NURS100 Fundamentals of Nursing Assessment 2026 – WCU
1. Which step of the nursing process involves the systematic collection of data
regarding a patient’s health status?
A. Diagnosis
B. Planning
C. Assessment
D. Evaluation
Answer: C
Rationale: Assessment is the first step of the nursing process, where the nurse collects,
organizes, and validates data to identify health needs.
2. A nurse is caring for a patient who is at risk for falls. Which intervention is the
highest priority?
A. Placing a ‘Fall Risk’ sign on the door
B. Keeping the bed in the lowest position
C. Instructing the patient to call for help before ambulating
D. Reviewing the patient’s medications
Answer: B
Rationale: Keeping the bed in the lowest position is a primary physical safety measure to
prevent injury if a patient attempts to get out of bed.
,3. What is the single most effective way to prevent the transmission of
healthcare-associated infections?
A. Performing hand hygiene
B. Wearing sterile gloves for all procedures
C. Administering prophylactic antibiotics
D. Using negative pressure rooms
Answer: A
Rationale: Hand hygiene is consistently recognized as the most effective method for
preventing the spread of pathogens in healthcare settings.
4. A nurse observes a non-blanchable redness on a patient’s sacrum. How
should this be documented?
A. Stage 1 pressure injury
B. Stage 2 pressure injury
C. Deep tissue injury
D. Unstageable pressure injury
Answer: A
Rationale: A Stage 1 pressure injury is characterized by intact skin with localized non-
blanchable erythema (redness).
5. Which ethical principle refers to the nurse’s obligation to do no harm to the
patient?
A. Autonomy
B. Nonmaleficence
C. Beneficence
D. Fidelity
Answer: B
Rationale: Nonmaleficence is the ethical duty to avoid causing harm or hurt to others.
, 6. When assessing a patient’s blood pressure, the nurse uses a cuff that is too
small. What is the likely result?
A. A falsely low reading
B. An accurate reading
C. A falsely high reading
D. No reading can be obtained
Answer: C
Rationale: Using a blood pressure cuff that is too narrow or small results in a falsely high
blood pressure reading.
7. What is the primary purpose of the ‘Planning’ phase of the nursing process?
A. To implement nursing interventions
B. To develop measurable goals and outcomes
C. To determine if patient goals were met
D. To analyze subjective and objective data
Answer: B
Rationale: The planning phase involves setting priorities, identifying patient-centered
goals, and selecting nursing interventions.
8. A patient is on airborne precautions. Which of the following is a requirement
for healthcare workers entering the room?
A. Surgical mask
B. Goggles and face shield
C. N95 respirator
D. Gown and gloves only
Answer: C
Rationale: Airborne precautions require the use of a specially fitted N95 respirator to filter
out small droplets that remain suspended in the air.
1. Which step of the nursing process involves the systematic collection of data
regarding a patient’s health status?
A. Diagnosis
B. Planning
C. Assessment
D. Evaluation
Answer: C
Rationale: Assessment is the first step of the nursing process, where the nurse collects,
organizes, and validates data to identify health needs.
2. A nurse is caring for a patient who is at risk for falls. Which intervention is the
highest priority?
A. Placing a ‘Fall Risk’ sign on the door
B. Keeping the bed in the lowest position
C. Instructing the patient to call for help before ambulating
D. Reviewing the patient’s medications
Answer: B
Rationale: Keeping the bed in the lowest position is a primary physical safety measure to
prevent injury if a patient attempts to get out of bed.
,3. What is the single most effective way to prevent the transmission of
healthcare-associated infections?
A. Performing hand hygiene
B. Wearing sterile gloves for all procedures
C. Administering prophylactic antibiotics
D. Using negative pressure rooms
Answer: A
Rationale: Hand hygiene is consistently recognized as the most effective method for
preventing the spread of pathogens in healthcare settings.
4. A nurse observes a non-blanchable redness on a patient’s sacrum. How
should this be documented?
A. Stage 1 pressure injury
B. Stage 2 pressure injury
C. Deep tissue injury
D. Unstageable pressure injury
Answer: A
Rationale: A Stage 1 pressure injury is characterized by intact skin with localized non-
blanchable erythema (redness).
5. Which ethical principle refers to the nurse’s obligation to do no harm to the
patient?
A. Autonomy
B. Nonmaleficence
C. Beneficence
D. Fidelity
Answer: B
Rationale: Nonmaleficence is the ethical duty to avoid causing harm or hurt to others.
, 6. When assessing a patient’s blood pressure, the nurse uses a cuff that is too
small. What is the likely result?
A. A falsely low reading
B. An accurate reading
C. A falsely high reading
D. No reading can be obtained
Answer: C
Rationale: Using a blood pressure cuff that is too narrow or small results in a falsely high
blood pressure reading.
7. What is the primary purpose of the ‘Planning’ phase of the nursing process?
A. To implement nursing interventions
B. To develop measurable goals and outcomes
C. To determine if patient goals were met
D. To analyze subjective and objective data
Answer: B
Rationale: The planning phase involves setting priorities, identifying patient-centered
goals, and selecting nursing interventions.
8. A patient is on airborne precautions. Which of the following is a requirement
for healthcare workers entering the room?
A. Surgical mask
B. Goggles and face shield
C. N95 respirator
D. Gown and gloves only
Answer: C
Rationale: Airborne precautions require the use of a specially fitted N95 respirator to filter
out small droplets that remain suspended in the air.
