PNR 106/PNR106 Exam 4 V3 | Foundations
of Nursing Q&A with Rationale | Fortis
College
1. Which muscle is the preferred site for an intramuscular injection in an infant?
A. Deltoid
B. Ventrogluteal
C. Dorsogluteal
D. Vastus lateralis
Correct Answer: D
Expert Explanation: The vastus lateralis is the preferred site for IM injections in infants
because it is the most developed muscle at birth. Avoiding the gluteal sites prevents
potential injury to the sciatic nerve. This standard is critical for pediatric safety in
foundational nursing practice.
2. A nurse is caring for a patient who is on a clear liquid diet. Which item should the nurse
remove from the tray?
A. Apple juice
B. Chicken broth
C. Lemon gelatin
D. Vanilla pudding
,Correct Answer: D
Expert Explanation: Vanilla pudding contains dairy and is considered a full liquid, not a
clear liquid. Clear liquids must be transparent to light and liquid at room temperature.
Providing incorrect dietary items can interfere with diagnostic tests or post-operative
recovery.
3. During a physical assessment, the nurse notes the patient’s heart rate is 115 beats per
minute. How should the nurse document this finding?
A. Bradycardia
B. Tachycardia
C. Eupnea
D. Normal sinus rhythm
Correct Answer: B
Expert Explanation: Tachycardia is defined as a heart rate greater than 100 beats per
minute in an adult. Normal adult heart rates typically range from 60 to 100 bpm. Accurate
documentation of vital sign abnormalities is essential for identifying clinical deterioration.
4. Which ethical principle is the nurse practicing when they respect a patient’s right to refuse
medication?
A. Beneficence
B. Autonomy
, C. Nonmaleficence
D. Justice
Correct Answer: B
Expert Explanation: Autonomy refers to the right of patients to make their own decisions
about their healthcare. Nurses must uphold this principle even when the patient’s choice
conflicts with medical advice. This is a foundational element of the Patient’s Bill of Rights.
5. A nurse discovers a small fire in a patient’s trash can. What is the immediate priority action
according to the RACE acronym?
A. Extinguish the fire
B. Activate the alarm
C. Confine the fire
D. Rescue the patient
Correct Answer: D
Expert Explanation: The RACE acronym stands for Rescue, Alarm, Confine, and
Extinguish. The immediate priority is always to remove the patient from harm’s way before
taking other actions. Safety protocols ensure that human life is protected first during
emergencies.
6. What is the correct procedure for performing hand hygiene with an alcohol-based rub?
A. Rinse hands with warm water after rubbing
of Nursing Q&A with Rationale | Fortis
College
1. Which muscle is the preferred site for an intramuscular injection in an infant?
A. Deltoid
B. Ventrogluteal
C. Dorsogluteal
D. Vastus lateralis
Correct Answer: D
Expert Explanation: The vastus lateralis is the preferred site for IM injections in infants
because it is the most developed muscle at birth. Avoiding the gluteal sites prevents
potential injury to the sciatic nerve. This standard is critical for pediatric safety in
foundational nursing practice.
2. A nurse is caring for a patient who is on a clear liquid diet. Which item should the nurse
remove from the tray?
A. Apple juice
B. Chicken broth
C. Lemon gelatin
D. Vanilla pudding
,Correct Answer: D
Expert Explanation: Vanilla pudding contains dairy and is considered a full liquid, not a
clear liquid. Clear liquids must be transparent to light and liquid at room temperature.
Providing incorrect dietary items can interfere with diagnostic tests or post-operative
recovery.
3. During a physical assessment, the nurse notes the patient’s heart rate is 115 beats per
minute. How should the nurse document this finding?
A. Bradycardia
B. Tachycardia
C. Eupnea
D. Normal sinus rhythm
Correct Answer: B
Expert Explanation: Tachycardia is defined as a heart rate greater than 100 beats per
minute in an adult. Normal adult heart rates typically range from 60 to 100 bpm. Accurate
documentation of vital sign abnormalities is essential for identifying clinical deterioration.
4. Which ethical principle is the nurse practicing when they respect a patient’s right to refuse
medication?
A. Beneficence
B. Autonomy
, C. Nonmaleficence
D. Justice
Correct Answer: B
Expert Explanation: Autonomy refers to the right of patients to make their own decisions
about their healthcare. Nurses must uphold this principle even when the patient’s choice
conflicts with medical advice. This is a foundational element of the Patient’s Bill of Rights.
5. A nurse discovers a small fire in a patient’s trash can. What is the immediate priority action
according to the RACE acronym?
A. Extinguish the fire
B. Activate the alarm
C. Confine the fire
D. Rescue the patient
Correct Answer: D
Expert Explanation: The RACE acronym stands for Rescue, Alarm, Confine, and
Extinguish. The immediate priority is always to remove the patient from harm’s way before
taking other actions. Safety protocols ensure that human life is protected first during
emergencies.
6. What is the correct procedure for performing hand hygiene with an alcohol-based rub?
A. Rinse hands with warm water after rubbing
