PNR 106/PNR106 Exam 3 V2 | Foundations
of Nursing Q&A with Rationale | Fortis
College
1. A nurse is caring for a patient who reports pain as an 8 on a scale of 0 to 10. The patient is
currently laughing and talking with visitors. Which action should the nurse take?
A. Reassess the pain level after the visitors leave the room.
B. Assume the patient is drug-seeking and notify the physician.
C. Document that the patient appears to be in no acute distress.
D. Administer the prescribed analgesic based on the patient’s report.
Correct Answer: D
Expert Explanation: Pain is a subjective experience and is whatever the person
experiencing it says it is. The patient’s self-report is the most reliable indicator of pain
intensity regardless of behavioral cues. Failing to treat based on physical appearance alone
violates the principles of pain management and patient advocacy.
2. The nurse is explaining the gate control theory of pain to a student nurse. Which
intervention best illustrates this theory?
A. Administering an intravenous opioid medication.
B. Providing a quiet environment for the patient to rest.
C. Explaining the side effects of a prescribed analgesic.
,D. Massaging the patient’s back to stimulate large-diameter nerve fibers.
Correct Answer: D
Expert Explanation: The gate control theory suggests that stimulating large-diameter
sensory fibers can close the ‘gate’ in the spinal cord to pain impulses. Non-pharmacological
interventions like massage or heat/cold application utilize this mechanism to reduce the
perception of pain. This provides the nurse with independent interventions to improve
patient comfort alongside medical treatments.
3. A client is experiencing insomnia and asks the nurse about the function of REM sleep.
Which statement by the nurse is most accurate?
A. REM sleep is primarily for physical restoration and tissue repair.
B. This stage is when the heart rate and respirations significantly decrease.
C. REM sleep is essential for mental and emotional restoration and memory consolidation.
D. It is the lightest stage of sleep from which a person is easily awakened.
Correct Answer: C
Expert Explanation: Rapid Eye Movement (REM) sleep is crucial for cognitive restoration,
learning, and psychological well-being. During this stage, brain activity is high, similar to
wakefulness, which supports memory processing. Lack of REM sleep can lead to irritability,
confusion, and decreased concentration.
, 4. A nurse is caring for a patient who has been prescribed a clear liquid diet. Which item
should the nurse remove from the patient’s meal tray?
A. Apple juice
B. Chicken broth
C. Orange juice with pulp
D. Gelatin
Correct Answer: C
Expert Explanation: A clear liquid diet consists of fluids that are transparent to light and
liquid at room temperature. Orange juice with pulp is considered a full liquid because the
pulp adds residue that is not clear. Proper adherence to this diet is essential for patients
preparing for surgery or transitioning from NPO status.
5. Which clinical manifestation should the nurse expect to find in a patient with a potassium
level of 2.8 mEq/L?
A. Hypertension and bounding pulses
B. Positive Chvostek’s sign and tetany
C. Muscle weakness and cardiac dysrhythmias
D. Hyperreflexia and muscle twitching
Correct Answer: C
of Nursing Q&A with Rationale | Fortis
College
1. A nurse is caring for a patient who reports pain as an 8 on a scale of 0 to 10. The patient is
currently laughing and talking with visitors. Which action should the nurse take?
A. Reassess the pain level after the visitors leave the room.
B. Assume the patient is drug-seeking and notify the physician.
C. Document that the patient appears to be in no acute distress.
D. Administer the prescribed analgesic based on the patient’s report.
Correct Answer: D
Expert Explanation: Pain is a subjective experience and is whatever the person
experiencing it says it is. The patient’s self-report is the most reliable indicator of pain
intensity regardless of behavioral cues. Failing to treat based on physical appearance alone
violates the principles of pain management and patient advocacy.
2. The nurse is explaining the gate control theory of pain to a student nurse. Which
intervention best illustrates this theory?
A. Administering an intravenous opioid medication.
B. Providing a quiet environment for the patient to rest.
C. Explaining the side effects of a prescribed analgesic.
,D. Massaging the patient’s back to stimulate large-diameter nerve fibers.
Correct Answer: D
Expert Explanation: The gate control theory suggests that stimulating large-diameter
sensory fibers can close the ‘gate’ in the spinal cord to pain impulses. Non-pharmacological
interventions like massage or heat/cold application utilize this mechanism to reduce the
perception of pain. This provides the nurse with independent interventions to improve
patient comfort alongside medical treatments.
3. A client is experiencing insomnia and asks the nurse about the function of REM sleep.
Which statement by the nurse is most accurate?
A. REM sleep is primarily for physical restoration and tissue repair.
B. This stage is when the heart rate and respirations significantly decrease.
C. REM sleep is essential for mental and emotional restoration and memory consolidation.
D. It is the lightest stage of sleep from which a person is easily awakened.
Correct Answer: C
Expert Explanation: Rapid Eye Movement (REM) sleep is crucial for cognitive restoration,
learning, and psychological well-being. During this stage, brain activity is high, similar to
wakefulness, which supports memory processing. Lack of REM sleep can lead to irritability,
confusion, and decreased concentration.
, 4. A nurse is caring for a patient who has been prescribed a clear liquid diet. Which item
should the nurse remove from the patient’s meal tray?
A. Apple juice
B. Chicken broth
C. Orange juice with pulp
D. Gelatin
Correct Answer: C
Expert Explanation: A clear liquid diet consists of fluids that are transparent to light and
liquid at room temperature. Orange juice with pulp is considered a full liquid because the
pulp adds residue that is not clear. Proper adherence to this diet is essential for patients
preparing for surgery or transitioning from NPO status.
5. Which clinical manifestation should the nurse expect to find in a patient with a potassium
level of 2.8 mEq/L?
A. Hypertension and bounding pulses
B. Positive Chvostek’s sign and tetany
C. Muscle weakness and cardiac dysrhythmias
D. Hyperreflexia and muscle twitching
Correct Answer: C
