NUR 101 | NUR 101 Nursing Fundamentals Exam 4
Version 3 | Questions with Correct Answers and
Expert Explanation for Each Question | Saint Paul’s
School of Nursing
1. A nurse finds a patient who has fallen on the floor near the bathroom. Which action
should the nurse perform first?
A. Call the healthcare provider immediately.
B. Assess the patient for injuries and vital signs.
C. Complete an incident report for the facility.
D. Assist the patient back to bed with a coworker.
Correct Answer: B
Expert Explanation: The first step in any emergency or incident is to assess the
patient’s physical status. This ensures that any life-threatening injuries are
addressed before moving the patient. Assessment provides the necessary data to
communicate with the provider later. Only after the patient is stable should they be
moved back to bed. This approach prioritizes patient safety and follows the nursing
process systematically.
2. When preparing to administer medication, the nurse realizes the dosage is higher
than the standard range. What is the most appropriate action?
A. Contact the prescribing provider to clarify the order.
,B. Administer the dose as written by the provider.
C. Give half of the dose and document the change.
D. Ask another nurse if the dose seems safe to give.
Correct Answer: A
Expert Explanation: Nurses are legally and ethically responsible for the
medications they administer to patients. If an order appears incorrect or unsafe,
clarification must be sought from the prescriber. Administering an unsafe dose can
lead to severe patient harm and legal liability. The nurse should never
independently alter a prescribed dosage without an official order. This intervention
demonstrates clinical reasoning and a commitment to patient safety.
3. A nurse is caring for a patient with a known history of falls. Which intervention is
most effective for fall prevention?
A. Keep all four side rails in the up position.
B. Instruct the patient to wait for help before moving.
C. Administer a sedative to keep the patient in bed.
D. Place the call bell within the patient’s reach.
Correct Answer: D
,Expert Explanation: Ensuring the call bell is reachable allows the patient to
request assistance whenever needed. While instructions are helpful, patients may
forget or attempt to get up regardless. Keeping four side rails up is often considered
a restraint and can increase injury risk. Sedatives are not a primary fall prevention
strategy and may increase confusion. This patient-centered intervention focuses on
accessibility and safety within the environment.
4. Which documentation entry is considered most accurate and objective?
A. The patient seems to be feeling much better today.
B. The patient was very difficult and uncooperative.
C. The patient drank 240 mL of water with breakfast.
D. The patient’s wound looks like it is finally healing.
Correct Answer: C
Expert Explanation: Objective documentation relies on measurable data rather
than personal opinions or interpretations. Recording the exact amount of fluid
intake provides a clear picture of the patient’s status. Descriptive words like
‘difficult’ or ‘better’ are subjective and vary between observers. Accurate
documentation is essential for tracking patient progress and ensuring continuity of
care. This practice supports legal standards and effective communication within the
healthcare team.
, 5. The nurse is practicing hand hygiene. When is it most appropriate to use soap and
water instead of alcohol-based hand rub?
A. Before touching a patient’s intact skin.
B. After removing clean gloves following a procedure.
C. Before moving from a contaminated site to a clean site.
D. When the hands are visibly soiled with blood or body fluids.
Correct Answer: D
Expert Explanation: Soap and water are required whenever hands are visibly dirty
or contaminated with proteinaceous material. Alcohol-based rubs are effective for
routine decontamination but cannot remove physical debris. Using soap and water
is also mandatory when caring for patients with certain infections like C. difficile.
Proper hand hygiene is the single most effective way to prevent the spread of
infection. This knowledge is fundamental to maintaining a safe clinical environment
for all patients.
6. A nurse is delegating tasks to an Unlicensed Assistive Personnel (UAP). Which task is
appropriate for the UAP to perform?
A. Assessing a patient’s surgical incision site.
B. Teaching a patient how to use a walker safely.
C. Measuring and recording a patient’s intake and output.
Version 3 | Questions with Correct Answers and
Expert Explanation for Each Question | Saint Paul’s
School of Nursing
1. A nurse finds a patient who has fallen on the floor near the bathroom. Which action
should the nurse perform first?
A. Call the healthcare provider immediately.
B. Assess the patient for injuries and vital signs.
C. Complete an incident report for the facility.
D. Assist the patient back to bed with a coworker.
Correct Answer: B
Expert Explanation: The first step in any emergency or incident is to assess the
patient’s physical status. This ensures that any life-threatening injuries are
addressed before moving the patient. Assessment provides the necessary data to
communicate with the provider later. Only after the patient is stable should they be
moved back to bed. This approach prioritizes patient safety and follows the nursing
process systematically.
2. When preparing to administer medication, the nurse realizes the dosage is higher
than the standard range. What is the most appropriate action?
A. Contact the prescribing provider to clarify the order.
,B. Administer the dose as written by the provider.
C. Give half of the dose and document the change.
D. Ask another nurse if the dose seems safe to give.
Correct Answer: A
Expert Explanation: Nurses are legally and ethically responsible for the
medications they administer to patients. If an order appears incorrect or unsafe,
clarification must be sought from the prescriber. Administering an unsafe dose can
lead to severe patient harm and legal liability. The nurse should never
independently alter a prescribed dosage without an official order. This intervention
demonstrates clinical reasoning and a commitment to patient safety.
3. A nurse is caring for a patient with a known history of falls. Which intervention is
most effective for fall prevention?
A. Keep all four side rails in the up position.
B. Instruct the patient to wait for help before moving.
C. Administer a sedative to keep the patient in bed.
D. Place the call bell within the patient’s reach.
Correct Answer: D
,Expert Explanation: Ensuring the call bell is reachable allows the patient to
request assistance whenever needed. While instructions are helpful, patients may
forget or attempt to get up regardless. Keeping four side rails up is often considered
a restraint and can increase injury risk. Sedatives are not a primary fall prevention
strategy and may increase confusion. This patient-centered intervention focuses on
accessibility and safety within the environment.
4. Which documentation entry is considered most accurate and objective?
A. The patient seems to be feeling much better today.
B. The patient was very difficult and uncooperative.
C. The patient drank 240 mL of water with breakfast.
D. The patient’s wound looks like it is finally healing.
Correct Answer: C
Expert Explanation: Objective documentation relies on measurable data rather
than personal opinions or interpretations. Recording the exact amount of fluid
intake provides a clear picture of the patient’s status. Descriptive words like
‘difficult’ or ‘better’ are subjective and vary between observers. Accurate
documentation is essential for tracking patient progress and ensuring continuity of
care. This practice supports legal standards and effective communication within the
healthcare team.
, 5. The nurse is practicing hand hygiene. When is it most appropriate to use soap and
water instead of alcohol-based hand rub?
A. Before touching a patient’s intact skin.
B. After removing clean gloves following a procedure.
C. Before moving from a contaminated site to a clean site.
D. When the hands are visibly soiled with blood or body fluids.
Correct Answer: D
Expert Explanation: Soap and water are required whenever hands are visibly dirty
or contaminated with proteinaceous material. Alcohol-based rubs are effective for
routine decontamination but cannot remove physical debris. Using soap and water
is also mandatory when caring for patients with certain infections like C. difficile.
Proper hand hygiene is the single most effective way to prevent the spread of
infection. This knowledge is fundamental to maintaining a safe clinical environment
for all patients.
6. A nurse is delegating tasks to an Unlicensed Assistive Personnel (UAP). Which task is
appropriate for the UAP to perform?
A. Assessing a patient’s surgical incision site.
B. Teaching a patient how to use a walker safely.
C. Measuring and recording a patient’s intake and output.
