Leigh
NUR 155 COMPREHENSIVE ANSWER KEY + RATIONALES (150 QUESTIONS)
COMPLETE NURSING ASSESSMENT EXAM GUIDE
1. B – Hand hygiene
Medical asepsis focuses on reducing microorganisms; hand hygiene before patient contact is
the most effective measure.
2. C – N95 respirator
Airborne precautions require an N95 respirator for diseases spread by small particles (e.g., TB).
3. C – All patients
Standard precautions apply to all patients regardless of diagnosis or infection status.
4. D – Contact
C. difficile is spread by spores and requires contact precautions with gown and gloves.
5. A – UTI 48 hours after admission
Infections that appear ≥48 hours after admission are considered healthcare-associated.
6. B – Gloves
Gloves are the most contaminated item and should be removed first to avoid self-
contamination.
7. C – Full-thickness loss covered by slough/eschar
Unstageable pressure injuries have full-thickness tissue loss obscured by slough/eschar.
8. B – Open blister or shallow ulcer
Stage 2 involves partial-thickness skin loss, often presenting as a blister or shallow open ulcer.
9. B – Hand hygiene
Hand washing or sanitizing is the single most effective measure to prevent infection spread.
10. B – Fluid in alveoli
Crackles usually indicate fluid in the alveoli, commonly seen in heart failure or pneumonia.
11. B – Low-pitched snoring sounds
, Leigh
Rhonchi are low-pitched, snoring or gurgling sounds caused by secretions in large airways.
12. C – Decreased urine output
Decreased urine output is a more reliable indicator of dehydration than dry lips or low-grade
fever.
13. B – “Tell me more about how you’re feeling.”
This open-ended statement encourages expression and is therapeutic.
14. B – “Let’s talk about what’s frightening you.”
This explores the patient’s feelings instead of minimizing them, making it therapeutic.
15. D – Rectal
Rectal temperatures most closely reflect core body temperature and are considered the most
accurate.
16. C – Assess pain characteristics
Assessment always precedes intervention; gather more detail before choosing an intervention.
17. C – BP drops when standing
Orthostatic hypotension is defined by a significant drop in BP (e.g., ≥20 mmHg systolic) upon
standing.
18. C – 83-year-old with confusion
Older adults with confusion are at highest risk for falls due to impaired judgment and balance.
19. C – Alternatives ineffective and safety at risk
Restraints are a last resort used only when necessary to protect the patient and others.
20. B – Check circulation every 2 hours
Restraints require frequent assessment of skin, circulation, and need for continued use.
21. B – High Fowler’s
Elevating the head of bed eases breathing by improving lung expansion.
22. A – Assess respiratory status
NUR 155 COMPREHENSIVE ANSWER KEY + RATIONALES (150 QUESTIONS)
COMPLETE NURSING ASSESSMENT EXAM GUIDE
1. B – Hand hygiene
Medical asepsis focuses on reducing microorganisms; hand hygiene before patient contact is
the most effective measure.
2. C – N95 respirator
Airborne precautions require an N95 respirator for diseases spread by small particles (e.g., TB).
3. C – All patients
Standard precautions apply to all patients regardless of diagnosis or infection status.
4. D – Contact
C. difficile is spread by spores and requires contact precautions with gown and gloves.
5. A – UTI 48 hours after admission
Infections that appear ≥48 hours after admission are considered healthcare-associated.
6. B – Gloves
Gloves are the most contaminated item and should be removed first to avoid self-
contamination.
7. C – Full-thickness loss covered by slough/eschar
Unstageable pressure injuries have full-thickness tissue loss obscured by slough/eschar.
8. B – Open blister or shallow ulcer
Stage 2 involves partial-thickness skin loss, often presenting as a blister or shallow open ulcer.
9. B – Hand hygiene
Hand washing or sanitizing is the single most effective measure to prevent infection spread.
10. B – Fluid in alveoli
Crackles usually indicate fluid in the alveoli, commonly seen in heart failure or pneumonia.
11. B – Low-pitched snoring sounds
, Leigh
Rhonchi are low-pitched, snoring or gurgling sounds caused by secretions in large airways.
12. C – Decreased urine output
Decreased urine output is a more reliable indicator of dehydration than dry lips or low-grade
fever.
13. B – “Tell me more about how you’re feeling.”
This open-ended statement encourages expression and is therapeutic.
14. B – “Let’s talk about what’s frightening you.”
This explores the patient’s feelings instead of minimizing them, making it therapeutic.
15. D – Rectal
Rectal temperatures most closely reflect core body temperature and are considered the most
accurate.
16. C – Assess pain characteristics
Assessment always precedes intervention; gather more detail before choosing an intervention.
17. C – BP drops when standing
Orthostatic hypotension is defined by a significant drop in BP (e.g., ≥20 mmHg systolic) upon
standing.
18. C – 83-year-old with confusion
Older adults with confusion are at highest risk for falls due to impaired judgment and balance.
19. C – Alternatives ineffective and safety at risk
Restraints are a last resort used only when necessary to protect the patient and others.
20. B – Check circulation every 2 hours
Restraints require frequent assessment of skin, circulation, and need for continued use.
21. B – High Fowler’s
Elevating the head of bed eases breathing by improving lung expansion.
22. A – Assess respiratory status
