scale
D. FLACC Scale
Correct Answer: A
Expert Explanation: The Braden Scale is a validated tool specifically used to assess a
patient’s risk for developing pressure injuries by evaluating factors like sensory perception,
moisture, activity, mobility, nutrition, and friction/shear. Scoring helps determine the level
of nursing intervention required to prevent skin compromise. Other scales like Morse focus
on falls, Glasgow on neurological status, and FLACC on pain in non-verbal patients.
2. While preparing to perform sterile wound irrigation, the nurse accidentally touches the
inner surface of the sterile glove with their bare hand. What is the priority action?
A. Wipe the glove with an alcohol swab
B. Continue the procedure to save time
,C. Apply another pair of clean gloves over the contaminated ones
D. Discard the gloves and obtain a new sterile pair
Correct Answer: D
Expert Explanation: Once a sterile object or surface is touched by a non-sterile object, it is
considered contaminated and cannot be used. Maintaining surgical asepsis is critical for
wound care to prevent the introduction of pathogens and subsequent infection. The nurse
must immediately discard the contaminated gloves and start the donning process over with
a fresh sterile kit.
3. A nurse is teaching a patient about using a incentive spirometer. Which instruction should
the nurse include in the teaching?
A. Exhale forcefully into the device
B. Hold your breath for at least 30 seconds after inhalation
C. Use the device only once every 8 hours
D. Inhale slowly and deeply through the mouthpiece
Correct Answer: D
Expert Explanation: The purpose of an incentive spirometer is to promote deep breathing
and prevent atelectasis by encouraging the patient to take slow, deep inspirations. The
patient should seal their lips around the mouthpiece and inhale until the target volume is
reached, then hold their breath for 3 to 5 seconds. This exercise helps expand the alveoli
and improves lung ventilation, especially after surgery.
, 4. Which of the following is the most effective way for a nurse to prevent the spread of
healthcare-associated infections (HAIs)?
A. Wearing a mask for every patient interaction
B. Administering prophylactic antibiotics to all patients
C. Performing frequent and thorough hand hygiene
D. Keeping all patient room doors closed at all times
Correct Answer: C
Expert Explanation: Hand hygiene is universally recognized as the single most important
practice to reduce the transmission of infectious agents in clinical settings. Nurses must
wash hands or use alcohol-based rubs before and after patient contact and after removing
gloves. This simple intervention significantly lowers the incidence of cross-contamination
between patients and staff.
5. A nurse finds a fire in a patient’s trash can. According to the RACE acronym, which action
should the nurse take first?
A. Activate the fire alarm
B. Extinguish the fire
C. Confine the fire by closing doors
D. Rescue the patient from immediate danger
Correct Answer: D
of Nursing Q&A with Rationale | Fortis
College
1. A nurse is caring for a patient who is at high risk for skin breakdown. Which of the
following assessment tools is most appropriate for the nurse to utilize?
A. Braden Scale
B. Glasgow Coma Scale
C. Morse Fall Scale
D. FLACC Scale
Correct Answer: A
Expert Explanation: The Braden Scale is a validated tool specifically used to assess a
patient’s risk for developing pressure injuries by evaluating factors like sensory perception,
moisture, activity, mobility, nutrition, and friction/shear. Scoring helps determine the level
of nursing intervention required to prevent skin compromise. Other scales like Morse focus
on falls, Glasgow on neurological status, and FLACC on pain in non-verbal patients.
2. While preparing to perform sterile wound irrigation, the nurse accidentally touches the
inner surface of the sterile glove with their bare hand. What is the priority action?
A. Wipe the glove with an alcohol swab
B. Continue the procedure to save time
,C. Apply another pair of clean gloves over the contaminated ones
D. Discard the gloves and obtain a new sterile pair
Correct Answer: D
Expert Explanation: Once a sterile object or surface is touched by a non-sterile object, it is
considered contaminated and cannot be used. Maintaining surgical asepsis is critical for
wound care to prevent the introduction of pathogens and subsequent infection. The nurse
must immediately discard the contaminated gloves and start the donning process over with
a fresh sterile kit.
3. A nurse is teaching a patient about using a incentive spirometer. Which instruction should
the nurse include in the teaching?
A. Exhale forcefully into the device
B. Hold your breath for at least 30 seconds after inhalation
C. Use the device only once every 8 hours
D. Inhale slowly and deeply through the mouthpiece
Correct Answer: D
Expert Explanation: The purpose of an incentive spirometer is to promote deep breathing
and prevent atelectasis by encouraging the patient to take slow, deep inspirations. The
patient should seal their lips around the mouthpiece and inhale until the target volume is
reached, then hold their breath for 3 to 5 seconds. This exercise helps expand the alveoli
and improves lung ventilation, especially after surgery.
, 4. Which of the following is the most effective way for a nurse to prevent the spread of
healthcare-associated infections (HAIs)?
A. Wearing a mask for every patient interaction
B. Administering prophylactic antibiotics to all patients
C. Performing frequent and thorough hand hygiene
D. Keeping all patient room doors closed at all times
Correct Answer: C
Expert Explanation: Hand hygiene is universally recognized as the single most important
practice to reduce the transmission of infectious agents in clinical settings. Nurses must
wash hands or use alcohol-based rubs before and after patient contact and after removing
gloves. This simple intervention significantly lowers the incidence of cross-contamination
between patients and staff.
5. A nurse finds a fire in a patient’s trash can. According to the RACE acronym, which action
should the nurse take first?
A. Activate the fire alarm
B. Extinguish the fire
C. Confine the fire by closing doors
D. Rescue the patient from immediate danger
Correct Answer: D
