NUR 104/NUR104 Final Exam V3 |
Foundations of Nursing Q&A with
Rationale | Fortis College
1. A nurse is performing a physical assessment on a client. Which of the following should the
nurse recognize as subjective data?
A. The client reports a sharp pain in their right lower abdomen.
B. The client’s blood pressure is 140/90 mmHg.
C. The client’s surgical wound is red and edematous.
D. The nurse observes the client grimacing while moving.
Correct Answer: A
Expert Explanation: Subjective data consists of information provided by the client that
cannot be measured by the nurse, such as feelings or perceptions. The report of pain is a
classic example of subjective information because it is based on the client’s internal
experience. Objective data, on the other hand, consists of observable and measurable signs
like blood pressure and physical appearance of a wound.
2. Which action is the most effective way for a nurse to prevent the spread of infection in a
clinical setting?
A. Performing hand hygiene before and after patient contact.
B. Administering prophylactic antibiotics to all patients.
,C. Wearing a mask for every patient interaction.
D. Using sterile gloves for all routine nursing tasks.
Correct Answer: A
Expert Explanation: Hand hygiene remains the single most important intervention for
preventing the transmission of healthcare-associated infections. It removes transient
microorganisms that could be transferred between patients or surfaces. Nurses must
adhere to hand hygiene protocols before touching a patient, before clean procedures, and
after exposure to body fluids.
3. A nurse is preparing to administer an oral medication to a client. Which of the following is
the first step the nurse should take?
A. Document the medication administration in the MAR.
B. Check the expiration date on the medication package.
C. Verify the client’s identity using two identifiers.
D. Assess the client’s ability to swallow the tablet.
Correct Answer: C
Expert Explanation: Identifying the client correctly is the first safety priority in the
medication administration process to prevent errors. The nurse should use at least two
patient identifiers, such as name and date of birth, according to Joint Commission
standards. This ensures the right medication is given to the right person before any other
actions are taken.
, 4. A client is at risk for developing pressure injuries. Which nursing intervention is most
appropriate to prevent skin breakdown?
A. Massage reddened bony prominences every four hours.
B. Keep the head of the bed elevated at 90 degrees.
C. Reposition the client at least every two hours.
D. Apply a thick layer of cornstarch to the skin.
Correct Answer: C
Expert Explanation: Frequent repositioning relieves pressure on tissues and prevents
ischemia, which is the primary cause of pressure injuries. Standard practice requires
turning immobile clients every two hours while they are in bed. Massaging reddened areas
should be avoided as it can cause further tissue damage to already compromised areas.
5. A nurse is caring for a client who has a prescription for a clear liquid diet. Which food item
should the nurse include on the client’s meal tray?
A. Vanilla pudding
B. Cream of mushroom soup
C. Orange juice with pulp
D. Apple juice
Correct Answer: D
Foundations of Nursing Q&A with
Rationale | Fortis College
1. A nurse is performing a physical assessment on a client. Which of the following should the
nurse recognize as subjective data?
A. The client reports a sharp pain in their right lower abdomen.
B. The client’s blood pressure is 140/90 mmHg.
C. The client’s surgical wound is red and edematous.
D. The nurse observes the client grimacing while moving.
Correct Answer: A
Expert Explanation: Subjective data consists of information provided by the client that
cannot be measured by the nurse, such as feelings or perceptions. The report of pain is a
classic example of subjective information because it is based on the client’s internal
experience. Objective data, on the other hand, consists of observable and measurable signs
like blood pressure and physical appearance of a wound.
2. Which action is the most effective way for a nurse to prevent the spread of infection in a
clinical setting?
A. Performing hand hygiene before and after patient contact.
B. Administering prophylactic antibiotics to all patients.
,C. Wearing a mask for every patient interaction.
D. Using sterile gloves for all routine nursing tasks.
Correct Answer: A
Expert Explanation: Hand hygiene remains the single most important intervention for
preventing the transmission of healthcare-associated infections. It removes transient
microorganisms that could be transferred between patients or surfaces. Nurses must
adhere to hand hygiene protocols before touching a patient, before clean procedures, and
after exposure to body fluids.
3. A nurse is preparing to administer an oral medication to a client. Which of the following is
the first step the nurse should take?
A. Document the medication administration in the MAR.
B. Check the expiration date on the medication package.
C. Verify the client’s identity using two identifiers.
D. Assess the client’s ability to swallow the tablet.
Correct Answer: C
Expert Explanation: Identifying the client correctly is the first safety priority in the
medication administration process to prevent errors. The nurse should use at least two
patient identifiers, such as name and date of birth, according to Joint Commission
standards. This ensures the right medication is given to the right person before any other
actions are taken.
, 4. A client is at risk for developing pressure injuries. Which nursing intervention is most
appropriate to prevent skin breakdown?
A. Massage reddened bony prominences every four hours.
B. Keep the head of the bed elevated at 90 degrees.
C. Reposition the client at least every two hours.
D. Apply a thick layer of cornstarch to the skin.
Correct Answer: C
Expert Explanation: Frequent repositioning relieves pressure on tissues and prevents
ischemia, which is the primary cause of pressure injuries. Standard practice requires
turning immobile clients every two hours while they are in bed. Massaging reddened areas
should be avoided as it can cause further tissue damage to already compromised areas.
5. A nurse is caring for a client who has a prescription for a clear liquid diet. Which food item
should the nurse include on the client’s meal tray?
A. Vanilla pudding
B. Cream of mushroom soup
C. Orange juice with pulp
D. Apple juice
Correct Answer: D
