NURS 103 Fundamentals of Nursing - Actual Exam 2 (WCU) 2026
|WCU
1. A nurse is caring for a client diagnosed with Clostridium difficile (C. diff).
Which hand hygiene practice is required when leaving the client’s room?
A. Washing hands with soap and water for at least 20 seconds
B. Using an alcohol-based hand rub for 15 seconds
C. Wiping hands with a sterile 2% chlorhexidine wipe
D. Using hand sanitizer containing at least 60% alcohol
Answer: A
Rationale: Alcohol-based sanitizers do not kill C. diff spores; physical friction and rinsing
with soap and water are necessary to remove them from the skin.
2. When performing a physical assessment of the abdomen, in what order
should the nurse perform the following techniques?
A. Inspection, Palpation, Percussion, Auscultation
B. Inspection, Auscultation, Percussion, Palpation
C. Palpation, Percussion, Auscultation, Inspection
D. Auscultation, Inspection, Palpation, Percussion
Answer: B
Rationale: Auscultation is performed before percussion and palpation to avoid stimulating
bowel sounds, which would lead to an inaccurate assessment.
,3. A nurse is assessing a patient’s radial pulse and notes it is irregular. Which
action should the nurse take next?
A. Assess the apical pulse for one full minute
B. Measure the pulse for 30 seconds and multiply by 2
C. Report the finding to the provider immediately
D. Document the pulse as ‘thready’ and move to the next vital sign
Answer: A
Rationale: If a peripheral pulse is irregular, the nurse must assess the apical pulse for 60
seconds to obtain the most accurate heart rate and rhythm.
4. Which of the following findings is considered a ‘late’ sign of systemic
hypoxia?
A. Restlessness and agitation
B. Tachypnea and diaphoresis
C. Tachycardia and hypertension
D. Cyanosis of the mucous membranes
Answer: D
Rationale: Restlessness and tachycardia are early signs of hypoxia; cyanosis is a late sign
indicating severe oxygen deprivation.
5. The nurse is applying a wrist restraint to a patient who is pulling at their
endotracheal tube. Which action ensures safe application?
A. Ensure two fingers can be inserted between the restraint and the wrist
B. Attach the restraint straps to the side rails of the bed
C. Tie the restraint using a double knot for security
D. Remove the restraint every 4 hours to assess skin integrity
Answer: A
Rationale: Proper fit (two fingers) prevents neurovascular compromise. Restraints should
be tied to the bed frame (not rails) using a quick-release knot and removed every 2 hours.
, 6. A client has a Braden Scale score of 12. What is the nurse’s priority
interpretation of this score?
A. The client is at low risk for skin breakdown
B. The client is at high risk for pressure injury development
C. The client has an existing Stage 2 pressure injury
D. The client is at no risk for skin breakdown
Answer: B
Rationale: On the Braden Scale, lower scores indicate higher risk. A score of 12 typically
indicates high risk (usually 10-12 range).
7. The nurse notes that a patient’s surgical wound has a thick, yellow-green
drainage. How should the nurse document this?
A. Serosanguineous drainage
B. Serous drainage
C. Purulent drainage
D. Sanguineous drainage
Answer: C
Rationale: Purulent drainage is thick and consists of WBCs, dead tissue, and bacteria, often
appearing yellow, green, or brown.
8. When moving a patient up in bed using a drawsheet, what is the most
important action to prevent nurse back injury?
A. Keep the knees locked while pulling
B. Maintain a narrow base of support
C. Pull from a position at the foot of the bed
D. Flex the knees and keep the back straight
Answer: D
Rationale: Using major muscle groups (legs) while maintaining an upright spine reduces
the risk of musculoskeletal injury.
|WCU
1. A nurse is caring for a client diagnosed with Clostridium difficile (C. diff).
Which hand hygiene practice is required when leaving the client’s room?
A. Washing hands with soap and water for at least 20 seconds
B. Using an alcohol-based hand rub for 15 seconds
C. Wiping hands with a sterile 2% chlorhexidine wipe
D. Using hand sanitizer containing at least 60% alcohol
Answer: A
Rationale: Alcohol-based sanitizers do not kill C. diff spores; physical friction and rinsing
with soap and water are necessary to remove them from the skin.
2. When performing a physical assessment of the abdomen, in what order
should the nurse perform the following techniques?
A. Inspection, Palpation, Percussion, Auscultation
B. Inspection, Auscultation, Percussion, Palpation
C. Palpation, Percussion, Auscultation, Inspection
D. Auscultation, Inspection, Palpation, Percussion
Answer: B
Rationale: Auscultation is performed before percussion and palpation to avoid stimulating
bowel sounds, which would lead to an inaccurate assessment.
,3. A nurse is assessing a patient’s radial pulse and notes it is irregular. Which
action should the nurse take next?
A. Assess the apical pulse for one full minute
B. Measure the pulse for 30 seconds and multiply by 2
C. Report the finding to the provider immediately
D. Document the pulse as ‘thready’ and move to the next vital sign
Answer: A
Rationale: If a peripheral pulse is irregular, the nurse must assess the apical pulse for 60
seconds to obtain the most accurate heart rate and rhythm.
4. Which of the following findings is considered a ‘late’ sign of systemic
hypoxia?
A. Restlessness and agitation
B. Tachypnea and diaphoresis
C. Tachycardia and hypertension
D. Cyanosis of the mucous membranes
Answer: D
Rationale: Restlessness and tachycardia are early signs of hypoxia; cyanosis is a late sign
indicating severe oxygen deprivation.
5. The nurse is applying a wrist restraint to a patient who is pulling at their
endotracheal tube. Which action ensures safe application?
A. Ensure two fingers can be inserted between the restraint and the wrist
B. Attach the restraint straps to the side rails of the bed
C. Tie the restraint using a double knot for security
D. Remove the restraint every 4 hours to assess skin integrity
Answer: A
Rationale: Proper fit (two fingers) prevents neurovascular compromise. Restraints should
be tied to the bed frame (not rails) using a quick-release knot and removed every 2 hours.
, 6. A client has a Braden Scale score of 12. What is the nurse’s priority
interpretation of this score?
A. The client is at low risk for skin breakdown
B. The client is at high risk for pressure injury development
C. The client has an existing Stage 2 pressure injury
D. The client is at no risk for skin breakdown
Answer: B
Rationale: On the Braden Scale, lower scores indicate higher risk. A score of 12 typically
indicates high risk (usually 10-12 range).
7. The nurse notes that a patient’s surgical wound has a thick, yellow-green
drainage. How should the nurse document this?
A. Serosanguineous drainage
B. Serous drainage
C. Purulent drainage
D. Sanguineous drainage
Answer: C
Rationale: Purulent drainage is thick and consists of WBCs, dead tissue, and bacteria, often
appearing yellow, green, or brown.
8. When moving a patient up in bed using a drawsheet, what is the most
important action to prevent nurse back injury?
A. Keep the knees locked while pulling
B. Maintain a narrow base of support
C. Pull from a position at the foot of the bed
D. Flex the knees and keep the back straight
Answer: D
Rationale: Using major muscle groups (legs) while maintaining an upright spine reduces
the risk of musculoskeletal injury.
