NUR 104/NUR104 Exam 4 V3 | Foundations
of Nursing Q&A with Rationale | Fortis
College
1. A nurse is caring for a client who has a Stage 2 pressure injury on the coccyx. Which of the
following descriptions should the nurse expect to observe?
A. Partial-thickness skin loss with a shallow open ulcer and a red-pink wound bed.
B. Non-blanchable erythema of intact skin.
C. Full-thickness skin loss with visible adipose tissue.
D. Full-thickness tissue loss with exposed bone or muscle.
Correct Answer: A
Expert Explanation: A Stage 2 pressure injury involves partial-thickness loss of the dermis
and presents as a shallow open ulcer. It may also manifest as an intact or ruptured serum-
filled blister. This stage specifically excludes slough, bruising, or deep tissue involvement.
2. A nurse is performing tracheostomy care for a client. Which of the following actions should
the nurse take first?
A. Open the sterile tracheostomy kit.
B. Clean the inner cannula with hydrogen peroxide.
C. Suction the tracheostomy tube for 15 seconds.
,D. Perform hand hygiene and identify the client.
Correct Answer: D
Expert Explanation: Safety and infection control are the primary priorities in any nursing
procedure. Hand hygiene reduces the risk of pathogen transmission before interacting with
the client’s airway. Correct client identification ensures the right procedure is performed
on the right patient according to facility protocol.
3. Which of the following is a late sign of hypoxia that a nurse should monitor for in a client
with respiratory distress?
A. Cyanosis
B. Tachycardia
C. Restlessness
D. Apprehension
Correct Answer: A
Expert Explanation: Cyanosis is a late clinical sign of hypoxia and signifies a significant
decrease in arterial oxygen saturation. Early signs usually include restlessness, anxiety, and
tachycardia as the body attempts to compensate. Recognizing cyanosis requires immediate
intervention as it indicates the compensatory mechanisms are failing.
4. A nurse is teaching a client about the use of an incentive spirometer. Which instruction
should the nurse include?
A. Hold your breath for at least 10 seconds after exhaling.
, B. Exhale forcefully into the device as hard as possible.
C. Use the device once every 4 hours while awake.
D. Inhale slowly and deeply through the mouthpiece.
Correct Answer: D
Expert Explanation: The purpose of the incentive spirometer is to promote lung
expansion and prevent atelectasis by encouraging deep inhalation. The nurse should
instruct the client to inhale slowly and hold their breath for 3 to 5 seconds at the peak of
inspiration. Most protocols recommend using the device 5 to 10 times every hour while
awake.
5. When assessing a surgical wound, the nurse notes the presence of thin, watery, pale red
drainage. How should the nurse document this finding?
A. Serous drainage
B. Serosanguineous drainage
C. Sanguineous drainage
D. Purulent drainage
Correct Answer: B
Expert Explanation: Serosanguineous drainage is a mixture of serum and red blood cells,
resulting in a light pink or watery red appearance. Serous is clear/yellow, while
of Nursing Q&A with Rationale | Fortis
College
1. A nurse is caring for a client who has a Stage 2 pressure injury on the coccyx. Which of the
following descriptions should the nurse expect to observe?
A. Partial-thickness skin loss with a shallow open ulcer and a red-pink wound bed.
B. Non-blanchable erythema of intact skin.
C. Full-thickness skin loss with visible adipose tissue.
D. Full-thickness tissue loss with exposed bone or muscle.
Correct Answer: A
Expert Explanation: A Stage 2 pressure injury involves partial-thickness loss of the dermis
and presents as a shallow open ulcer. It may also manifest as an intact or ruptured serum-
filled blister. This stage specifically excludes slough, bruising, or deep tissue involvement.
2. A nurse is performing tracheostomy care for a client. Which of the following actions should
the nurse take first?
A. Open the sterile tracheostomy kit.
B. Clean the inner cannula with hydrogen peroxide.
C. Suction the tracheostomy tube for 15 seconds.
,D. Perform hand hygiene and identify the client.
Correct Answer: D
Expert Explanation: Safety and infection control are the primary priorities in any nursing
procedure. Hand hygiene reduces the risk of pathogen transmission before interacting with
the client’s airway. Correct client identification ensures the right procedure is performed
on the right patient according to facility protocol.
3. Which of the following is a late sign of hypoxia that a nurse should monitor for in a client
with respiratory distress?
A. Cyanosis
B. Tachycardia
C. Restlessness
D. Apprehension
Correct Answer: A
Expert Explanation: Cyanosis is a late clinical sign of hypoxia and signifies a significant
decrease in arterial oxygen saturation. Early signs usually include restlessness, anxiety, and
tachycardia as the body attempts to compensate. Recognizing cyanosis requires immediate
intervention as it indicates the compensatory mechanisms are failing.
4. A nurse is teaching a client about the use of an incentive spirometer. Which instruction
should the nurse include?
A. Hold your breath for at least 10 seconds after exhaling.
, B. Exhale forcefully into the device as hard as possible.
C. Use the device once every 4 hours while awake.
D. Inhale slowly and deeply through the mouthpiece.
Correct Answer: D
Expert Explanation: The purpose of the incentive spirometer is to promote lung
expansion and prevent atelectasis by encouraging deep inhalation. The nurse should
instruct the client to inhale slowly and hold their breath for 3 to 5 seconds at the peak of
inspiration. Most protocols recommend using the device 5 to 10 times every hour while
awake.
5. When assessing a surgical wound, the nurse notes the presence of thin, watery, pale red
drainage. How should the nurse document this finding?
A. Serous drainage
B. Serosanguineous drainage
C. Sanguineous drainage
D. Purulent drainage
Correct Answer: B
Expert Explanation: Serosanguineous drainage is a mixture of serum and red blood cells,
resulting in a light pink or watery red appearance. Serous is clear/yellow, while
