NURS100 Fundamentals of Nursing Comprehensive Assessment 2026
– WCU
1. A nurse is performing an admission assessment. Which of the following is
considered subjective data?
A. The patient’s blood pressure is 140/90 mmHg.
B. The patient’s skin appears pale and cool.
C. The patient reports feeling nauseous and dizzy.
D. The nurse observes a small wound on the left foot.
Answer: C
Rationale: Subjective data consists of information provided by the patient that cannot be
measured or observed by others, such as feelings or symptoms like nausea.
2. What is the most effective way for a nurse to prevent the spread of
healthcare-associated infections?
A. Wearing gloves at all times in the hospital.
B. Administering prophylactic antibiotics to all patients.
C. Keeping all patient room doors closed.
D. Performing meticulous hand hygiene.
Answer: D
Rationale: Hand hygiene is the single most important and effective practice to reduce the
transmission of infectious agents in healthcare settings.
,3. A patient has a blood pressure of 88/50 mmHg. Which term best describes
this finding?
A. Hypertension
B. Orthostatic tachycardia
C. Hypotension
D. Normal blood pressure
Answer: C
Rationale: Hypotension is defined as a systolic blood pressure below 90 mmHg or a
diastolic blood pressure below 60 mmHg.
4. During which phase of the nursing process does the nurse prioritize patient
problems and set goals?
A. Assessment
B. Implementation
C. Diagnosis
D. Planning
Answer: D
Rationale: The planning phase involves setting priorities, identifying patient-centered
goals and expected outcomes, and selecting nursing interventions.
5. The nurse is preparing to administer an intramuscular injection. At what angle
should the needle be inserted?
A. 15 degrees
B. 45 degrees
C. 90 degrees
D. 10 degrees
Answer: C
Rationale: Intramuscular (IM) injections are administered at a 90-degree angle to reach
the muscle tissue deep under the subcutaneous layer.
, 6. Which ethical principle refers to the nurse’s obligation to do no harm to the
patient?
A. Autonomy
B. Beneficence
C. Justice
D. Nonmaleficence
Answer: D
Rationale: Nonmaleficence is the ethical principle of ‘doing no harm.’ It is often balanced
with beneficence (doing good).
7. A patient is scheduled for surgery and expresses fear of the procedure. Which
response by the nurse is most therapeutic?
A. Don’t worry, the surgeon is the best in the state.
B. Everyone feels this way before surgery; it’s normal.
C. Tell me more about what is making you feel afraid.
D. I will call the doctor to give you a sedative.
Answer: C
Rationale: Open-ended questions and active listening are key components of therapeutic
communication, allowing the patient to express concerns.
8. Which of the following describes a Stage 2 pressure injury?
A. Partial-thickness loss of skin with exposed dermis.
B. Non-blanchable erythema of intact skin.
C. Full-thickness skin loss with visible adipose tissue.
D. Full-thickness skin and tissue loss with exposed bone.
Answer: A
Rationale: Stage 2 pressure injuries involve partial-thickness loss of the dermis, often
presenting as a shallow open ulcer or a ruptured blister.
– WCU
1. A nurse is performing an admission assessment. Which of the following is
considered subjective data?
A. The patient’s blood pressure is 140/90 mmHg.
B. The patient’s skin appears pale and cool.
C. The patient reports feeling nauseous and dizzy.
D. The nurse observes a small wound on the left foot.
Answer: C
Rationale: Subjective data consists of information provided by the patient that cannot be
measured or observed by others, such as feelings or symptoms like nausea.
2. What is the most effective way for a nurse to prevent the spread of
healthcare-associated infections?
A. Wearing gloves at all times in the hospital.
B. Administering prophylactic antibiotics to all patients.
C. Keeping all patient room doors closed.
D. Performing meticulous hand hygiene.
Answer: D
Rationale: Hand hygiene is the single most important and effective practice to reduce the
transmission of infectious agents in healthcare settings.
,3. A patient has a blood pressure of 88/50 mmHg. Which term best describes
this finding?
A. Hypertension
B. Orthostatic tachycardia
C. Hypotension
D. Normal blood pressure
Answer: C
Rationale: Hypotension is defined as a systolic blood pressure below 90 mmHg or a
diastolic blood pressure below 60 mmHg.
4. During which phase of the nursing process does the nurse prioritize patient
problems and set goals?
A. Assessment
B. Implementation
C. Diagnosis
D. Planning
Answer: D
Rationale: The planning phase involves setting priorities, identifying patient-centered
goals and expected outcomes, and selecting nursing interventions.
5. The nurse is preparing to administer an intramuscular injection. At what angle
should the needle be inserted?
A. 15 degrees
B. 45 degrees
C. 90 degrees
D. 10 degrees
Answer: C
Rationale: Intramuscular (IM) injections are administered at a 90-degree angle to reach
the muscle tissue deep under the subcutaneous layer.
, 6. Which ethical principle refers to the nurse’s obligation to do no harm to the
patient?
A. Autonomy
B. Beneficence
C. Justice
D. Nonmaleficence
Answer: D
Rationale: Nonmaleficence is the ethical principle of ‘doing no harm.’ It is often balanced
with beneficence (doing good).
7. A patient is scheduled for surgery and expresses fear of the procedure. Which
response by the nurse is most therapeutic?
A. Don’t worry, the surgeon is the best in the state.
B. Everyone feels this way before surgery; it’s normal.
C. Tell me more about what is making you feel afraid.
D. I will call the doctor to give you a sedative.
Answer: C
Rationale: Open-ended questions and active listening are key components of therapeutic
communication, allowing the patient to express concerns.
8. Which of the following describes a Stage 2 pressure injury?
A. Partial-thickness loss of skin with exposed dermis.
B. Non-blanchable erythema of intact skin.
C. Full-thickness skin loss with visible adipose tissue.
D. Full-thickness skin and tissue loss with exposed bone.
Answer: A
Rationale: Stage 2 pressure injuries involve partial-thickness loss of the dermis, often
presenting as a shallow open ulcer or a ruptured blister.
