NSG 3100 – Exam 1 | Galen College |
Fundamentals of Nursing Exam with
Rationales
This Exam Contain:
Multiple Choices (A-D)
100% Guaranteed Pass
Each Question Include Correct Answer
Expert Verified Explanation.
,Domain 1: Safe & Effective Care Environment (Questions 1-12)
1. A nurse is preparing to insert a urinary catheter. Which action demonstrates proper sterile technique?
A. Opening the sterile kit and placing the catheter on the bedside table
B. Using sterile gloves to handle the catheter after cleansing the perineum
C. Setting up the sterile field, then reaching across it to retrieve more supplies
D. Wearing the same sterile gloves to both cleanse the meatus and insert the catheter
Correct Answer: B
Rationale: Sterile gloves must be worn to handle the catheter after the perineum is cleansed to prevent
introducing microorganisms.
2. A client falls while attempting to get out of bed independently. What is the nurse’s priority action?
A. Complete an incident report
B. Assess the client for injuries
C. Notify the healthcare provider
D. Place the client in a wrist restraint
Correct Answer: B
Rationale: Assessment is the first step of the nursing process. The nurse must determine injury severity
before other actions.
3. A nurse receives a telephone order from a physician for a new medication. Which of the following should the
nurse do? (SATA)
A. Repeat the order back to the physician
B. Write “TO” (telephone order) and sign the order
C. Have another nurse listen to the phone call
D. Read the order back to the physician using read-back verification
E. Administer the medication immediately before writing it down
Correct Answers: A, B, D
Rationale:
o A & D: Read-back verification is required for all telephone orders.
o B: Telephone orders must be clearly identified.
o C: Not required unless facility policy states.
o E: Must be written and verified before administration.
4. Which of the following clients should the nurse see first?
A. A client with pneumonia who has an oxygen saturation of 91%
B. A client post-op day 2 with a temperature of 99.2°F (37.3°C)
C. A client with diabetes reporting a blood glucose of 140 mg/dL
D. A client with a urinary catheter whose urine output is 30 mL in 4 hours
Correct Answer: D
, Rationale: Oliguria (<30 mL/hour) can indicate acute kidney injury or dehydration. This is a priority over
stable vital signs.
5. A nurse is delegating vital sign measurement to an unlicensed assistive personnel (UAP). Which statement
indicates proper delegation?
A. “Take the blood pressure on any arm that is free.”
B. “Report if the blood pressure is above 140/90 or below 90/60.”
C. “You can assess the patient’s pain level while you’re in there.”
D. “Don’t worry about documenting; I’ll do that later.”
Correct Answer: B
Rationale: Delegation includes clear reporting parameters. UAP can measure vitals but must report
abnormal findings.
6. A client is placed in wrist restraints after pulling out an IV. How often must the nurse assess this client?
A. Every 15 minutes
B. Every 30 minutes
C. Every 1 hour
D. Every 2 hours
Correct Answer: A
Rationale: Restrained clients require q15min checks for circulation, comfort, and safety per CMS guidelines.
7. A nurse is preparing a sterile field for a wound dressing change. Which action would contaminate the field?
A. Opening the sterile package away from the body
B. Placing a sterile item 1 inch from the edge of the field
C. Holding a sterile object above waist level
D. Reaching over the sterile field to adjust a light
Correct Answer: D
Rationale: Reaching over a sterile field contaminates it because non-sterile items (clothing, hair) may shed
microbes.
8. A nurse is reviewing a client’s advance directives. The client states, “I don’t want to be put on a breathing
machine.” Which action should the nurse take?
A. Tell the client they need to sign a DNR form
B. Respect the client’s wishes and document them
C. Notify the ethics committee immediately
D. Ask the family to make the decision for the client
Correct Answer: B
Rationale: Competent clients have the right to refuse treatment. The nurse should document the client’s
wishes.
9. A nurse observes another nurse documenting “patient seems anxious” in a progress note. This is an example of:
A. Objective data
B. Subjective data
C. Legal documentation
D. Factual reporting
Fundamentals of Nursing Exam with
Rationales
This Exam Contain:
Multiple Choices (A-D)
100% Guaranteed Pass
Each Question Include Correct Answer
Expert Verified Explanation.
,Domain 1: Safe & Effective Care Environment (Questions 1-12)
1. A nurse is preparing to insert a urinary catheter. Which action demonstrates proper sterile technique?
A. Opening the sterile kit and placing the catheter on the bedside table
B. Using sterile gloves to handle the catheter after cleansing the perineum
C. Setting up the sterile field, then reaching across it to retrieve more supplies
D. Wearing the same sterile gloves to both cleanse the meatus and insert the catheter
Correct Answer: B
Rationale: Sterile gloves must be worn to handle the catheter after the perineum is cleansed to prevent
introducing microorganisms.
2. A client falls while attempting to get out of bed independently. What is the nurse’s priority action?
A. Complete an incident report
B. Assess the client for injuries
C. Notify the healthcare provider
D. Place the client in a wrist restraint
Correct Answer: B
Rationale: Assessment is the first step of the nursing process. The nurse must determine injury severity
before other actions.
3. A nurse receives a telephone order from a physician for a new medication. Which of the following should the
nurse do? (SATA)
A. Repeat the order back to the physician
B. Write “TO” (telephone order) and sign the order
C. Have another nurse listen to the phone call
D. Read the order back to the physician using read-back verification
E. Administer the medication immediately before writing it down
Correct Answers: A, B, D
Rationale:
o A & D: Read-back verification is required for all telephone orders.
o B: Telephone orders must be clearly identified.
o C: Not required unless facility policy states.
o E: Must be written and verified before administration.
4. Which of the following clients should the nurse see first?
A. A client with pneumonia who has an oxygen saturation of 91%
B. A client post-op day 2 with a temperature of 99.2°F (37.3°C)
C. A client with diabetes reporting a blood glucose of 140 mg/dL
D. A client with a urinary catheter whose urine output is 30 mL in 4 hours
Correct Answer: D
, Rationale: Oliguria (<30 mL/hour) can indicate acute kidney injury or dehydration. This is a priority over
stable vital signs.
5. A nurse is delegating vital sign measurement to an unlicensed assistive personnel (UAP). Which statement
indicates proper delegation?
A. “Take the blood pressure on any arm that is free.”
B. “Report if the blood pressure is above 140/90 or below 90/60.”
C. “You can assess the patient’s pain level while you’re in there.”
D. “Don’t worry about documenting; I’ll do that later.”
Correct Answer: B
Rationale: Delegation includes clear reporting parameters. UAP can measure vitals but must report
abnormal findings.
6. A client is placed in wrist restraints after pulling out an IV. How often must the nurse assess this client?
A. Every 15 minutes
B. Every 30 minutes
C. Every 1 hour
D. Every 2 hours
Correct Answer: A
Rationale: Restrained clients require q15min checks for circulation, comfort, and safety per CMS guidelines.
7. A nurse is preparing a sterile field for a wound dressing change. Which action would contaminate the field?
A. Opening the sterile package away from the body
B. Placing a sterile item 1 inch from the edge of the field
C. Holding a sterile object above waist level
D. Reaching over the sterile field to adjust a light
Correct Answer: D
Rationale: Reaching over a sterile field contaminates it because non-sterile items (clothing, hair) may shed
microbes.
8. A nurse is reviewing a client’s advance directives. The client states, “I don’t want to be put on a breathing
machine.” Which action should the nurse take?
A. Tell the client they need to sign a DNR form
B. Respect the client’s wishes and document them
C. Notify the ethics committee immediately
D. Ask the family to make the decision for the client
Correct Answer: B
Rationale: Competent clients have the right to refuse treatment. The nurse should document the client’s
wishes.
9. A nurse observes another nurse documenting “patient seems anxious” in a progress note. This is an example of:
A. Objective data
B. Subjective data
C. Legal documentation
D. Factual reporting
