PNR 106/PNR106 Exam 4 V2 | Foundations
of Nursing Q&A with Rationale | Fortis
College
1. A nurse is preparing a client for surgery. The client expresses concern about the procedure.
What is the nurse’s primary role regarding the informed consent process?
A. Explain the risks and benefits of the surgery to the client.
B. Obtain the signature from the next of kin if the client is nervous.
C. Describe alternative treatments available to the client.
D. Witness the client’s signature on the consent form.
Correct Answer: D
Expert Explanation: The nurse acts as a witness to the signature and ensures the client
appears competent to sign. It is the surgeon’s legal responsibility to explain the risks,
benefits, and alternatives of the procedure. If the client does not understand the surgery,
the nurse must notify the surgeon before the consent is signed.
2. A postoperative nurse is monitoring a client who just arrived in the PACU. Which
assessment finding is the highest priority?
A. Pain level of 8 on a 0 to 10 scale.
B. Slight shivering and reports of feeling cold.
C. Hypoactive bowel sounds in all quadrants.
,D. Oxygen saturation of 88% on room air.
Correct Answer: D
Expert Explanation: According to the ABC (Airway, Breathing, Circulation) framework,
respiratory status is always the highest priority. An oxygen saturation of 88% indicates
hypoxia, which requires immediate intervention such as oxygen administration or airway
repositioning. Pain and comfort issues are important but secondary to maintaining
adequate oxygenation.
3. A nurse is assessing a client’s wound and notes the presence of thick, yellow drainage. How
should the nurse document this finding?
A. Serous drainage
B. Purulent drainage
C. Sanguineous drainage
D. Serosanguineous drainage
Correct Answer: B
Expert Explanation: Purulent drainage is thick and consists of white blood cells, dead
tissue, and bacteria, often appearing yellow, green, or brown. This type of drainage is a
clinical sign of infection and requires further assessment. Serous drainage is clear, while
sanguineous is bright red blood.
, 4. Which stage of pressure injury is characterized by full-thickness skin loss with visible
adipose tissue but no exposed bone or muscle?
A. Stage 1
B. Stage 3
C. Stage 2
D. Stage 4
Correct Answer: B
Expert Explanation: A Stage 3 pressure injury involves full-thickness skin loss involving
the subcutaneous tissue. Adipose fat may be visible, but bone, tendon, and muscle are not
yet exposed. Slough or eschar may be present but does not obscure the depth of tissue loss.
5. A client is 48 hours postoperative and has not had a bowel movement. Which intervention
should the nurse implement first to promote peristalsis?
A. Administer a prescribed saline enema.
B. Assist the client with early and frequent ambulation.
C. Encourage the client to increase oral fluid intake.
D. Request a prescription for a stimulant laxative.
Correct Answer: B
Expert Explanation: Early ambulation is one of the most effective non-pharmacological
interventions to stimulate peristalsis and prevent paralytic ileus. It also helps prevent other
of Nursing Q&A with Rationale | Fortis
College
1. A nurse is preparing a client for surgery. The client expresses concern about the procedure.
What is the nurse’s primary role regarding the informed consent process?
A. Explain the risks and benefits of the surgery to the client.
B. Obtain the signature from the next of kin if the client is nervous.
C. Describe alternative treatments available to the client.
D. Witness the client’s signature on the consent form.
Correct Answer: D
Expert Explanation: The nurse acts as a witness to the signature and ensures the client
appears competent to sign. It is the surgeon’s legal responsibility to explain the risks,
benefits, and alternatives of the procedure. If the client does not understand the surgery,
the nurse must notify the surgeon before the consent is signed.
2. A postoperative nurse is monitoring a client who just arrived in the PACU. Which
assessment finding is the highest priority?
A. Pain level of 8 on a 0 to 10 scale.
B. Slight shivering and reports of feeling cold.
C. Hypoactive bowel sounds in all quadrants.
,D. Oxygen saturation of 88% on room air.
Correct Answer: D
Expert Explanation: According to the ABC (Airway, Breathing, Circulation) framework,
respiratory status is always the highest priority. An oxygen saturation of 88% indicates
hypoxia, which requires immediate intervention such as oxygen administration or airway
repositioning. Pain and comfort issues are important but secondary to maintaining
adequate oxygenation.
3. A nurse is assessing a client’s wound and notes the presence of thick, yellow drainage. How
should the nurse document this finding?
A. Serous drainage
B. Purulent drainage
C. Sanguineous drainage
D. Serosanguineous drainage
Correct Answer: B
Expert Explanation: Purulent drainage is thick and consists of white blood cells, dead
tissue, and bacteria, often appearing yellow, green, or brown. This type of drainage is a
clinical sign of infection and requires further assessment. Serous drainage is clear, while
sanguineous is bright red blood.
, 4. Which stage of pressure injury is characterized by full-thickness skin loss with visible
adipose tissue but no exposed bone or muscle?
A. Stage 1
B. Stage 3
C. Stage 2
D. Stage 4
Correct Answer: B
Expert Explanation: A Stage 3 pressure injury involves full-thickness skin loss involving
the subcutaneous tissue. Adipose fat may be visible, but bone, tendon, and muscle are not
yet exposed. Slough or eschar may be present but does not obscure the depth of tissue loss.
5. A client is 48 hours postoperative and has not had a bowel movement. Which intervention
should the nurse implement first to promote peristalsis?
A. Administer a prescribed saline enema.
B. Assist the client with early and frequent ambulation.
C. Encourage the client to increase oral fluid intake.
D. Request a prescription for a stimulant laxative.
Correct Answer: B
Expert Explanation: Early ambulation is one of the most effective non-pharmacological
interventions to stimulate peristalsis and prevent paralytic ileus. It also helps prevent other
