NURS 103 FUNDAMENTALS – High-Yield
Notes & Practice Questions | 2026/2027
Complete Nursing Fundamentals Mastery Pack with
200 Questions, Rationales & NCLEX-Aligned Concepts
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
Rationale: 1 oz = 30 mL. Juice 120 mL + milk 240 mL + soup 180 mL = 540 mL oral + 250 mL
IV = 790 mL.
11. Which patient is at highest risk for impaired skin integrity?
a) A 45-year-old with asthma using inhalers
b) A 60-year-old with controlled hypertension
c) An 80-year-old with urinary incontinence and immobility
d) A 30-year-old with a sprained ankle
Rationale: Incontinence + immobility = moisture, pressure, shear, friction – major pressure
injury risks.
12. A nurse hears an order for "KCl 40 mEq IV push." What is the best action?
a) Administer as ordered
b) Clarify the order with the provider
c) Dilute and give over 5 minutes
d) Check potassium level first
Rationale: IV push potassium is dangerous (cardiac arrest). Must be diluted and infused slowly
via pump. Clarify immediately – likely meant IV piggyback.
13. A patient has a living will that states no CPR. The patient is found unresponsive. What should
the nurse do?
a) Begin CPR until the provider arrives
b) Confirm the living will is valid and follow it
c) Call family for permission
Notes & Practice Questions | 2026/2027
Complete Nursing Fundamentals Mastery Pack with
200 Questions, Rationales & NCLEX-Aligned Concepts
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
Rationale: 1 oz = 30 mL. Juice 120 mL + milk 240 mL + soup 180 mL = 540 mL oral + 250 mL
IV = 790 mL.
11. Which patient is at highest risk for impaired skin integrity?
a) A 45-year-old with asthma using inhalers
b) A 60-year-old with controlled hypertension
c) An 80-year-old with urinary incontinence and immobility
d) A 30-year-old with a sprained ankle
Rationale: Incontinence + immobility = moisture, pressure, shear, friction – major pressure
injury risks.
12. A nurse hears an order for "KCl 40 mEq IV push." What is the best action?
a) Administer as ordered
b) Clarify the order with the provider
c) Dilute and give over 5 minutes
d) Check potassium level first
Rationale: IV push potassium is dangerous (cardiac arrest). Must be diluted and infused slowly
via pump. Clarify immediately – likely meant IV piggyback.
13. A patient has a living will that states no CPR. The patient is found unresponsive. What should
the nurse do?
a) Begin CPR until the provider arrives
b) Confirm the living will is valid and follow it
c) Call family for permission
