NUR2115/NUR 2115 Exam 3 V2 |
Fundamentals of Professional
Nursing Q&A with Rationale |
Rasmussen University
1. When preparing to administer a new medication, which of the following is the first priority
for the nurse?
A. Verifying the patient’s identity using two unique identifiers.
B. Checking the expiration date on the medication packaging.
C. Documenting the administration in the electronic health record.
D. Assess the patient’s knowledge regarding the medication purpose.
Correct Answer: A
Expert Explanation: The nurse must first ensure the medication is being given to the
correct individual by verifying two identifiers such as name and date of birth. This action is
the fundamental step in the six rights of medication administration to prevent medical
errors. Following this protocol strictly ensures patient safety and adheres to hospital policy
standards.
2. A nurse is caring for a patient with a Stage 2 pressure injury. How should this wound be
characterized?
A. Non-blanchable erythema of intact skin over a bony prominence.
,B. Full-thickness tissue loss with visible subcutaneous fat.
C. Partial-thickness loss of dermis presenting as a shallow open ulcer.
D. Full-thickness tissue loss with exposed bone, tendon, or muscle.
Correct Answer: C
Expert Explanation: Stage 2 pressure injuries involve partial-thickness loss of the skin
layers and often look like an abrasion or a shallow crater. It is important to distinguish this
from Stage 1, which involves intact skin, or Stage 3, which goes deeper into the fat. Proper
staging allows for the selection of appropriate wound care dressings to promote healing.
3. What is the primary purpose of the ‘R’ in the RACE acronym for fire safety?
A. Run to the nearest exit as quickly as possible.
B. Relocate all medical equipment to a safe storage zone.
C. Report the fire to the local fire department immediately.
D. Rescue anyone in immediate danger from the fire.
Correct Answer: D
Expert Explanation: The RACE acronym stands for Rescue, Alarm, Confine, and
Extinguish/Evacuate. The first priority in a fire situation is to rescue patients and staff who
are in immediate danger. This sequence ensures that human life is prioritized before
property or notification systems are addressed.
, 4. The nurse is performing a physical assessment on a patient and notes a heart rate of 115
beats per minute. How is this documented?
A. Bradycardia
B. Pulse Deficit
C. Normal Sinus Rhythm
D. Tachycardia
Correct Answer: D
Expert Explanation: A heart rate greater than 100 beats per minute in an adult is clinically
defined as tachycardia. The nurse must assess the patient for underlying causes such as
pain, fever, or dehydration. Documenting this accurately is vital for the healthcare team to
monitor changes in the patient’s hemodynamic status.
5. A patient is on a clear liquid diet. Which item is appropriate for the nurse to provide?
A. Apple juice
B. Vanilla pudding
C. Orange juice with pulp
D. Cream of mushroom soup
Correct Answer: A
Expert Explanation: Apple juice is considered a clear liquid because it is translucent and
leaves no residue in the gastrointestinal tract. Clear liquid diets are often prescribed before
Fundamentals of Professional
Nursing Q&A with Rationale |
Rasmussen University
1. When preparing to administer a new medication, which of the following is the first priority
for the nurse?
A. Verifying the patient’s identity using two unique identifiers.
B. Checking the expiration date on the medication packaging.
C. Documenting the administration in the electronic health record.
D. Assess the patient’s knowledge regarding the medication purpose.
Correct Answer: A
Expert Explanation: The nurse must first ensure the medication is being given to the
correct individual by verifying two identifiers such as name and date of birth. This action is
the fundamental step in the six rights of medication administration to prevent medical
errors. Following this protocol strictly ensures patient safety and adheres to hospital policy
standards.
2. A nurse is caring for a patient with a Stage 2 pressure injury. How should this wound be
characterized?
A. Non-blanchable erythema of intact skin over a bony prominence.
,B. Full-thickness tissue loss with visible subcutaneous fat.
C. Partial-thickness loss of dermis presenting as a shallow open ulcer.
D. Full-thickness tissue loss with exposed bone, tendon, or muscle.
Correct Answer: C
Expert Explanation: Stage 2 pressure injuries involve partial-thickness loss of the skin
layers and often look like an abrasion or a shallow crater. It is important to distinguish this
from Stage 1, which involves intact skin, or Stage 3, which goes deeper into the fat. Proper
staging allows for the selection of appropriate wound care dressings to promote healing.
3. What is the primary purpose of the ‘R’ in the RACE acronym for fire safety?
A. Run to the nearest exit as quickly as possible.
B. Relocate all medical equipment to a safe storage zone.
C. Report the fire to the local fire department immediately.
D. Rescue anyone in immediate danger from the fire.
Correct Answer: D
Expert Explanation: The RACE acronym stands for Rescue, Alarm, Confine, and
Extinguish/Evacuate. The first priority in a fire situation is to rescue patients and staff who
are in immediate danger. This sequence ensures that human life is prioritized before
property or notification systems are addressed.
, 4. The nurse is performing a physical assessment on a patient and notes a heart rate of 115
beats per minute. How is this documented?
A. Bradycardia
B. Pulse Deficit
C. Normal Sinus Rhythm
D. Tachycardia
Correct Answer: D
Expert Explanation: A heart rate greater than 100 beats per minute in an adult is clinically
defined as tachycardia. The nurse must assess the patient for underlying causes such as
pain, fever, or dehydration. Documenting this accurately is vital for the healthcare team to
monitor changes in the patient’s hemodynamic status.
5. A patient is on a clear liquid diet. Which item is appropriate for the nurse to provide?
A. Apple juice
B. Vanilla pudding
C. Orange juice with pulp
D. Cream of mushroom soup
Correct Answer: A
Expert Explanation: Apple juice is considered a clear liquid because it is translucent and
leaves no residue in the gastrointestinal tract. Clear liquid diets are often prescribed before
