NUR 320 Foundations of Nursing Exam #4 Summer 2025
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Free NUR 320 Foundations of Nursing Exam #4 Summer 2025 Questions
A client has recently arrived in the ED. Upon assessment, which observation by the nurse will indicate the client is at risk for pressure injury formation?
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The client is working daily with PT and OT.
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The client is eating 75–100% of their daily meals.
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The client is immobile and is currently bedbound.
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The client appears to have a capillary refill of less than 2 seconds.
Explanation
Immobility is one of the primary risk factors for pressure injury formation. When a client is bedbound, constant pressure on bony prominences reduces blood flow to tissues, leading to ischemia and skin breakdown. Without frequent repositioning, adequate nutrition, and pressure relief, tissue damage can progress to ulcer formation. Thus, a bedbound client is at the highest risk for developing pressure injuries.
The nurse is assessing the way a client ambulates. Which aspects are the nurse assessing during ambulation? (Select all that apply. One, some, or all may be correct.)
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Risk for fall
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Body alignment
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Activity tolerance
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Gait and balance
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Skin turgor
Explanation
While observing ambulation, the nurse evaluates whether the client demonstrates weakness, unsteady movements, or poor coordination—all indicators of increased fall risk. Identifying this risk is essential for preventing injury.
B. Body alignment
Proper body alignment ensures that the head, spine, and limbs are positioned to minimize strain and support balance. The nurse observes posture and symmetry to assess for musculoskeletal or neurological issues affecting movement.
C. Activity tolerance
The nurse assesses how well the client tolerates physical activity, noting signs of fatigue, shortness of breath, or changes in heart rate or color during ambulation. This determines the client’s ability to perform daily activities safely.
D. Gait and balance
The nurse observes gait (the style or pattern of walking) and balance (the client’s ability to maintain an upright posture while moving). This helps identify neuromuscular deficits or coordination problems.
After obtaining handoff communication from the previous shift's nurse, the nurse knows that which client is the PRIORITY?
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A 75-year-old client who can perform active ROM exercises independently and will be discharged today.
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A 24-year-old client who is grieving after receiving a cancer diagnosis.
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A 65-year-old client who has been admitted from a long-term care facility and has several wounds with slough.
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A 55-year-old client who is newly admitted and is refusing to be turned every 2 hours.
Explanation
The priority client is the newly admitted client refusing to be turned, as this behavior increases the immediate risk for pressure injury, impaired skin integrity, and complications from immobility. Early intervention and patient education are crucial to prevent rapid skin breakdown, ensure safety, and establish trust and compliance with the care plan. Newly admitted clients also require close assessment for baseline condition and orientation to care expectations.
A physician prescribes 3000 mL of D5W to be administered over 24 hours. A nurse determines that how many milliliters per hour will be administered to the client? (Round to the nearest whole number. Include units in your answer.)
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100 mL/hr
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115 mL/hr
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125 mL/hr
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150 mL/hr
Explanation
mL per hour=Total volume (mL) ÷ Total time (hr)
mL per hour=3000÷24
mL per hour=125 mL/hr
Final Answer:
The nurse should set the IV pump to 125 mL/hr.
When caring for clients with pressure injuries, it is important to know what stage the wound is before wound care can begin. What two things prevent a pressure injury from being stageable and healing?
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Odor & Discharge
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Depth & Redness
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Size & Shape
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Eschar or Slough
Explanation
Eschar (dead, leathery tissue) and slough (yellow or white stringy tissue) prevent accurate staging and delay healing of a pressure injury. These tissues cover the wound bed, obscuring its depth and extent of damage. Until they are removed through debridement, the true stage cannot be determined, and healing cannot progress effectively because necrotic tissue impedes new cell growth and increases infection risk.
A nurse is assessing a client for possible orthostatic hypotension. Which finding will help confirm orthostatic hypotension?
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Blood pressure sitting 126/64; blood pressure standing 120/58
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Blood pressure sitting 140/60; blood pressure standing 138/58
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Blood pressure sitting 130/60; blood pressure standing 100/60
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Blood pressure sitting 120/64; blood pressure standing 120/64
Explanation
Orthostatic hypotension is confirmed when there is a drop in systolic blood pressure of at least 20 mmHg or a drop in diastolic blood pressure of at least 10 mmHg upon standing. In this case, the client’s systolic pressure decreases from 130 to 100 mmHg—a 30 mmHg drop—indicating orthostatic hypotension, which can lead to dizziness or fainting due to reduced cerebral perfusion.
A client is receiving palliative care for symptom management related to dyspnea and pain. A family member asks if the client is dying since the client is receiving palliative care. Which response of the nurse is most appropriate?
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Palliative care is focused on curing the client’s illness.
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Palliative care and hospice care are the same thing.
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Palliative care is focused on relieving symptoms of illness and treatment.
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Palliative care is only for clients with 6 months or less to live.
Explanation
The nurse’s response should clarify that palliative care does not necessarily mean the client is dying. Instead, it prioritizes comfort, dignity, and holistic well-being, supporting both the client and their family through symptom management, psychosocial care, and spiritual support.
A client feels faint upon raising from the bed to walk to the bathroom and falls. After sitting on the floor for a few minutes, the client is helped to a standing position by the nurse. The client is able to walk to the bathroom and back to bed without further problems. After the client is safely back in bed, the nurse believes the client may have had an episode of orthostatic hypotension. How should the nurse assess for orthostatic hypotension?
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Measure the client's pulse only while the client is in the sitting and standing positions.
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Take the client's blood pressure when the client is in the lying and sitting positions.
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Measure the client's blood pressure while the client is in the lying and standing positions.
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Take the client's blood pressure while the client is in the lying, sitting, and standing positions.
Explanation
Orthostatic hypotension is assessed by measuring blood pressure and heart rate in three positions—lying, sitting, and standing. Readings are taken a few minutes apart to identify a drop in systolic pressure (≥20 mmHg) or diastolic pressure (≥10 mmHg) upon standing. This method accurately determines the body’s ability to regulate blood pressure with position changes and confirms orthostatic hypotension, which commonly causes dizziness or fainting upon standing.
A nursing student is administering an IM influenza vaccine. The nurse preceptor knows to intervene when the nursing student makes which of the following statements?
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"I can give the IM injection 2 inches from the umbilicus."
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"I will utilize the Z-track method for all IM injections."
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"I will administer the IM injection at a 90 degree angle."
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"I will administer the vaccine in the client's deltoid because it is less than 1 mL in volume."
Explanation
The statement “I can give the IM injection 2 inches from the umbilicus” is incorrect because this site is appropriate for subcutaneous injections, not intramuscular (IM) injections. IM injections must be given into muscle tissue such as the deltoid, ventrogluteal, or vastus lateralis to ensure safe and effective medication absorption. Injecting near the umbilicus risks damaging abdominal structures and provides inadequate muscle depth for IM delivery.
A physician's prescription reads phenytoin (Dilantin) 0.2 g orally twice daily. The medication label states 100 mg capsules. A nurse prepares how many capsule(s) to administer one dose? Round to the nearest whole number and include units in your answer.
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1 capsule
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2 capsules
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3 capsules
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4 capsules
Explanation
Convert the prescribed dose from grams to milligrams: 0.2 g × 1000 mg/g = 200 mg per dose. Each capsule is 100 mg. Calculate the number of capsules: 200 mg ÷ 100 mg per capsule = 2 capsules. Rounded to the nearest whole number, the nurse should administer 2 capsules for one dose.
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