Galen College of Nursing NUR 155 Exam 2 Practice Questions
on Safety, Mobility, Skin Integrity, and Pain Management with
Answers and Rationales
Question 1
The nurse is caring for an older adult patient who is at high risk for falls. Which intervention is
the priority?
A. Keep all four side rails raised at all times
B. Place the call light within reach and keep the bed in the lowest position
C. Encourage the patient to walk independently
D. Apply wrist restraints during the night
Correct Answer: B
Rationale:
B is correct because fall prevention begins with safe environmental measures such as low bed
position and easy access to the call light.
A is incorrect because raising all four side rails may be considered a restraint and can increase
injury risk.
C is incorrect because high-risk patients should not ambulate independently without assessment.
D is incorrect because restraints are not the first intervention.
Question 2
The nurse is caring for a confused patient who keeps attempting to get out of bed. Which action
should the nurse take first?
A. Apply bilateral wrist restraints
B. Request a sedative medication
C. Use a bed alarm and frequent rounding
D. Move the patient to a private room alone
Correct Answer: C
Rationale:
C is correct because least restrictive interventions such as bed alarms and frequent observation
should be used first.
A is incorrect because restraints are a last resort.
B is incorrect because sedation is not the first choice.
D is incorrect because isolation may worsen confusion and reduce monitoring.
,Question 3
The nurse is assisting a patient from the bed to a chair. Which action demonstrates proper body
mechanics?
A. Bend at the waist while lifting
B. Keep feet close together for balance
C. Bend at the knees and keep the back straight
D. Twist the spine while turning the patient
Correct Answer: C
Rationale:
C is correct because bending at the knees and keeping the back straight reduces injury risk.
A is incorrect because bending at the waist strains the back.
B is incorrect because a wide base of support improves balance.
D is incorrect because twisting increases injury risk.
Question 4
A nurse is assessing a patient with limited mobility. Which complication of immobility should
the nurse identify as a priority?
A. Improved appetite
B. Pressure injuries
C. Increased bone density
D. Faster wound healing
Correct Answer: B
Rationale:
B is correct because immobility significantly increases the risk for pressure injuries.
A is incorrect because immobility often decreases appetite.
C is incorrect because immobility decreases bone density.
D is incorrect because immobility delays healing.
Question 5
The nurse is caring for a patient with a reddened area on the sacrum that does not blanch. How
should this be documented?
, A. Stage II pressure injury
B. Stage I pressure injury
C. Stage III pressure injury
D. Unstageable pressure injury
Correct Answer: B
Rationale:
B is correct because non-blanchable redness with intact skin indicates Stage I pressure injury.
A involves partial-thickness skin loss.
C involves full-thickness skin loss.
D involves tissue obscured by slough or eschar.
Question 6
A patient has a shallow open ulcer with a red-pink wound bed and no slough. Which stage of
pressure injury is this?
A. Stage I
B. Stage II
C. Stage III
D. Stage IV
Correct Answer: B
Rationale:
B is correct because Stage II involves partial-thickness skin loss with a shallow open ulcer.
A has intact skin only.
C extends into subcutaneous tissue.
D exposes deeper structures like bone or muscle.
Question 7
The nurse is using the Braden Scale. What is the purpose of this tool?
A. Measure pain intensity
B. Assess risk for pressure injuries
C. Evaluate wound drainage
D. Determine level of consciousness
Correct Answer: B
on Safety, Mobility, Skin Integrity, and Pain Management with
Answers and Rationales
Question 1
The nurse is caring for an older adult patient who is at high risk for falls. Which intervention is
the priority?
A. Keep all four side rails raised at all times
B. Place the call light within reach and keep the bed in the lowest position
C. Encourage the patient to walk independently
D. Apply wrist restraints during the night
Correct Answer: B
Rationale:
B is correct because fall prevention begins with safe environmental measures such as low bed
position and easy access to the call light.
A is incorrect because raising all four side rails may be considered a restraint and can increase
injury risk.
C is incorrect because high-risk patients should not ambulate independently without assessment.
D is incorrect because restraints are not the first intervention.
Question 2
The nurse is caring for a confused patient who keeps attempting to get out of bed. Which action
should the nurse take first?
A. Apply bilateral wrist restraints
B. Request a sedative medication
C. Use a bed alarm and frequent rounding
D. Move the patient to a private room alone
Correct Answer: C
Rationale:
C is correct because least restrictive interventions such as bed alarms and frequent observation
should be used first.
A is incorrect because restraints are a last resort.
B is incorrect because sedation is not the first choice.
D is incorrect because isolation may worsen confusion and reduce monitoring.
,Question 3
The nurse is assisting a patient from the bed to a chair. Which action demonstrates proper body
mechanics?
A. Bend at the waist while lifting
B. Keep feet close together for balance
C. Bend at the knees and keep the back straight
D. Twist the spine while turning the patient
Correct Answer: C
Rationale:
C is correct because bending at the knees and keeping the back straight reduces injury risk.
A is incorrect because bending at the waist strains the back.
B is incorrect because a wide base of support improves balance.
D is incorrect because twisting increases injury risk.
Question 4
A nurse is assessing a patient with limited mobility. Which complication of immobility should
the nurse identify as a priority?
A. Improved appetite
B. Pressure injuries
C. Increased bone density
D. Faster wound healing
Correct Answer: B
Rationale:
B is correct because immobility significantly increases the risk for pressure injuries.
A is incorrect because immobility often decreases appetite.
C is incorrect because immobility decreases bone density.
D is incorrect because immobility delays healing.
Question 5
The nurse is caring for a patient with a reddened area on the sacrum that does not blanch. How
should this be documented?
, A. Stage II pressure injury
B. Stage I pressure injury
C. Stage III pressure injury
D. Unstageable pressure injury
Correct Answer: B
Rationale:
B is correct because non-blanchable redness with intact skin indicates Stage I pressure injury.
A involves partial-thickness skin loss.
C involves full-thickness skin loss.
D involves tissue obscured by slough or eschar.
Question 6
A patient has a shallow open ulcer with a red-pink wound bed and no slough. Which stage of
pressure injury is this?
A. Stage I
B. Stage II
C. Stage III
D. Stage IV
Correct Answer: B
Rationale:
B is correct because Stage II involves partial-thickness skin loss with a shallow open ulcer.
A has intact skin only.
C extends into subcutaneous tissue.
D exposes deeper structures like bone or muscle.
Question 7
The nurse is using the Braden Scale. What is the purpose of this tool?
A. Measure pain intensity
B. Assess risk for pressure injuries
C. Evaluate wound drainage
D. Determine level of consciousness
Correct Answer: B
