Hondros NUR 163 Exam 1 Actual Exam with
Accurate Answers | Nursing Fundamentals |
Complete Questions & Rationales | Pass
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Foundations of Nursing & the Nursing Process
Q1: A nursing instructor is teaching a group of students about the history of nursing.
She asks the class which nurse is best known for establishing environmental theory and
emphasizing the importance of fresh air, cleanliness, and sanitation during the Crimean
War.
A. Clara Barton
B. Florence Nightingale
C. Dorothea Dix
D. Virginia Henderson
Correct Answer: B
Rationale: Florence Nightingale is considered the founder of modern nursing and
developed the Environmental Theory, which asserts that manipulating the patient's
environment (fresh air, light, warmth, cleanliness) can facilitate the body's reparative
processes.
Q2: The nurse is caring for a patient who refuses a blood transfusion due to religious
beliefs. The nurse advocates for the patient by ensuring this refusal is documented and
respected. Which role of the nurse is being demonstrated?
A. Educator
B. Caregiver
C. Advocate
D. Manager
Correct Answer: C
Rationale: The nurse is acting as an advocate by supporting the patient's rights and
autonomy, specifically the right to refuse treatment, and ensuring those wishes are
communicated to the healthcare team.
Q3: A registered nurse (RN) is delegating tasks to an unlicensed assistive personnel
(UAP). Which of the following tasks is most appropriate for the RN to delegate?
A. Performing the initial admission assessment
B. Developing the nursing care plan
C. Measuring vital signs on a stable patient
,D. Administering intravenous medication
Correct Answer: C
Rationale: Measuring vital signs on a stable patient is a standardized, repetitive task
that falls within the scope of practice for a UAP, whereas assessment, care planning,
and IV medication administration require RN-level education and licensure.
Q4: A patient is admitted to a rehabilitation center to learn how to use a prosthetic limb
after an amputation. This type of healthcare is categorized as which level of prevention?
A. Primary prevention
B. Secondary prevention
C. Tertiary prevention
D. Restorative care
Correct Answer: D
Rationale: Restorative care focuses on helping a patient regain maximum functional
ability and independence after an illness or injury, which fits the scenario of learning to
use a prosthetic limb.
Q5: The nurse is preparing to perform a head-to-toe assessment on a newly admitted
patient. When analyzing data, the nurse differentiates between subjective and objective
information. Which of the following is an example of subjective data?
A. The patient reports pain as a 7 on a scale of 0 to 10.
B. The patient’s skin is warm and dry to the touch.
C. The patient’s blood pressure is 138/88 mmHg.
D. The patient has a surgical incision on the left knee.
Correct Answer: A
Rationale: Subjective data is what the patient tells you (symptoms), such as pain levels,
feelings, or perceptions; objective data is what you measure or observe (signs) through
physical assessment or laboratory tests.
Q6: A nurse is formulating a nursing diagnosis for a patient with dyspnea. The nurse
writes "Impaired Gas Exchange related to retained secretions as evidenced by oxygen
saturation of 88% and crackles in the lower lobes." Which part of this statement
represents the etiology?
A. Impaired Gas Exchange
B. Retained secretions
C. Oxygen saturation of 88%
D. Crackles in the lower lobes
Correct Answer: B
Rationale: In a nursing diagnosis statement (PES format), the "related to" (Rt) clause
identifies the cause or contributing factor (etiology) of the problem.
, Q7: A patient states, "I feel like I’m going to throw up." The nurse documents this as
"Patient reports nausea." This action by the nurse best describes which step of the
nursing process?
A. Assessment
B. Diagnosis
C. Planning
D. Evaluation
Correct Answer: A
Rationale: Assessment involves data collection, which includes validating patient
statements and documenting them accurately as subjective data.
Q8: The nurse is reviewing the medical record of a patient diagnosed with "Pneumonia"
and the nursing diagnosis of "Ineffective Airway Clearance." Which statement best
explains the difference between these two diagnoses?
A. A medical diagnosis focuses on the disease process, while a nursing diagnosis
focuses on the patient's response to the illness.
B. A medical diagnosis is treated by nurses, while a nursing diagnosis is treated by
physicians.
C. A medical diagnosis remains constant, while a nursing diagnosis changes every
hour.
D. There is no difference; they are interchangeable terms.
Correct Answer: A
Rationale: Medical diagnoses identify the pathology or disease (e.g., Pneumonia)
treated by the physician, whereas nursing diagnoses identify the human response to
actual or potential health problems (e.g., Ineffective Airway Clearance) managed by the
nurse.
Q9: A nurse sets the following goal: "The patient will tolerate clear liquids without
nausea or vomiting by postoperative day 2." Which characteristic of a SMART goal does
this statement demonstrate?
A. Specific
B. Measurable
C. Time-bound
D. Relevant
Correct Answer: C
Rationale: The phrase "by postoperative day 2" provides a specific time frame for the
goal to be achieved, fulfilling the "Time-bound" criteria of SMART goals.
Q10: A nurse performs a dressing change on a postoperative wound without a specific
physician's order because the standard of care dictates wound care. This type of
intervention is best described as:
Accurate Answers | Nursing Fundamentals |
Complete Questions & Rationales | Pass
Guaranteed - A+ Graded
Foundations of Nursing & the Nursing Process
Q1: A nursing instructor is teaching a group of students about the history of nursing.
She asks the class which nurse is best known for establishing environmental theory and
emphasizing the importance of fresh air, cleanliness, and sanitation during the Crimean
War.
A. Clara Barton
B. Florence Nightingale
C. Dorothea Dix
D. Virginia Henderson
Correct Answer: B
Rationale: Florence Nightingale is considered the founder of modern nursing and
developed the Environmental Theory, which asserts that manipulating the patient's
environment (fresh air, light, warmth, cleanliness) can facilitate the body's reparative
processes.
Q2: The nurse is caring for a patient who refuses a blood transfusion due to religious
beliefs. The nurse advocates for the patient by ensuring this refusal is documented and
respected. Which role of the nurse is being demonstrated?
A. Educator
B. Caregiver
C. Advocate
D. Manager
Correct Answer: C
Rationale: The nurse is acting as an advocate by supporting the patient's rights and
autonomy, specifically the right to refuse treatment, and ensuring those wishes are
communicated to the healthcare team.
Q3: A registered nurse (RN) is delegating tasks to an unlicensed assistive personnel
(UAP). Which of the following tasks is most appropriate for the RN to delegate?
A. Performing the initial admission assessment
B. Developing the nursing care plan
C. Measuring vital signs on a stable patient
,D. Administering intravenous medication
Correct Answer: C
Rationale: Measuring vital signs on a stable patient is a standardized, repetitive task
that falls within the scope of practice for a UAP, whereas assessment, care planning,
and IV medication administration require RN-level education and licensure.
Q4: A patient is admitted to a rehabilitation center to learn how to use a prosthetic limb
after an amputation. This type of healthcare is categorized as which level of prevention?
A. Primary prevention
B. Secondary prevention
C. Tertiary prevention
D. Restorative care
Correct Answer: D
Rationale: Restorative care focuses on helping a patient regain maximum functional
ability and independence after an illness or injury, which fits the scenario of learning to
use a prosthetic limb.
Q5: The nurse is preparing to perform a head-to-toe assessment on a newly admitted
patient. When analyzing data, the nurse differentiates between subjective and objective
information. Which of the following is an example of subjective data?
A. The patient reports pain as a 7 on a scale of 0 to 10.
B. The patient’s skin is warm and dry to the touch.
C. The patient’s blood pressure is 138/88 mmHg.
D. The patient has a surgical incision on the left knee.
Correct Answer: A
Rationale: Subjective data is what the patient tells you (symptoms), such as pain levels,
feelings, or perceptions; objective data is what you measure or observe (signs) through
physical assessment or laboratory tests.
Q6: A nurse is formulating a nursing diagnosis for a patient with dyspnea. The nurse
writes "Impaired Gas Exchange related to retained secretions as evidenced by oxygen
saturation of 88% and crackles in the lower lobes." Which part of this statement
represents the etiology?
A. Impaired Gas Exchange
B. Retained secretions
C. Oxygen saturation of 88%
D. Crackles in the lower lobes
Correct Answer: B
Rationale: In a nursing diagnosis statement (PES format), the "related to" (Rt) clause
identifies the cause or contributing factor (etiology) of the problem.
, Q7: A patient states, "I feel like I’m going to throw up." The nurse documents this as
"Patient reports nausea." This action by the nurse best describes which step of the
nursing process?
A. Assessment
B. Diagnosis
C. Planning
D. Evaluation
Correct Answer: A
Rationale: Assessment involves data collection, which includes validating patient
statements and documenting them accurately as subjective data.
Q8: The nurse is reviewing the medical record of a patient diagnosed with "Pneumonia"
and the nursing diagnosis of "Ineffective Airway Clearance." Which statement best
explains the difference between these two diagnoses?
A. A medical diagnosis focuses on the disease process, while a nursing diagnosis
focuses on the patient's response to the illness.
B. A medical diagnosis is treated by nurses, while a nursing diagnosis is treated by
physicians.
C. A medical diagnosis remains constant, while a nursing diagnosis changes every
hour.
D. There is no difference; they are interchangeable terms.
Correct Answer: A
Rationale: Medical diagnoses identify the pathology or disease (e.g., Pneumonia)
treated by the physician, whereas nursing diagnoses identify the human response to
actual or potential health problems (e.g., Ineffective Airway Clearance) managed by the
nurse.
Q9: A nurse sets the following goal: "The patient will tolerate clear liquids without
nausea or vomiting by postoperative day 2." Which characteristic of a SMART goal does
this statement demonstrate?
A. Specific
B. Measurable
C. Time-bound
D. Relevant
Correct Answer: C
Rationale: The phrase "by postoperative day 2" provides a specific time frame for the
goal to be achieved, fulfilling the "Time-bound" criteria of SMART goals.
Q10: A nurse performs a dressing change on a postoperative wound without a specific
physician's order because the standard of care dictates wound care. This type of
intervention is best described as:
