Fundamentals of Nursing Final
Exam: Frequently Asked
Questions & Step-by-Step
Rationales”
**1. Q:** A nurse is preparing to insert an indwelling urinary catheter.
Which technique requires sterile gloves?
**A:** Sterile gloves are required for any procedure that enters a
sterile body cavity, such as urinary catheterization, to prevent
introducing pathogens into the bladder.
**Rationale:** Sterile technique (surgical asepsis) eliminates all
microorganisms. Indwelling catheterization breaches the urinary tract’s
normal defenses, so sterile gloves, drapes, and antiseptic cleaning are
mandatory.
**2. Q:** A client on fall precautions needs to use the bathroom at
night. What is the nurse’s priority action?
**A:** Assist the client to the bathroom using a gait belt and non-slip
footwear.
**Rationale:** The priority is preventing a fall by providing direct
assistance. Nighttime confusion, dim lighting, and urgency increase fall
risk. A gait belt allows the nurse to control a sudden loss of balance.
,**3. Q:** Which type of precaution is required for a client with active
pulmonary tuberculosis?
**A:** Airborne precautions (negative pressure room, N95 respirator).
**Rationale:** TB spreads via droplet nuclei that remain airborne.
Standard and droplet precautions are insufficient. The nurse must wear
an N95 mask and place the client in an airborne infection isolation
room.
**4. Q:** A nurse’s hands are visibly soiled with blood. What hand
hygiene method should be used?
**A:** Wash with soap and running water for at least 15-20 seconds.
**Rationale:** Alcohol-based hand rub is effective for non-visibly
soiled hands, but organic material (blood) inactivates alcohol. Soap and
water mechanically remove proteins and pathogens.
**5. Q:** A client is on contact precautions for C. difficile. What is
correct about PPE removal?
**A:** Remove gloves first, then gown, then perform hand hygiene.
**Rationale:** Gloves are most contaminated; removing them first
prevents transfer to the gown. Hand hygiene after removal of all PPE is
critical because C. difficile spores are not killed by alcohol rub—soap
and water must be used.
**6. Q:** A fire occurs in a client’s room. After removing the client,
what is the next step using RACE?
,**A:** Activate the alarm (pull the nearest fire alarm).
**Rationale:** RACE = Rescue, Alarm, Contain, Extinguish. After
rescuing the immediate client, the alarm alerts others to contain the
fire (close doors) and use extinguishers (PASS: Pull, Aim, Squeeze,
Sweep).
**7. Q:** A client is receiving oxygen via nasal cannula at 4 L/min.
Which safety precaution is essential?
**A:** Post “Oxygen in Use” sign and ensure no open flames or
electrical sparks.
**Rationale:** Oxygen supports combustion, not explosion. The sign
warns others. Cotton blankets (not wool) and no petroleum-based
lubricants reduce static/spark risk. Smoking is prohibited.
**8. Q:** A nurse accidentally sticks themselves with a used needle.
What is the first action?
**A:** Wash the site with soap and water, then report to supervisor.
**Rationale:** Immediate washing reduces pathogen load. Reporting
initiates post-exposure prophylaxis (HIV, hepatitis B/C). Squeezing or
sucking the wound is no longer recommended due to tissue damage.
**9. Q:** For a client with a new diagnosis of MRSA in a wound, what is
the most important nursing action?
**A:** Implement contact precautions and educate the client and
family on hand hygiene.
, **Rationale:** MRSA spreads by direct contact. Contact precautions
(gloves, gown, dedicated equipment) prevent transmission. Hand
hygiene is the single most effective measure to stop spread to others.
**10. Q:** A confused client keeps trying to get out of bed. What is the
least restrictive intervention first?
**A:** Offer toileting, reorientation, and a bed alarm.
**Rationale:** Restraints (physical or chemical) are last resort. First,
address unmet needs (pain, hunger, toilet). A bed alarm alerts staff
without restricting freedom, preserving dignity and preventing falls.
### 11-20: Vital Signs & Assessment
**11. Q:** A client’s temperature is 38.9°C (102°F) orally. Which phase
of fever is this?
**A:** Plateau (or stadium) phase.
**Rationale:** Fever phases: onset (rising, chills), plateau (elevated
stable, flushed skin), defervescence (falling, sweating). 102°F sustained
indicates plateau; treatment depends on client comfort, not number
alone.
**12. Q:** A nurse palpates a client’s radial pulse for 30 seconds,
counts 40 beats. What is the heart rate?
**A:** 80 beats per minute (40 x 2).
Exam: Frequently Asked
Questions & Step-by-Step
Rationales”
**1. Q:** A nurse is preparing to insert an indwelling urinary catheter.
Which technique requires sterile gloves?
**A:** Sterile gloves are required for any procedure that enters a
sterile body cavity, such as urinary catheterization, to prevent
introducing pathogens into the bladder.
**Rationale:** Sterile technique (surgical asepsis) eliminates all
microorganisms. Indwelling catheterization breaches the urinary tract’s
normal defenses, so sterile gloves, drapes, and antiseptic cleaning are
mandatory.
**2. Q:** A client on fall precautions needs to use the bathroom at
night. What is the nurse’s priority action?
**A:** Assist the client to the bathroom using a gait belt and non-slip
footwear.
**Rationale:** The priority is preventing a fall by providing direct
assistance. Nighttime confusion, dim lighting, and urgency increase fall
risk. A gait belt allows the nurse to control a sudden loss of balance.
,**3. Q:** Which type of precaution is required for a client with active
pulmonary tuberculosis?
**A:** Airborne precautions (negative pressure room, N95 respirator).
**Rationale:** TB spreads via droplet nuclei that remain airborne.
Standard and droplet precautions are insufficient. The nurse must wear
an N95 mask and place the client in an airborne infection isolation
room.
**4. Q:** A nurse’s hands are visibly soiled with blood. What hand
hygiene method should be used?
**A:** Wash with soap and running water for at least 15-20 seconds.
**Rationale:** Alcohol-based hand rub is effective for non-visibly
soiled hands, but organic material (blood) inactivates alcohol. Soap and
water mechanically remove proteins and pathogens.
**5. Q:** A client is on contact precautions for C. difficile. What is
correct about PPE removal?
**A:** Remove gloves first, then gown, then perform hand hygiene.
**Rationale:** Gloves are most contaminated; removing them first
prevents transfer to the gown. Hand hygiene after removal of all PPE is
critical because C. difficile spores are not killed by alcohol rub—soap
and water must be used.
**6. Q:** A fire occurs in a client’s room. After removing the client,
what is the next step using RACE?
,**A:** Activate the alarm (pull the nearest fire alarm).
**Rationale:** RACE = Rescue, Alarm, Contain, Extinguish. After
rescuing the immediate client, the alarm alerts others to contain the
fire (close doors) and use extinguishers (PASS: Pull, Aim, Squeeze,
Sweep).
**7. Q:** A client is receiving oxygen via nasal cannula at 4 L/min.
Which safety precaution is essential?
**A:** Post “Oxygen in Use” sign and ensure no open flames or
electrical sparks.
**Rationale:** Oxygen supports combustion, not explosion. The sign
warns others. Cotton blankets (not wool) and no petroleum-based
lubricants reduce static/spark risk. Smoking is prohibited.
**8. Q:** A nurse accidentally sticks themselves with a used needle.
What is the first action?
**A:** Wash the site with soap and water, then report to supervisor.
**Rationale:** Immediate washing reduces pathogen load. Reporting
initiates post-exposure prophylaxis (HIV, hepatitis B/C). Squeezing or
sucking the wound is no longer recommended due to tissue damage.
**9. Q:** For a client with a new diagnosis of MRSA in a wound, what is
the most important nursing action?
**A:** Implement contact precautions and educate the client and
family on hand hygiene.
, **Rationale:** MRSA spreads by direct contact. Contact precautions
(gloves, gown, dedicated equipment) prevent transmission. Hand
hygiene is the single most effective measure to stop spread to others.
**10. Q:** A confused client keeps trying to get out of bed. What is the
least restrictive intervention first?
**A:** Offer toileting, reorientation, and a bed alarm.
**Rationale:** Restraints (physical or chemical) are last resort. First,
address unmet needs (pain, hunger, toilet). A bed alarm alerts staff
without restricting freedom, preserving dignity and preventing falls.
### 11-20: Vital Signs & Assessment
**11. Q:** A client’s temperature is 38.9°C (102°F) orally. Which phase
of fever is this?
**A:** Plateau (or stadium) phase.
**Rationale:** Fever phases: onset (rising, chills), plateau (elevated
stable, flushed skin), defervescence (falling, sweating). 102°F sustained
indicates plateau; treatment depends on client comfort, not number
alone.
**12. Q:** A nurse palpates a client’s radial pulse for 30 seconds,
counts 40 beats. What is the heart rate?
**A:** 80 beats per minute (40 x 2).
