NUR2115/NUR 2115 Exam 4 V1 |
Fundamentals of Professional
Nursing Q&A with Rationale |
Rasmussen University
1. A nurse is caring for a client who is post-operative and reports difficulty voiding. Which of
the following actions should the nurse take first?
A. Perform a bladder scan.
B. Insert a straight catheter.
C. Encourage increased fluid intake.
D. Apply a cold compress to the suprapubic area.
Correct Answer: A
Expert Explanation: The first step in the nursing process is assessment, and a bladder
scan is a non-invasive way to determine the volume of urine in the bladder. This data helps
the nurse decide if the issue is urinary retention or a lack of urine production. By obtaining
this information first, the nurse can provide a more accurate report to the provider and
avoid unnecessary invasive procedures.
2. Which clinical manifestation is a nurse most likely to observe in a client experiencing acute
hypoxia?
A. Tachycardia
,B. Bradypnea
C. Cyanosis
D. Clubbing of the fingers
Correct Answer: A
Expert Explanation: In the early stages of hypoxia, the body attempts to compensate for
low oxygen levels by increasing the heart rate to circulate what oxygen is available more
quickly. Tachycardia is often accompanied by restlessness and elevated blood pressure.
Cyanosis and clubbing are typically late signs of respiratory distress or indicators of
chronic hypoxemia rather than acute early onset.
3. A client has a prescription for a clear liquid diet. Which of the following items should the
nurse include on the client’s tray?
A. Orange juice with pulp
B. Apple juice
C. Vanilla pudding
D. Tomato soup
Correct Answer: B
Expert Explanation: Apple juice is considered a clear liquid because it is transparent and
liquid at room temperature. Clear liquid diets are often used before or after surgery to
minimize strain on the digestive system while providing hydration. Items like pudding and
, tomato soup are considered part of a full liquid diet because they are opaque and contain
dairy or more complex solids.
4. A nurse is teaching a client about performing range-of-motion (ROM) exercises. What is the
primary purpose of these exercises?
A. To increase muscle mass and strength.
B. To reduce the risk of skin breakdown.
C. To improve cardiovascular endurance.
D. To prevent joint contractures and maintain flexibility.
Correct Answer: D
Expert Explanation: Range-of-motion exercises are designed to move joints through their
full functional range to prevent stiffness and permanent shortening of the muscles, known
as contractures. While movement helps circulation, the primary focus is musculoskeletal
health and mobility. Consistent ROM helps ensure the client can continue to perform
activities of daily living independently.
5. When administering an enema to a client, in which position should the nurse place the
client?
A. High-Fowler’s position
B. Supine position
C. Left Sims’ position
Fundamentals of Professional
Nursing Q&A with Rationale |
Rasmussen University
1. A nurse is caring for a client who is post-operative and reports difficulty voiding. Which of
the following actions should the nurse take first?
A. Perform a bladder scan.
B. Insert a straight catheter.
C. Encourage increased fluid intake.
D. Apply a cold compress to the suprapubic area.
Correct Answer: A
Expert Explanation: The first step in the nursing process is assessment, and a bladder
scan is a non-invasive way to determine the volume of urine in the bladder. This data helps
the nurse decide if the issue is urinary retention or a lack of urine production. By obtaining
this information first, the nurse can provide a more accurate report to the provider and
avoid unnecessary invasive procedures.
2. Which clinical manifestation is a nurse most likely to observe in a client experiencing acute
hypoxia?
A. Tachycardia
,B. Bradypnea
C. Cyanosis
D. Clubbing of the fingers
Correct Answer: A
Expert Explanation: In the early stages of hypoxia, the body attempts to compensate for
low oxygen levels by increasing the heart rate to circulate what oxygen is available more
quickly. Tachycardia is often accompanied by restlessness and elevated blood pressure.
Cyanosis and clubbing are typically late signs of respiratory distress or indicators of
chronic hypoxemia rather than acute early onset.
3. A client has a prescription for a clear liquid diet. Which of the following items should the
nurse include on the client’s tray?
A. Orange juice with pulp
B. Apple juice
C. Vanilla pudding
D. Tomato soup
Correct Answer: B
Expert Explanation: Apple juice is considered a clear liquid because it is transparent and
liquid at room temperature. Clear liquid diets are often used before or after surgery to
minimize strain on the digestive system while providing hydration. Items like pudding and
, tomato soup are considered part of a full liquid diet because they are opaque and contain
dairy or more complex solids.
4. A nurse is teaching a client about performing range-of-motion (ROM) exercises. What is the
primary purpose of these exercises?
A. To increase muscle mass and strength.
B. To reduce the risk of skin breakdown.
C. To improve cardiovascular endurance.
D. To prevent joint contractures and maintain flexibility.
Correct Answer: D
Expert Explanation: Range-of-motion exercises are designed to move joints through their
full functional range to prevent stiffness and permanent shortening of the muscles, known
as contractures. While movement helps circulation, the primary focus is musculoskeletal
health and mobility. Consistent ROM helps ensure the client can continue to perform
activities of daily living independently.
5. When administering an enema to a client, in which position should the nurse place the
client?
A. High-Fowler’s position
B. Supine position
C. Left Sims’ position
