NURS 103 Fundamentals of Nursing Exam 1 - 2026/2027 Update WCU
1. Which nursing action is the highest priority when a nurse first enters a
patient’s room to perform an initial assessment?
A. Wash hands and observe for immediate environmental safety hazards.
B. Assess the patient’s respiratory rate and effort.
C. Check the patient’s wristband for name and date of birth.
D. Ask the patient if they are experiencing any pain.
Answer: A
Rationale: Infection control and environmental safety (checking for spills, side rails,
equipment failure) must occur immediately upon entry, followed by patient identification
and assessment.
2. A patient’s blood pressure is 158/92 mmHg. According to current guidelines,
how should the nurse document this finding?
A. Stage 2 Hypertension
B. Elevated blood pressure
C. Normal blood pressure
D. Hypertensive Crisis
Answer: A
Rationale: Stage 2 Hypertension is defined as a systolic pressure of 140 mmHg or higher
or a diastolic pressure of 90 mmHg or higher.
,3. While assessing a patient’s radial pulse, the nurse notes the rhythm is
irregular. What is the most appropriate next action?
A. Wait 30 minutes and recheck the radial pulse.
B. Document the pulse as ‘irregular’ and notify the physician.
C. Count the apical pulse for 60 seconds.
D. Ask another nurse to check the pulse simultaneously.
Answer: C
Rationale: When an irregular peripheral pulse is noted, the nurse must assess the apical
pulse for a full minute to determine the exact heart rate and identify any pulse deficits.
4. When preparing to lift a heavy patient up in bed, which principle of body
mechanics should the nurse implement?
A. Keep the knees straight and bend at the waist.
B. Keep the center of gravity high for better leverage.
C. Twist the torso to shift weight quickly.
D. Maintain a wide base of support and bend at the knees.
Answer: D
Rationale: Bending at the knees and maintaining a wide base of support lowers the center
of gravity and uses strong leg muscles, reducing the risk of back injury.
5. A patient with Clostridioides difficile (C. diff) is placed on contact precautions.
Which action is required for proper hand hygiene?
A. Use an alcohol-based hand rub for 15 seconds.
B. Wear gloves, which eliminates the need for hand hygiene.
C. Wash hands with soap and water for at least 20 seconds.
D. Apply sterile water to hands before and after care.
Answer: C
Rationale: Alcohol-based hand rubs are ineffective against C. diff spores; physical
scrubbing with soap and water is required to mechanically remove them.
, 6. During the planning phase of the nursing process, the nurse develops
‘SMART’ goals. What does the ‘M’ in SMART represent?
A. Meaningful
B. Motivational
C. Measurable
D. Manageable
Answer: C
Rationale: SMART goals must be Specific, Measurable, Attainable, Relevant, and Time-
bound to effectively evaluate patient progress.
7. Which stage of the nursing process involves the nurse determining if the
patient’s outcomes were met?
A. Implementation
B. Evaluation
C. Diagnosis
D. Assessment
Answer: B
Rationale: Evaluation is the step where the nurse compares the patient’s current status
with the desired outcomes to see if the goals were achieved.
8. A nurse is caring for a patient who is at high risk for falls. Which intervention
is most appropriate?
A. Keep all four side rails up at all times.
B. Place the bed in the highest position for easier exit.
C. Turn off all lights in the room at night to promote sleep.
D. Ensure the call light is within reach and explain its use.
Answer: D
Rationale: Keeping the call light within reach ensures the patient can ask for help before
attempting to move; four side rails up is considered a restraint and should be avoided.
1. Which nursing action is the highest priority when a nurse first enters a
patient’s room to perform an initial assessment?
A. Wash hands and observe for immediate environmental safety hazards.
B. Assess the patient’s respiratory rate and effort.
C. Check the patient’s wristband for name and date of birth.
D. Ask the patient if they are experiencing any pain.
Answer: A
Rationale: Infection control and environmental safety (checking for spills, side rails,
equipment failure) must occur immediately upon entry, followed by patient identification
and assessment.
2. A patient’s blood pressure is 158/92 mmHg. According to current guidelines,
how should the nurse document this finding?
A. Stage 2 Hypertension
B. Elevated blood pressure
C. Normal blood pressure
D. Hypertensive Crisis
Answer: A
Rationale: Stage 2 Hypertension is defined as a systolic pressure of 140 mmHg or higher
or a diastolic pressure of 90 mmHg or higher.
,3. While assessing a patient’s radial pulse, the nurse notes the rhythm is
irregular. What is the most appropriate next action?
A. Wait 30 minutes and recheck the radial pulse.
B. Document the pulse as ‘irregular’ and notify the physician.
C. Count the apical pulse for 60 seconds.
D. Ask another nurse to check the pulse simultaneously.
Answer: C
Rationale: When an irregular peripheral pulse is noted, the nurse must assess the apical
pulse for a full minute to determine the exact heart rate and identify any pulse deficits.
4. When preparing to lift a heavy patient up in bed, which principle of body
mechanics should the nurse implement?
A. Keep the knees straight and bend at the waist.
B. Keep the center of gravity high for better leverage.
C. Twist the torso to shift weight quickly.
D. Maintain a wide base of support and bend at the knees.
Answer: D
Rationale: Bending at the knees and maintaining a wide base of support lowers the center
of gravity and uses strong leg muscles, reducing the risk of back injury.
5. A patient with Clostridioides difficile (C. diff) is placed on contact precautions.
Which action is required for proper hand hygiene?
A. Use an alcohol-based hand rub for 15 seconds.
B. Wear gloves, which eliminates the need for hand hygiene.
C. Wash hands with soap and water for at least 20 seconds.
D. Apply sterile water to hands before and after care.
Answer: C
Rationale: Alcohol-based hand rubs are ineffective against C. diff spores; physical
scrubbing with soap and water is required to mechanically remove them.
, 6. During the planning phase of the nursing process, the nurse develops
‘SMART’ goals. What does the ‘M’ in SMART represent?
A. Meaningful
B. Motivational
C. Measurable
D. Manageable
Answer: C
Rationale: SMART goals must be Specific, Measurable, Attainable, Relevant, and Time-
bound to effectively evaluate patient progress.
7. Which stage of the nursing process involves the nurse determining if the
patient’s outcomes were met?
A. Implementation
B. Evaluation
C. Diagnosis
D. Assessment
Answer: B
Rationale: Evaluation is the step where the nurse compares the patient’s current status
with the desired outcomes to see if the goals were achieved.
8. A nurse is caring for a patient who is at high risk for falls. Which intervention
is most appropriate?
A. Keep all four side rails up at all times.
B. Place the bed in the highest position for easier exit.
C. Turn off all lights in the room at night to promote sleep.
D. Ensure the call light is within reach and explain its use.
Answer: D
Rationale: Keeping the call light within reach ensures the patient can ask for help before
attempting to move; four side rails up is considered a restraint and should be avoided.
