NURS100: Fundamentals of Nursing - Assessment 3 2026 – WCU
1. Which of the following is the most effective way to break the chain of
infection?
A. Hand hygiene
B. Wearing gloves at all times
C. Using a mask for all patient contact
D. Administering prophylactic antibiotics
Answer: A
Rationale: Hand hygiene is considered the single most important practice to reduce the
transmission of infectious agents in healthcare settings.
2. When assessing a patient’s radial pulse, the nurse notes an irregular rhythm.
What is the priority nursing action?
A. Apply a pulse oximeter immediately
B. Re-assess the radial pulse in 15 minutes
C. Document the finding and notify the physician
D. Assess the apical pulse for one full minute
Answer: D
Rationale: If a peripheral pulse is irregular, the nurse should assess the apical pulse for 60
seconds to obtain a more accurate heart rate and rhythm.
,3. A nurse is preparing to administer an intramuscular injection into the
ventrogluteal site. Which landmark should the nurse use?
A. The acromion process
B. The greater trochanter and the anterior superior iliac spine
C. The vastus lateralis muscle
D. The posterior superior iliac spine
Answer: B
Rationale: The ventrogluteal site is located by placing the palm over the greater trochanter
and the index finger on the anterior superior iliac spine.
4. Which phase of the nursing process involves setting patient-centered goals
and expected outcomes?
A. Assessment
B. Planning
C. Diagnosis
D. Implementation
Answer: B
Rationale: The planning phase involves the nurse collaborating with the patient to develop
a plan of care, which includes setting priorities and identifying goals.
5. A patient is on droplet precautions. Which of the following personal
protective equipment (PPE) is required when entering the room?
A. N95 respirator
B. Shoe covers and head cap
C. Gown and gloves only
D. Surgical mask
Answer: D
Rationale: Droplet precautions require the use of a standard surgical mask when within 3
to 6 feet of the patient to prevent transmission of large-particle droplets.
, 6. What is the recommended position for a patient receiving a tube feeding to
prevent aspiration?
A. Supine
B. Left side-lying
C. Semi-Fowler’s to High-Fowler’s
D. Trendelenburg
Answer: C
Rationale: Elevating the head of the bed to at least 30-45 degrees (Semi-Fowler’s) helps
prevent the reflux of gastric contents and subsequent aspiration.
7. The nurse is providing oral care to an unconscious patient. What is the most
important safety action?
A. Using a soft toothbrush
B. Using lemon-glycerin swabs
C. Applying petroleum jelly to the lips
D. Positioning the patient on their side
Answer: D
Rationale: To prevent aspiration of fluids during oral care in an unconscious patient, the
patient should be placed in a side-lying (lateral) position.
8. In the chain of infection, a contaminated stethoscope is an example of a:
A. Fomite
B. Portal of entry
C. Reservoir
D. Susceptible host
Answer: A
Rationale: A fomite is an inanimate object that can become contaminated with infectious
agents and serve as a mechanism for transmission.
1. Which of the following is the most effective way to break the chain of
infection?
A. Hand hygiene
B. Wearing gloves at all times
C. Using a mask for all patient contact
D. Administering prophylactic antibiotics
Answer: A
Rationale: Hand hygiene is considered the single most important practice to reduce the
transmission of infectious agents in healthcare settings.
2. When assessing a patient’s radial pulse, the nurse notes an irregular rhythm.
What is the priority nursing action?
A. Apply a pulse oximeter immediately
B. Re-assess the radial pulse in 15 minutes
C. Document the finding and notify the physician
D. Assess the apical pulse for one full minute
Answer: D
Rationale: If a peripheral pulse is irregular, the nurse should assess the apical pulse for 60
seconds to obtain a more accurate heart rate and rhythm.
,3. A nurse is preparing to administer an intramuscular injection into the
ventrogluteal site. Which landmark should the nurse use?
A. The acromion process
B. The greater trochanter and the anterior superior iliac spine
C. The vastus lateralis muscle
D. The posterior superior iliac spine
Answer: B
Rationale: The ventrogluteal site is located by placing the palm over the greater trochanter
and the index finger on the anterior superior iliac spine.
4. Which phase of the nursing process involves setting patient-centered goals
and expected outcomes?
A. Assessment
B. Planning
C. Diagnosis
D. Implementation
Answer: B
Rationale: The planning phase involves the nurse collaborating with the patient to develop
a plan of care, which includes setting priorities and identifying goals.
5. A patient is on droplet precautions. Which of the following personal
protective equipment (PPE) is required when entering the room?
A. N95 respirator
B. Shoe covers and head cap
C. Gown and gloves only
D. Surgical mask
Answer: D
Rationale: Droplet precautions require the use of a standard surgical mask when within 3
to 6 feet of the patient to prevent transmission of large-particle droplets.
, 6. What is the recommended position for a patient receiving a tube feeding to
prevent aspiration?
A. Supine
B. Left side-lying
C. Semi-Fowler’s to High-Fowler’s
D. Trendelenburg
Answer: C
Rationale: Elevating the head of the bed to at least 30-45 degrees (Semi-Fowler’s) helps
prevent the reflux of gastric contents and subsequent aspiration.
7. The nurse is providing oral care to an unconscious patient. What is the most
important safety action?
A. Using a soft toothbrush
B. Using lemon-glycerin swabs
C. Applying petroleum jelly to the lips
D. Positioning the patient on their side
Answer: D
Rationale: To prevent aspiration of fluids during oral care in an unconscious patient, the
patient should be placed in a side-lying (lateral) position.
8. In the chain of infection, a contaminated stethoscope is an example of a:
A. Fomite
B. Portal of entry
C. Reservoir
D. Susceptible host
Answer: A
Rationale: A fomite is an inanimate object that can become contaminated with infectious
agents and serve as a mechanism for transmission.
