NUR 104/NUR104 Exam 2 V2 | Foundations
of Nursing Q&A with Rationale | Fortis
College
1. A nurse is preparing to provide oral care for a client who is unconscious. In which of the
following positions should the nurse place the client?
A. Supine with the head of the bed flat
B. Prone position
C. High-Fowler’s position
D. Lateral (side-lying) position
Correct Answer: D
Expert Explanation: Placing an unconscious client in a lateral position helps prevent
aspiration by allowing saliva or oral secretions to drain out of the mouth. This is a safety
priority because unconscious clients lack a gag reflex and cannot protect their own airway.
The nurse should also have suction equipment readily available during the procedure.
2. The nurse is assessing a pressure injury and finds full-thickness skin loss with visible
subcutaneous fat, but no bone or muscle is exposed. How should this be documented?
A. Stage III
B. Stage II
C. Stage I
,D. Stage IV
Correct Answer: A
Expert Explanation: A Stage III pressure injury involves full-thickness tissue loss where
subcutaneous fat may be visible. Stage II involves partial-thickness loss of the dermis,
whereas Stage IV involves exposed bone, tendon, or muscle. Correct staging is essential for
determining the appropriate wound care interventions and monitoring healing progress.
3. A nurse is caring for a client who has a prescription for a 24-hour urine collection. Which of
the following actions should the nurse take?
A. Save the very first voiding at the start of the 24-hour period
B. Keep the urine at room temperature throughout the day
C. Discard the first voiding and then start the timer
D. Ask the client to void into a clean toilet
Correct Answer: C
Expert Explanation: To begin a 24-hour urine collection, the nurse must have the client
void and discard that first specimen to ensure the collection starts with an empty bladder.
All subsequent urine for the next 24 hours must be collected in the designated container.
The container is typically kept on ice or refrigerated to prevent bacterial growth and
chemical changes.
, 4. Which of the following items should the nurse include in a clear liquid diet for a
postoperative client?
A. Apple juice
B. Vanilla pudding
C. Orange juice with pulp
D. Full-fat milk
Correct Answer: A
Expert Explanation: A clear liquid diet consists of foods that are liquid at room
temperature and transparent. Apple juice, broth, and gelatin are acceptable because they
do not leave residue in the digestive tract. Pudding and milk are part of a full liquid diet,
and pulp is contraindicated in a clear liquid diet.
5. A nurse is caring for a client with Clostridioides difficile (C. diff). Which infection control
precaution is most appropriate?
A. Airborne precautions
B. Droplet precautions
C. Contact precautions
D. Standard precautions only
Correct Answer: C
of Nursing Q&A with Rationale | Fortis
College
1. A nurse is preparing to provide oral care for a client who is unconscious. In which of the
following positions should the nurse place the client?
A. Supine with the head of the bed flat
B. Prone position
C. High-Fowler’s position
D. Lateral (side-lying) position
Correct Answer: D
Expert Explanation: Placing an unconscious client in a lateral position helps prevent
aspiration by allowing saliva or oral secretions to drain out of the mouth. This is a safety
priority because unconscious clients lack a gag reflex and cannot protect their own airway.
The nurse should also have suction equipment readily available during the procedure.
2. The nurse is assessing a pressure injury and finds full-thickness skin loss with visible
subcutaneous fat, but no bone or muscle is exposed. How should this be documented?
A. Stage III
B. Stage II
C. Stage I
,D. Stage IV
Correct Answer: A
Expert Explanation: A Stage III pressure injury involves full-thickness tissue loss where
subcutaneous fat may be visible. Stage II involves partial-thickness loss of the dermis,
whereas Stage IV involves exposed bone, tendon, or muscle. Correct staging is essential for
determining the appropriate wound care interventions and monitoring healing progress.
3. A nurse is caring for a client who has a prescription for a 24-hour urine collection. Which of
the following actions should the nurse take?
A. Save the very first voiding at the start of the 24-hour period
B. Keep the urine at room temperature throughout the day
C. Discard the first voiding and then start the timer
D. Ask the client to void into a clean toilet
Correct Answer: C
Expert Explanation: To begin a 24-hour urine collection, the nurse must have the client
void and discard that first specimen to ensure the collection starts with an empty bladder.
All subsequent urine for the next 24 hours must be collected in the designated container.
The container is typically kept on ice or refrigerated to prevent bacterial growth and
chemical changes.
, 4. Which of the following items should the nurse include in a clear liquid diet for a
postoperative client?
A. Apple juice
B. Vanilla pudding
C. Orange juice with pulp
D. Full-fat milk
Correct Answer: A
Expert Explanation: A clear liquid diet consists of foods that are liquid at room
temperature and transparent. Apple juice, broth, and gelatin are acceptable because they
do not leave residue in the digestive tract. Pudding and milk are part of a full liquid diet,
and pulp is contraindicated in a clear liquid diet.
5. A nurse is caring for a client with Clostridioides difficile (C. diff). Which infection control
precaution is most appropriate?
A. Airborne precautions
B. Droplet precautions
C. Contact precautions
D. Standard precautions only
Correct Answer: C
