PNR 106/PNR106 Exam 3 V1 | Foundations
of Nursing Q&A with Rationale | Fortis
College
1. A nurse is preparing to administer a subcutaneous injection to a client. At which angle
should the nurse insert the needle if the nurse can grasp 2 inches of skin?
A. 15 degrees
B. 90 degrees
C. 45 degrees
D. 30 degrees
Correct Answer: B
Expert Explanation: When the nurse can grasp 2 inches (5 cm) of tissue, the needle should
be inserted at a 90-degree angle to reach the subcutaneous tissue. If only 1 inch of tissue
can be grasped, a 45-degree angle is appropriate to avoid intramuscular penetration. This
technique ensures medication is delivered to the correct anatomical layer for proper
absorption.
2. Which of the following actions is the highest priority for a nurse when a client is receiving
an intermittent enteral feeding via a nasogastric tube?
A. Check the residual volume before the feeding.
B. Flush the tube with 30 mL of water after the feeding.
,C. Verify the placement of the tube by pH testing or X-ray.
D. Warm the formula to room temperature.
Correct Answer: C
Expert Explanation: Verifying tube placement is the most critical safety step to prevent
pulmonary aspiration of the formula. Radiographic confirmation is the gold standard, while
pH testing of aspirate is a common bedside method. Failure to ensure correct placement
can lead to life-threatening complications for the client.
3. A nurse is caring for a client who has a Stage 2 pressure injury on the sacrum. Which of the
following findings should the nurse expect?
A. Non-blanchable erythema of intact skin.
B. Partial-thickness skin loss with a exposed dermis.
C. Full-thickness skin loss with visible adipose tissue.
D. Full-thickness tissue loss with exposed bone or muscle.
Correct Answer: B
Expert Explanation: A Stage 2 pressure injury involves partial-thickness loss of skin with
exposed dermis, often appearing as a shallow open ulcer or a ruptured blister. Stage 1
involves non-blanchable redness, whereas Stage 3 and 4 involve deeper tissue destruction.
Proper staging is essential for choosing the appropriate wound care interventions.
, 4. While administering a medication, the nurse realizes that the wrong dose was given to the
client. Which of the following actions should the nurse take first?
A. Notify the prescribing provider.
B. Inform the nurse manager of the error.
C. Complete an incident report.
D. Assess the client’s condition and vital signs.
Correct Answer: D
Expert Explanation: The primary concern in any medication error is the safety and well-
being of the client. Assessment must occur immediately to identify any adverse reactions or
changes in the client’s physiological status. Only after the client’s safety is ensured should
the nurse proceed with reporting and documentation protocols.
5. A nurse is providing discharge teaching to a client regarding a low-sodium diet. Which of
the following food choices by the client indicates an understanding of the teaching?
A. Canned vegetable soup.
B. Smoked turkey slices.
C. Fresh steamed broccoli.
D. Pickled cucumbers.
Correct Answer: C
of Nursing Q&A with Rationale | Fortis
College
1. A nurse is preparing to administer a subcutaneous injection to a client. At which angle
should the nurse insert the needle if the nurse can grasp 2 inches of skin?
A. 15 degrees
B. 90 degrees
C. 45 degrees
D. 30 degrees
Correct Answer: B
Expert Explanation: When the nurse can grasp 2 inches (5 cm) of tissue, the needle should
be inserted at a 90-degree angle to reach the subcutaneous tissue. If only 1 inch of tissue
can be grasped, a 45-degree angle is appropriate to avoid intramuscular penetration. This
technique ensures medication is delivered to the correct anatomical layer for proper
absorption.
2. Which of the following actions is the highest priority for a nurse when a client is receiving
an intermittent enteral feeding via a nasogastric tube?
A. Check the residual volume before the feeding.
B. Flush the tube with 30 mL of water after the feeding.
,C. Verify the placement of the tube by pH testing or X-ray.
D. Warm the formula to room temperature.
Correct Answer: C
Expert Explanation: Verifying tube placement is the most critical safety step to prevent
pulmonary aspiration of the formula. Radiographic confirmation is the gold standard, while
pH testing of aspirate is a common bedside method. Failure to ensure correct placement
can lead to life-threatening complications for the client.
3. A nurse is caring for a client who has a Stage 2 pressure injury on the sacrum. Which of the
following findings should the nurse expect?
A. Non-blanchable erythema of intact skin.
B. Partial-thickness skin loss with a exposed dermis.
C. Full-thickness skin loss with visible adipose tissue.
D. Full-thickness tissue loss with exposed bone or muscle.
Correct Answer: B
Expert Explanation: A Stage 2 pressure injury involves partial-thickness loss of skin with
exposed dermis, often appearing as a shallow open ulcer or a ruptured blister. Stage 1
involves non-blanchable redness, whereas Stage 3 and 4 involve deeper tissue destruction.
Proper staging is essential for choosing the appropriate wound care interventions.
, 4. While administering a medication, the nurse realizes that the wrong dose was given to the
client. Which of the following actions should the nurse take first?
A. Notify the prescribing provider.
B. Inform the nurse manager of the error.
C. Complete an incident report.
D. Assess the client’s condition and vital signs.
Correct Answer: D
Expert Explanation: The primary concern in any medication error is the safety and well-
being of the client. Assessment must occur immediately to identify any adverse reactions or
changes in the client’s physiological status. Only after the client’s safety is ensured should
the nurse proceed with reporting and documentation protocols.
5. A nurse is providing discharge teaching to a client regarding a low-sodium diet. Which of
the following food choices by the client indicates an understanding of the teaching?
A. Canned vegetable soup.
B. Smoked turkey slices.
C. Fresh steamed broccoli.
D. Pickled cucumbers.
Correct Answer: C
