NURS 103 Fundamentals of Nursing - Exam 1 Study Guide (2026/2027
Update) WCU
1. A nurse is caring for a patient who refuses a scheduled blood transfusion for
religious reasons. The nurse respects the patient’s decision and documents the
refusal. Which ethical principle is being demonstrated?
A. Beneficence
B. Justice
C. Non-maleficence
D. Autonomy
Answer: D
Rationale: Autonomy refers to the right of patients to make their own decisions about
their healthcare, even if the healthcare provider disagrees.
2. When assessing a patient’s abdomen, in which order should the nurse
perform the physical assessment techniques?
A. Inspection, Auscultation, Percussion, Palpation
B. Inspection, Palpation, Percussion, Auscultation
C. Auscultation, Inspection, Palpation, Percussion
D. Percussion, Auscultation, Palpation, Inspection
Answer: A
Rationale: For the abdominal assessment, auscultation is performed before percussion
and palpation to avoid stimulating bowel sounds and altering the assessment findings.
,3. A nurse is preparing to administer a medication to a patient. Which action by
the nurse represents the ‘Evaluation’ step of the nursing process?
A. Checking the patient’s heart rate before giving a beta-blocker.
B. Administering the medication via the oral route.
C. Documenting the time and dose of the medication in the MAR.
D. Checking the patient’s blood pressure 30 minutes after drug administration.
Answer: D
Rationale: Evaluation involves determining the patient’s response to the intervention and
whether the expected outcomes were met.
4. A nurse is caring for a patient with Clostridioides difficile (C. diff). Which
infection control measure is mandatory for this patient?
A. Using an alcohol-based hand rub for hand hygiene.
B. Maintaining a distance of 3 feet from the patient at all times.
C. Wearing an N95 respirator when entering the room.
D. Washing hands with soap and water after patient contact.
Answer: D
Rationale: C. diff spores are resistant to alcohol-based sanitizers; therefore, mechanical
scrubbing with soap and water is required to remove them from hands.
5. A nurse is educating a student about the ‘RACE’ acronym for fire safety. What
does the ‘E’ stand for?
A. Extinguish
B. Evacuate
C. Emergency
D. Examine
Answer: A
Rationale: RACE stands for Rescue, Alarm, Contain, and Extinguish/Evacuate.
, 6. A patient has an order for physical restraints. Which of the following is a legal
requirement for the use of restraints?
A. The nurse can apply restraints for up to 48 hours without a provider’s order.
B. The restraint order must be renewed every 24 hours by a physician.
C. The nurse should check the patient’s circulation every 4 hours.
D. Restraints should be tied to the side rails for easy access.
Answer: B
Rationale: Restraint orders must be time-limited and typically renewed every 24 hours for
adults. Monitoring of circulation and skin integrity should occur much more frequently,
usually every 15-30 minutes.
7. Which of the following is considered ‘subjective data’ in a patient
assessment?
A. The patient’s blood pressure is 140/90 mmHg.
B. The patient states, ‘I feel like my heart is racing.’
C. The patient’s skin is cool and clammy to the touch.
D. The nurse observes the patient grimacing while moving.
Answer: B
Rationale: Subjective data consists of the patient’s own perceptions, feelings, and
statements (symptoms). Objective data is observable and measurable by the nurse.
8. A nurse is assisting a patient with a weak left leg to walk with a cane. Where
should the patient hold the cane?
A. In the left hand.
B. In whichever hand feels more comfortable.
C. In the right hand.
D. The patient should use two canes, one in each hand.
Answer: C
Update) WCU
1. A nurse is caring for a patient who refuses a scheduled blood transfusion for
religious reasons. The nurse respects the patient’s decision and documents the
refusal. Which ethical principle is being demonstrated?
A. Beneficence
B. Justice
C. Non-maleficence
D. Autonomy
Answer: D
Rationale: Autonomy refers to the right of patients to make their own decisions about
their healthcare, even if the healthcare provider disagrees.
2. When assessing a patient’s abdomen, in which order should the nurse
perform the physical assessment techniques?
A. Inspection, Auscultation, Percussion, Palpation
B. Inspection, Palpation, Percussion, Auscultation
C. Auscultation, Inspection, Palpation, Percussion
D. Percussion, Auscultation, Palpation, Inspection
Answer: A
Rationale: For the abdominal assessment, auscultation is performed before percussion
and palpation to avoid stimulating bowel sounds and altering the assessment findings.
,3. A nurse is preparing to administer a medication to a patient. Which action by
the nurse represents the ‘Evaluation’ step of the nursing process?
A. Checking the patient’s heart rate before giving a beta-blocker.
B. Administering the medication via the oral route.
C. Documenting the time and dose of the medication in the MAR.
D. Checking the patient’s blood pressure 30 minutes after drug administration.
Answer: D
Rationale: Evaluation involves determining the patient’s response to the intervention and
whether the expected outcomes were met.
4. A nurse is caring for a patient with Clostridioides difficile (C. diff). Which
infection control measure is mandatory for this patient?
A. Using an alcohol-based hand rub for hand hygiene.
B. Maintaining a distance of 3 feet from the patient at all times.
C. Wearing an N95 respirator when entering the room.
D. Washing hands with soap and water after patient contact.
Answer: D
Rationale: C. diff spores are resistant to alcohol-based sanitizers; therefore, mechanical
scrubbing with soap and water is required to remove them from hands.
5. A nurse is educating a student about the ‘RACE’ acronym for fire safety. What
does the ‘E’ stand for?
A. Extinguish
B. Evacuate
C. Emergency
D. Examine
Answer: A
Rationale: RACE stands for Rescue, Alarm, Contain, and Extinguish/Evacuate.
, 6. A patient has an order for physical restraints. Which of the following is a legal
requirement for the use of restraints?
A. The nurse can apply restraints for up to 48 hours without a provider’s order.
B. The restraint order must be renewed every 24 hours by a physician.
C. The nurse should check the patient’s circulation every 4 hours.
D. Restraints should be tied to the side rails for easy access.
Answer: B
Rationale: Restraint orders must be time-limited and typically renewed every 24 hours for
adults. Monitoring of circulation and skin integrity should occur much more frequently,
usually every 15-30 minutes.
7. Which of the following is considered ‘subjective data’ in a patient
assessment?
A. The patient’s blood pressure is 140/90 mmHg.
B. The patient states, ‘I feel like my heart is racing.’
C. The patient’s skin is cool and clammy to the touch.
D. The nurse observes the patient grimacing while moving.
Answer: B
Rationale: Subjective data consists of the patient’s own perceptions, feelings, and
statements (symptoms). Objective data is observable and measurable by the nurse.
8. A nurse is assisting a patient with a weak left leg to walk with a cane. Where
should the patient hold the cane?
A. In the left hand.
B. In whichever hand feels more comfortable.
C. In the right hand.
D. The patient should use two canes, one in each hand.
Answer: C
