NUR 104/NUR104 Final Exam V2 |
Foundations of Nursing Q&A with
Rationale | Fortis College
1. A nurse is caring for a client who is refusing a blood transfusion for religious reasons.
According to the principle of autonomy, which action should the nurse take?
A. Request a mental health consultation to evaluate the client’s decision-making capacity.
B. Respect the client’s right to refuse the treatment after ensuring they understand the
risks.
C. Inform the client’s family so they can persuade the client to accept the treatment.
D. Administer the blood transfusion regardless because it is a life-saving measure.
Correct Answer: B
Expert Explanation: Autonomy refers to the right of the patient to make their own
decisions regarding healthcare. The nurse’s role is to ensure the patient is fully informed of
the consequences of their refusal. If the patient is competent, their decision must be
honored even if it conflicts with medical advice.
2. When using the SBAR communication tool, which information should the nurse include in
the ‘B’ section?
A. The client’s medical history, allergies, and relevant laboratory results.
B. The client’s current vital signs and mental status.
,C. A specific request for a medication change or diagnostic test.
D. The reason the nurse is calling the healthcare provider.
Correct Answer: A
Expert Explanation: The ‘B’ in SBAR stands for Background, which provides context for
the current clinical situation. This includes pertinent medical history, admitting diagnosis,
and previous treatments. Providing this information allows the receiver to understand the
patient’s holistic status before making a clinical decision.
3. Which of the following is the most effective way for a nurse to prevent the spread of
healthcare-associated infections (HAIs)?
A. Wearing gloves for all patient contact.
B. Performing consistent and thorough hand hygiene.
C. Administering prophylactic antibiotics to all high-risk clients.
D. Ensuring all patients are placed in private rooms.
Correct Answer: B
Expert Explanation: Hand hygiene is widely recognized as the single most important
practice to reduce the transmission of infectious agents. It should be performed before and
after patient contact and after removing gloves. Following proper handwashing protocols
protects both the patient and the healthcare worker from cross-contamination.
, 4. A nurse discovers a pulse deficit when assessing a client with an irregular heart rhythm.
How should the nurse accurately calculate this?
A. Add the radial pulse rate to the apical pulse rate.
B. Subtract the apical pulse rate from the radial pulse rate.
C. Multiply the apical pulse rate by two.
D. Subtract the radial pulse rate from the apical pulse rate.
Correct Answer: D
Expert Explanation: A pulse deficit occurs when the heart’s contractions are too weak to
transmit a pulse wave to the peripheral site. To calculate it, two nurses should measure the
apical and radial pulses simultaneously for one full minute. The difference between the
apical and radial rates is the deficit, indicating inefficient cardiac output.
5. According to Maslow’s Hierarchy of Needs, which client should the nurse assess first?
A. A client who is expressing feelings of loneliness and isolation.
B. A client who is requesting a PRN medication for mild anxiety.
C. A client who is reporting difficulty breathing and has an oxygen saturation of 88%.
D. A client who is worried about being able to afford their discharge medications.
Correct Answer: C
Expert Explanation: Physiological needs, such as oxygenation and airway maintenance,
are at the base of Maslow’s hierarchy and must be met first. Breathing difficulty represents
Foundations of Nursing Q&A with
Rationale | Fortis College
1. A nurse is caring for a client who is refusing a blood transfusion for religious reasons.
According to the principle of autonomy, which action should the nurse take?
A. Request a mental health consultation to evaluate the client’s decision-making capacity.
B. Respect the client’s right to refuse the treatment after ensuring they understand the
risks.
C. Inform the client’s family so they can persuade the client to accept the treatment.
D. Administer the blood transfusion regardless because it is a life-saving measure.
Correct Answer: B
Expert Explanation: Autonomy refers to the right of the patient to make their own
decisions regarding healthcare. The nurse’s role is to ensure the patient is fully informed of
the consequences of their refusal. If the patient is competent, their decision must be
honored even if it conflicts with medical advice.
2. When using the SBAR communication tool, which information should the nurse include in
the ‘B’ section?
A. The client’s medical history, allergies, and relevant laboratory results.
B. The client’s current vital signs and mental status.
,C. A specific request for a medication change or diagnostic test.
D. The reason the nurse is calling the healthcare provider.
Correct Answer: A
Expert Explanation: The ‘B’ in SBAR stands for Background, which provides context for
the current clinical situation. This includes pertinent medical history, admitting diagnosis,
and previous treatments. Providing this information allows the receiver to understand the
patient’s holistic status before making a clinical decision.
3. Which of the following is the most effective way for a nurse to prevent the spread of
healthcare-associated infections (HAIs)?
A. Wearing gloves for all patient contact.
B. Performing consistent and thorough hand hygiene.
C. Administering prophylactic antibiotics to all high-risk clients.
D. Ensuring all patients are placed in private rooms.
Correct Answer: B
Expert Explanation: Hand hygiene is widely recognized as the single most important
practice to reduce the transmission of infectious agents. It should be performed before and
after patient contact and after removing gloves. Following proper handwashing protocols
protects both the patient and the healthcare worker from cross-contamination.
, 4. A nurse discovers a pulse deficit when assessing a client with an irregular heart rhythm.
How should the nurse accurately calculate this?
A. Add the radial pulse rate to the apical pulse rate.
B. Subtract the apical pulse rate from the radial pulse rate.
C. Multiply the apical pulse rate by two.
D. Subtract the radial pulse rate from the apical pulse rate.
Correct Answer: D
Expert Explanation: A pulse deficit occurs when the heart’s contractions are too weak to
transmit a pulse wave to the peripheral site. To calculate it, two nurses should measure the
apical and radial pulses simultaneously for one full minute. The difference between the
apical and radial rates is the deficit, indicating inefficient cardiac output.
5. According to Maslow’s Hierarchy of Needs, which client should the nurse assess first?
A. A client who is expressing feelings of loneliness and isolation.
B. A client who is requesting a PRN medication for mild anxiety.
C. A client who is reporting difficulty breathing and has an oxygen saturation of 88%.
D. A client who is worried about being able to afford their discharge medications.
Correct Answer: C
Expert Explanation: Physiological needs, such as oxygenation and airway maintenance,
are at the base of Maslow’s hierarchy and must be met first. Breathing difficulty represents
