NURS 103 Fundamentals of Nursing Comprehensive Final Exam 2026
|WCU
1. A nurse is caring for a client with a localized infection. Which of the following
assessment findings is the most specific indicator of a systemic infection?
A. Edema at the site of injury
B. Purulent drainage from a wound
C. Increase in immature white blood cells (shift to the left)
D. Pain and tenderness on palpation
Answer: C
Rationale: A ‘shift to the left’ indicates an increase in immature neutrophils (bands), which
is a classic sign that the body is responding to a systemic bacterial infection. Localized signs
like edema and drainage do not confirm systemic involvement.
2. When performing a sterile procedure, which action by the nurse would result
in a break in sterile technique?
A. Holding sterile gloved hands above the waist level
B. Opening the outer wrapper of a sterile kit away from the body
C. Dropping a sterile item onto the center of the sterile field
D. Turning one’s back to the sterile field to grab a trash can
Answer: D
Rationale: The sterile field must always be kept in view. Turning your back on a sterile
field or allowing it to fall below waist level is considered a breach of sterility.
,3. A nurse is measuring a client’s blood pressure. Which of the following errors
would result in a falsely low reading?
A. Arm positioned above the level of the heart
B. Cuff wrapped too loosely around the arm
C. Using a cuff that is too narrow
D. Deflating the cuff too slowly
Answer: A
Rationale: Positioning the arm above heart level causes a falsely low reading due to
gravity. Cuffs that are too narrow or loose typically cause falsely high readings.
4. According to Maslow’s Hierarchy of Needs, which of the following client
needs should the nurse prioritize first?
A. Assisting a client to express their feelings about a diagnosis
B. Administering oxygen to a client with an SpO2 of 88%
C. Encouraging family members to visit the client
D. Ensuring the client’s room is free of fall hazards
Answer: B
Rationale: Physiological needs (Oxygenation, Circulation, Nutrition) take priority over
safety, love/belonging, and self-esteem. ABCs (Airway, Breathing, Circulation) are the
highest priority.
5. A client is scheduled for surgery, and the nurse is witnessing the signature on
the informed consent form. What is the nurse’s primary responsibility in this
role?
A. Explaining the risks and benefits of the procedure
B. Providing alternative treatment options to the client
C. Ensuring the client is signing the form voluntarily
D. Describing the surgical steps in detail
Answer: C
, Rationale: The nurse’s role in witnessing consent is to verify that the signature is
authentic, that the client is competent, and that the consent was given voluntarily. The
surgeon is responsible for explaining the procedure.
6. Which of the following nursing interventions is an example of secondary
prevention?
A. Administering an influenza vaccine to an older adult
B. Educating a group of teenagers about the dangers of smoking
C. Performing a scoliosis screening for middle school students
D. Providing physical therapy for a client recovering from a stroke
Answer: C
Rationale: Secondary prevention focuses on early detection and screening. Primary
prevention is aimed at health promotion/prevention (vaccines), and tertiary prevention
focuses on rehabilitation.
7. A nurse is caring for a client with a Braden Scale score of 12. Which of the
following actions should the nurse include in the plan of care?
A. Apply a transparent dressing to the sacrum
B. Turn the client every 4 hours
C. Massage bony prominences to improve circulation
D. Implement a high-protein diet and frequent repositioning
Answer: D
Rationale: A Braden score of 12 indicates a high risk for pressure injuries. Interventions
include frequent turning (every 2 hours) and nutritional support. Massaging bony
prominences is contraindicated as it can cause tissue damage.
|WCU
1. A nurse is caring for a client with a localized infection. Which of the following
assessment findings is the most specific indicator of a systemic infection?
A. Edema at the site of injury
B. Purulent drainage from a wound
C. Increase in immature white blood cells (shift to the left)
D. Pain and tenderness on palpation
Answer: C
Rationale: A ‘shift to the left’ indicates an increase in immature neutrophils (bands), which
is a classic sign that the body is responding to a systemic bacterial infection. Localized signs
like edema and drainage do not confirm systemic involvement.
2. When performing a sterile procedure, which action by the nurse would result
in a break in sterile technique?
A. Holding sterile gloved hands above the waist level
B. Opening the outer wrapper of a sterile kit away from the body
C. Dropping a sterile item onto the center of the sterile field
D. Turning one’s back to the sterile field to grab a trash can
Answer: D
Rationale: The sterile field must always be kept in view. Turning your back on a sterile
field or allowing it to fall below waist level is considered a breach of sterility.
,3. A nurse is measuring a client’s blood pressure. Which of the following errors
would result in a falsely low reading?
A. Arm positioned above the level of the heart
B. Cuff wrapped too loosely around the arm
C. Using a cuff that is too narrow
D. Deflating the cuff too slowly
Answer: A
Rationale: Positioning the arm above heart level causes a falsely low reading due to
gravity. Cuffs that are too narrow or loose typically cause falsely high readings.
4. According to Maslow’s Hierarchy of Needs, which of the following client
needs should the nurse prioritize first?
A. Assisting a client to express their feelings about a diagnosis
B. Administering oxygen to a client with an SpO2 of 88%
C. Encouraging family members to visit the client
D. Ensuring the client’s room is free of fall hazards
Answer: B
Rationale: Physiological needs (Oxygenation, Circulation, Nutrition) take priority over
safety, love/belonging, and self-esteem. ABCs (Airway, Breathing, Circulation) are the
highest priority.
5. A client is scheduled for surgery, and the nurse is witnessing the signature on
the informed consent form. What is the nurse’s primary responsibility in this
role?
A. Explaining the risks and benefits of the procedure
B. Providing alternative treatment options to the client
C. Ensuring the client is signing the form voluntarily
D. Describing the surgical steps in detail
Answer: C
, Rationale: The nurse’s role in witnessing consent is to verify that the signature is
authentic, that the client is competent, and that the consent was given voluntarily. The
surgeon is responsible for explaining the procedure.
6. Which of the following nursing interventions is an example of secondary
prevention?
A. Administering an influenza vaccine to an older adult
B. Educating a group of teenagers about the dangers of smoking
C. Performing a scoliosis screening for middle school students
D. Providing physical therapy for a client recovering from a stroke
Answer: C
Rationale: Secondary prevention focuses on early detection and screening. Primary
prevention is aimed at health promotion/prevention (vaccines), and tertiary prevention
focuses on rehabilitation.
7. A nurse is caring for a client with a Braden Scale score of 12. Which of the
following actions should the nurse include in the plan of care?
A. Apply a transparent dressing to the sacrum
B. Turn the client every 4 hours
C. Massage bony prominences to improve circulation
D. Implement a high-protein diet and frequent repositioning
Answer: D
Rationale: A Braden score of 12 indicates a high risk for pressure injuries. Interventions
include frequent turning (every 2 hours) and nutritional support. Massaging bony
prominences is contraindicated as it can cause tissue damage.
