NURS 103 Fundamentals Mastery Pack 2026
| 200 Exam-Ready Questions with Detailed
Rationales | Core Nursing Concepts, Priority
Setting & Clinical Thinking Skills | High-Yield
A+ Study Guide for Guaranteed Success
1. A nurse is caring for a patient who is postoperative day 1 following abdominal surgery.
Which finding requires immediate intervention?
a) Pain score of 4 on a 0–10 scale
b) Serous drainage on the abdominal dressing
c) Temperature of 99.2°F (37.3°C)
d) Heart rate of 88 bpm
Rationale: Serous drainage (clear, watery) is expected initially; however, if it becomes
purulent or sanguineous, that would be concerning. A pain score of 4 is moderate and
expected. Temperature 99.2°F is normal. HR 88 is normal. No immediate intervention
needed here – trick: all are within normal/expected except the question asks “which
finding requires immediate intervention” – none do; but since the question implies a
correct choice, the “most expected” is serous drainage as a normal finding. Wait – the
correct answer is bolded? The question as written is tricky. To comply: The correct
answer is serous drainage as expected finding. But in NCLEX, none require immediate
intervention. However, for SEO-friendly content, the bolded correct answer is Serous
drainage on the abdominal dressing because it is the only one that is a normal
finding, while the others are also normal – this question is poorly constructed. Let me
redo question 1 properly.
Corrected question 1: A nurse assesses a patient’s surgical incision 12 hours after
surgery. Which finding is most concerning?
, a) Mild erythema at suture sites
b) Purulent green drainage with foul odor
c) Serosanguineous drainage on dressing
d) Edges of incision well-approximated
Rationale: Purulent green drainage indicates infection, requiring immediate notification
of provider. Mild erythema is expected. Serosanguineous drainage is normal early post-
op. Well-approximated edges are desired.
2. A nurse is preparing to insert a nasogastric (NG) tube for gastric decompression. Which
action demonstrates correct technique?
a) Place the patient in supine position with neck hyperextended
b) Measure from the nose to the xiphoid process
c) Lubricate the tube with water-soluble lubricant
d) Advance the tube rapidly during patient inspiration
Rationale: Water-soluble lubricant eases passage and reduces trauma. Patient should
sit upright with neck flexed. Measure from nose to earlobe to xiphoid. Advance slowly
during swallowing/expiration.
3. A patient on fall precautions tries to get up alone at night. What is the nurse’s priority
action?
a) Apply a bed alarm and reassure the patient
b) Assess why the patient is trying to get up
c) Raise all four side rails
d) Administer a sedative to promote sleep
Rationale: Assess the underlying need (e.g., need to void, thirst). Bed alarms help but
don’t address the cause. Side rails may be restraint. Sedatives increase fall risk.
4. Which finding indicates proper placement of a small-bowel feeding tube after initial
insertion?
, a) Patient coughs during tube advancement
b) Aspirate pH is 4 or less
c) Tube length from nose is 30 cm
d) Instilled air produces a gurgle over the epigastrium
Rationale: Gastric pH < 5 (often 4 or less) suggests gastric placement. Coughing
suggests tracheal placement. Tube length varies. Air auscultation is unreliable.
5. A nurse is teaching a patient with peripheral arterial disease about foot care. Which
statement by the patient indicates understanding?
a) "I will apply heat to my feet if they feel cold."
b) "I will inspect my feet daily for cuts or blisters."
c) "I will soak my feet in hot water each evening."
d) "I will wear tight shoes to improve circulation."
Rationale: Daily inspection prevents undetected injury. Heat and hot water risk burns
due to decreased sensation. Tight shoes impair circulation.
6. A patient receiving continuous enteral feeds develops abdominal distention and high
gastric residual volume (300 mL). What should the nurse do first?
a) Increase the feed rate
b) Hold the feeding and assess bowel sounds
c) Flush the tube with 50 mL of air
d) Change the feeding bag
Rationale: Hold feeding to prevent aspiration; assess for ileus/obstruction. Increasing
rate worsens distention. Flushing air increases distention. Changing bag doesn’t address
cause.
7. Which nursing intervention is most effective in preventing ventilator-associated
pneumonia (VAP)?
a) Change ventilator circuit daily
b) Elevate the head of the bed to 30–45 degrees
, c) Suction the patient every hour
d) Administer prophylactic antibiotics
Rationale: Semi-recumbent position reduces aspiration risk. Circuits changed only when
soiled. Routine suctioning traumatizes mucosa. Prophylactic antibiotics risk resistance.
8. A nurse observes clear, watery drainage from the nose of a patient who sustained a
basilar skull fracture. What action is most appropriate?
a) Suction the nares deeply
b) Test the drainage for glucose
c) Ask the patient to blow their nose
d) Pack the nostrils with gauze
Rationale: Clear drainage may be cerebrospinal fluid (CSF); glucose-positive suggests
CSF. No suctioning, nose-blowing, or packing (increases infection/meningitis risk).
9. A patient reports severe chest pain that radiates to the jaw, with nausea and diaphoresis.
Vital signs: BP 90/60, HR 118, RR 24. What should the nurse do first?
a) Give a sublingual nitroglycerin tablet
b) Administer oxygen at 4 L/min via nasal cannula
c) Obtain a 12-lead ECG
d) Start a peripheral IV line
Rationale: ABCs – oxygen first. Then ECG, IV access, then nitroglycerin (contraindicated
if BP <90 systolic).
10. A nurse is calculating intake for a patient with heart failure. The patient drank 4 oz of
juice, 8 oz of milk, and had 6 oz of soup. IV fluids were 250 mL. Total intake in mL is:
a) 540 mL
b) 680 mL
c) 790 mL
d) 840 mL
| 200 Exam-Ready Questions with Detailed
Rationales | Core Nursing Concepts, Priority
Setting & Clinical Thinking Skills | High-Yield
A+ Study Guide for Guaranteed Success
1. A nurse is caring for a patient who is postoperative day 1 following abdominal surgery.
Which finding requires immediate intervention?
a) Pain score of 4 on a 0–10 scale
b) Serous drainage on the abdominal dressing
c) Temperature of 99.2°F (37.3°C)
d) Heart rate of 88 bpm
Rationale: Serous drainage (clear, watery) is expected initially; however, if it becomes
purulent or sanguineous, that would be concerning. A pain score of 4 is moderate and
expected. Temperature 99.2°F is normal. HR 88 is normal. No immediate intervention
needed here – trick: all are within normal/expected except the question asks “which
finding requires immediate intervention” – none do; but since the question implies a
correct choice, the “most expected” is serous drainage as a normal finding. Wait – the
correct answer is bolded? The question as written is tricky. To comply: The correct
answer is serous drainage as expected finding. But in NCLEX, none require immediate
intervention. However, for SEO-friendly content, the bolded correct answer is Serous
drainage on the abdominal dressing because it is the only one that is a normal
finding, while the others are also normal – this question is poorly constructed. Let me
redo question 1 properly.
Corrected question 1: A nurse assesses a patient’s surgical incision 12 hours after
surgery. Which finding is most concerning?
, a) Mild erythema at suture sites
b) Purulent green drainage with foul odor
c) Serosanguineous drainage on dressing
d) Edges of incision well-approximated
Rationale: Purulent green drainage indicates infection, requiring immediate notification
of provider. Mild erythema is expected. Serosanguineous drainage is normal early post-
op. Well-approximated edges are desired.
2. A nurse is preparing to insert a nasogastric (NG) tube for gastric decompression. Which
action demonstrates correct technique?
a) Place the patient in supine position with neck hyperextended
b) Measure from the nose to the xiphoid process
c) Lubricate the tube with water-soluble lubricant
d) Advance the tube rapidly during patient inspiration
Rationale: Water-soluble lubricant eases passage and reduces trauma. Patient should
sit upright with neck flexed. Measure from nose to earlobe to xiphoid. Advance slowly
during swallowing/expiration.
3. A patient on fall precautions tries to get up alone at night. What is the nurse’s priority
action?
a) Apply a bed alarm and reassure the patient
b) Assess why the patient is trying to get up
c) Raise all four side rails
d) Administer a sedative to promote sleep
Rationale: Assess the underlying need (e.g., need to void, thirst). Bed alarms help but
don’t address the cause. Side rails may be restraint. Sedatives increase fall risk.
4. Which finding indicates proper placement of a small-bowel feeding tube after initial
insertion?
, a) Patient coughs during tube advancement
b) Aspirate pH is 4 or less
c) Tube length from nose is 30 cm
d) Instilled air produces a gurgle over the epigastrium
Rationale: Gastric pH < 5 (often 4 or less) suggests gastric placement. Coughing
suggests tracheal placement. Tube length varies. Air auscultation is unreliable.
5. A nurse is teaching a patient with peripheral arterial disease about foot care. Which
statement by the patient indicates understanding?
a) "I will apply heat to my feet if they feel cold."
b) "I will inspect my feet daily for cuts or blisters."
c) "I will soak my feet in hot water each evening."
d) "I will wear tight shoes to improve circulation."
Rationale: Daily inspection prevents undetected injury. Heat and hot water risk burns
due to decreased sensation. Tight shoes impair circulation.
6. A patient receiving continuous enteral feeds develops abdominal distention and high
gastric residual volume (300 mL). What should the nurse do first?
a) Increase the feed rate
b) Hold the feeding and assess bowel sounds
c) Flush the tube with 50 mL of air
d) Change the feeding bag
Rationale: Hold feeding to prevent aspiration; assess for ileus/obstruction. Increasing
rate worsens distention. Flushing air increases distention. Changing bag doesn’t address
cause.
7. Which nursing intervention is most effective in preventing ventilator-associated
pneumonia (VAP)?
a) Change ventilator circuit daily
b) Elevate the head of the bed to 30–45 degrees
, c) Suction the patient every hour
d) Administer prophylactic antibiotics
Rationale: Semi-recumbent position reduces aspiration risk. Circuits changed only when
soiled. Routine suctioning traumatizes mucosa. Prophylactic antibiotics risk resistance.
8. A nurse observes clear, watery drainage from the nose of a patient who sustained a
basilar skull fracture. What action is most appropriate?
a) Suction the nares deeply
b) Test the drainage for glucose
c) Ask the patient to blow their nose
d) Pack the nostrils with gauze
Rationale: Clear drainage may be cerebrospinal fluid (CSF); glucose-positive suggests
CSF. No suctioning, nose-blowing, or packing (increases infection/meningitis risk).
9. A patient reports severe chest pain that radiates to the jaw, with nausea and diaphoresis.
Vital signs: BP 90/60, HR 118, RR 24. What should the nurse do first?
a) Give a sublingual nitroglycerin tablet
b) Administer oxygen at 4 L/min via nasal cannula
c) Obtain a 12-lead ECG
d) Start a peripheral IV line
Rationale: ABCs – oxygen first. Then ECG, IV access, then nitroglycerin (contraindicated
if BP <90 systolic).
10. A nurse is calculating intake for a patient with heart failure. The patient drank 4 oz of
juice, 8 oz of milk, and had 6 oz of soup. IV fluids were 250 mL. Total intake in mL is:
a) 540 mL
b) 680 mL
c) 790 mL
d) 840 mL
