NUR 101 | NUR 101 Nursing Fundamentals Exam 1
Version 1 | Questions with Correct Answers and
Expert Explanation for Each Question | Saint Paul’s
School of Nursing
1. A nurse is performing an initial assessment on a newly admitted patient. Which of
the following is considered the primary source of data?
A. The patient’s family members
B. The patient themselves
C. The patient’s electronic health record
D. The shift-to-shift report
Correct Answer: B
Expert Explanation: Assessment begins with gathering data from the most direct
source available. The patient is always considered the primary source of
information during a nursing assessment. Secondary sources include family, medical
records, and other healthcare professionals. Understanding the distinction between
primary and secondary sources is vital for accurate data collection. This ensures
that the nursing care plan is based on the patient’s subjective and objective reality.
2. Which phase of the nursing process involves the nurse determining whether the
patient’s goals and outcomes have been met?
A. Assessment
,B. Implementation
C. Evaluation
D. Diagnosis
Correct Answer: C
Expert Explanation: Evaluation is the final step of the nursing process where the
nurse measures the client’s progress toward goals. During this phase, the nurse
compares the actual outcomes with the expected outcomes defined in the planning
stage. If goals are not met, the nurse must reassess and modify the care plan. This
step is continuous and helps ensure that the nursing care remains effective and
relevant. It requires critical thinking to determine if the interventions were
successful or need adjustment.
3. A nurse is washing their hands after providing care to a patient with a known
infection. According to standard precautions, when is it mandatory to use soap and
water instead of alcohol-based hand rub?
A. When the hands are not visibly soiled
B. When the hands are visibly soiled with blood or body fluids
C. Before touching a patient’s intact skin
D. After removing gloves when no soil is present
,Correct Answer: B
Expert Explanation: Hand hygiene is the most important measure in preventing
the spread of infection in healthcare settings. Soap and water must be used
whenever hands are visibly dirty or contaminated with proteinaceous material.
Alcohol-based rubs are efficient for routine decontamination when no visible soil is
present. However, certain pathogens like C. difficile require mechanical friction and
rinsing with water. Following these specific guidelines is a core component of
patient safety and infection control protocols.
4. While assessing a patient’s vital signs, the nurse notes a blood pressure of 150/96
mmHg. How should the nurse interpret this finding for an adult?
A. Normal blood pressure
B. Hypertension Stage 2
C. Hypotension
D. Elevated blood pressure
Correct Answer: B
Expert Explanation: Normal blood pressure for an adult is typically defined as less
than 120/80 mmHg. A systolic pressure of 140 or higher or a diastolic of 90 or
higher is classified as Stage 2 Hypertension. The nurse must recognize these values
to implement appropriate follow-up care and monitoring. Accurate interpretation of
, vital signs is essential for early detection of potential health complications. This
clinical judgment allows the nurse to communicate findings effectively to the
healthcare team.
5. The nurse is preparing to document care in the medical record. Which of the
following entries is the most accurate and objective?
A. The patient seems to be in a bad mood today.
B. The patient ate a good amount of their breakfast.
C. The patient stated, ‘I feel very short of breath right now.’
D. The patient slept poorly throughout the night.
Correct Answer: C
Expert Explanation: Documentation should be factual, accurate, and free of
personal bias or vague descriptions. Using direct quotes from the patient provides
objective evidence of their subjective experience. Phrases like ‘bad mood’ or ‘ate a
good amount’ are subjective and open to interpretation. Professional documentation
serves as a legal record and a communication tool between healthcare providers.
Ensuring that records are precise is a fundamental responsibility of the nursing role.
6. A nurse is caring for a patient who is at high risk for falls. Which intervention is the
highest priority to ensure patient safety?
A. Keep all four side rails in the upright position.
Version 1 | Questions with Correct Answers and
Expert Explanation for Each Question | Saint Paul’s
School of Nursing
1. A nurse is performing an initial assessment on a newly admitted patient. Which of
the following is considered the primary source of data?
A. The patient’s family members
B. The patient themselves
C. The patient’s electronic health record
D. The shift-to-shift report
Correct Answer: B
Expert Explanation: Assessment begins with gathering data from the most direct
source available. The patient is always considered the primary source of
information during a nursing assessment. Secondary sources include family, medical
records, and other healthcare professionals. Understanding the distinction between
primary and secondary sources is vital for accurate data collection. This ensures
that the nursing care plan is based on the patient’s subjective and objective reality.
2. Which phase of the nursing process involves the nurse determining whether the
patient’s goals and outcomes have been met?
A. Assessment
,B. Implementation
C. Evaluation
D. Diagnosis
Correct Answer: C
Expert Explanation: Evaluation is the final step of the nursing process where the
nurse measures the client’s progress toward goals. During this phase, the nurse
compares the actual outcomes with the expected outcomes defined in the planning
stage. If goals are not met, the nurse must reassess and modify the care plan. This
step is continuous and helps ensure that the nursing care remains effective and
relevant. It requires critical thinking to determine if the interventions were
successful or need adjustment.
3. A nurse is washing their hands after providing care to a patient with a known
infection. According to standard precautions, when is it mandatory to use soap and
water instead of alcohol-based hand rub?
A. When the hands are not visibly soiled
B. When the hands are visibly soiled with blood or body fluids
C. Before touching a patient’s intact skin
D. After removing gloves when no soil is present
,Correct Answer: B
Expert Explanation: Hand hygiene is the most important measure in preventing
the spread of infection in healthcare settings. Soap and water must be used
whenever hands are visibly dirty or contaminated with proteinaceous material.
Alcohol-based rubs are efficient for routine decontamination when no visible soil is
present. However, certain pathogens like C. difficile require mechanical friction and
rinsing with water. Following these specific guidelines is a core component of
patient safety and infection control protocols.
4. While assessing a patient’s vital signs, the nurse notes a blood pressure of 150/96
mmHg. How should the nurse interpret this finding for an adult?
A. Normal blood pressure
B. Hypertension Stage 2
C. Hypotension
D. Elevated blood pressure
Correct Answer: B
Expert Explanation: Normal blood pressure for an adult is typically defined as less
than 120/80 mmHg. A systolic pressure of 140 or higher or a diastolic of 90 or
higher is classified as Stage 2 Hypertension. The nurse must recognize these values
to implement appropriate follow-up care and monitoring. Accurate interpretation of
, vital signs is essential for early detection of potential health complications. This
clinical judgment allows the nurse to communicate findings effectively to the
healthcare team.
5. The nurse is preparing to document care in the medical record. Which of the
following entries is the most accurate and objective?
A. The patient seems to be in a bad mood today.
B. The patient ate a good amount of their breakfast.
C. The patient stated, ‘I feel very short of breath right now.’
D. The patient slept poorly throughout the night.
Correct Answer: C
Expert Explanation: Documentation should be factual, accurate, and free of
personal bias or vague descriptions. Using direct quotes from the patient provides
objective evidence of their subjective experience. Phrases like ‘bad mood’ or ‘ate a
good amount’ are subjective and open to interpretation. Professional documentation
serves as a legal record and a communication tool between healthcare providers.
Ensuring that records are precise is a fundamental responsibility of the nursing role.
6. A nurse is caring for a patient who is at high risk for falls. Which intervention is the
highest priority to ensure patient safety?
A. Keep all four side rails in the upright position.
