NUR 104/NUR104 Exam 3 V1 | Foundations
of Nursing Q&A with Rationale | Fortis
College
1. A nurse is assessing a patient with a pressure injury that shows full-thickness skin loss with
visible subcutaneous fat, but no bone or muscle is exposed. How should the nurse document
this stage?
A. Stage 1
B. Stage 2
C. Stage 3
D. Stage 4
Correct Answer: C
Expert Explanation: Stage 3 pressure injuries involve full-thickness skin loss where
adipose tissue is visible in the ulcer. Granulation tissue and epibole (rolled wound edges)
are often present at this stage. Slough or eschar may be visible but does not obscure the
depth of tissue loss.
2. Which clinical manifestation should a nurse prioritize when monitoring a patient with a
potassium level of 6.2 mEq/L?
A. Increased thirst
B. Polyuria
,C. Cardiac dysrhythmias
D. Hyperactive bowel sounds
Correct Answer: C
Expert Explanation: Hyperkalemia, defined as a potassium level above 5.0 mEq/L, poses a
significant risk for life-threatening cardiac arrhythmias. The nurse must prioritize ECG
monitoring to detect peaked T-waves or widened QRS complexes. Immediate intervention
is required to prevent cardiac arrest in these patients.
3. A nurse is teaching a postoperative patient about the use of an incentive spirometer.
Which instruction is correct?
A. Exhale forcefully into the device
B. Use the device only once every 4 hours
C. Inhale slowly and deeply through the mouthpiece
D. Lie flat while using the spirometer
Correct Answer: C
Expert Explanation: Incentive spirometry is designed to promote deep breathing and
prevent atelectasis by encouraging slow, sustained inspiration. Patients should be
instructed to hold their breath for 3 to 5 seconds at the peak of inspiration. The
recommended frequency is usually 5 to 10 breaths every hour while awake.
, 4. A patient is diagnosed with a fluid volume deficit. Which of the following assessment
findings should the nurse expect?
A. Distended neck veins
B. Bradycardia
C. Decreased skin turgor
D. Hypertension
Correct Answer: C
Expert Explanation: Fluid volume deficit, or dehydration, leads to a loss of skin elasticity,
resulting in poor skin turgor or ‘tenting.’ Other common signs include tachycardia,
hypotension, and dry mucous membranes. The nurse should also monitor for decreased
urine output and increased urine specific gravity.
5. A nurse is caring for a patient who has a Jackson-Pratt (JP) drain. Which action is essential
for maintaining the suction?
A. Keeping the drain above the level of the wound
B. Leaving the cap open to air
C. Compressing the bulb after emptying
D. Ensuring the tubing has a dependent loop
Correct Answer: C
of Nursing Q&A with Rationale | Fortis
College
1. A nurse is assessing a patient with a pressure injury that shows full-thickness skin loss with
visible subcutaneous fat, but no bone or muscle is exposed. How should the nurse document
this stage?
A. Stage 1
B. Stage 2
C. Stage 3
D. Stage 4
Correct Answer: C
Expert Explanation: Stage 3 pressure injuries involve full-thickness skin loss where
adipose tissue is visible in the ulcer. Granulation tissue and epibole (rolled wound edges)
are often present at this stage. Slough or eschar may be visible but does not obscure the
depth of tissue loss.
2. Which clinical manifestation should a nurse prioritize when monitoring a patient with a
potassium level of 6.2 mEq/L?
A. Increased thirst
B. Polyuria
,C. Cardiac dysrhythmias
D. Hyperactive bowel sounds
Correct Answer: C
Expert Explanation: Hyperkalemia, defined as a potassium level above 5.0 mEq/L, poses a
significant risk for life-threatening cardiac arrhythmias. The nurse must prioritize ECG
monitoring to detect peaked T-waves or widened QRS complexes. Immediate intervention
is required to prevent cardiac arrest in these patients.
3. A nurse is teaching a postoperative patient about the use of an incentive spirometer.
Which instruction is correct?
A. Exhale forcefully into the device
B. Use the device only once every 4 hours
C. Inhale slowly and deeply through the mouthpiece
D. Lie flat while using the spirometer
Correct Answer: C
Expert Explanation: Incentive spirometry is designed to promote deep breathing and
prevent atelectasis by encouraging slow, sustained inspiration. Patients should be
instructed to hold their breath for 3 to 5 seconds at the peak of inspiration. The
recommended frequency is usually 5 to 10 breaths every hour while awake.
, 4. A patient is diagnosed with a fluid volume deficit. Which of the following assessment
findings should the nurse expect?
A. Distended neck veins
B. Bradycardia
C. Decreased skin turgor
D. Hypertension
Correct Answer: C
Expert Explanation: Fluid volume deficit, or dehydration, leads to a loss of skin elasticity,
resulting in poor skin turgor or ‘tenting.’ Other common signs include tachycardia,
hypotension, and dry mucous membranes. The nurse should also monitor for decreased
urine output and increased urine specific gravity.
5. A nurse is caring for a patient who has a Jackson-Pratt (JP) drain. Which action is essential
for maintaining the suction?
A. Keeping the drain above the level of the wound
B. Leaving the cap open to air
C. Compressing the bulb after emptying
D. Ensuring the tubing has a dependent loop
Correct Answer: C
