NUR 104/NUR104 Final Exam V1 |
Foundations of Nursing Q&A with
Rationale | Fortis College
1. A nurse is preparing to perform hand hygiene before caring for a client. Which action is the
most important step in preventing the spread of microorganisms?
A. Using hot water to kill bacteria on the skin
B. Drying hands from the elbows down to the fingertips
C. Applying friction for at least 20 seconds during washing
D. Turning off the faucet with the bare hands after drying
Correct Answer: C
Expert Explanation: Friction is the most effective component of handwashing for
removing transient microorganisms. The CDC recommends scrubbing for at least 20
seconds to ensure adequate cleaning. Proper hand hygiene is the single most important
intervention in preventing healthcare-associated infections.
2. The nurse is caring for a client who is scheduled for surgery. The client expresses concern
about the procedure. Which response by the nurse demonstrates therapeutic
communication?
A. ‘Everything will be fine; the surgeon is very experienced.’
B. ‘Why are you feeling worried about the surgery?’
,C. ‘You should talk to your doctor about these fears.’
D. ‘Tell me more about what is concerning you regarding the procedure.’
Correct Answer: D
Expert Explanation: Using an open-ended statement like ‘Tell me more’ encourages the
client to express their feelings and promotes a therapeutic relationship. Providing false
reassurance or asking ‘why’ questions can block communication and make the client
defensive. This technique allows the nurse to gather more assessment data about the
client’s psychosocial state.
3. Which phase of the nursing process involves the nurse determining if the client’s goals and
outcomes have been met?
A. Assessment
B. Evaluation
C. Planning
D. Implementation
Correct Answer: B
Expert Explanation: Evaluation is the final step of the nursing process where the nurse
compares the client’s current status with the desired outcomes. This phase determines the
effectiveness of the nursing care plan and whether interventions need to be modified. It is a
continuous process that ensures the patient is progressing toward health goals.
, 4. A nurse is assessing a client’s blood pressure for the first time. To ensure an accurate
reading, what should the nurse do?
A. Deflate the cuff at a rate of 10 mmHg per second
B. Position the arm above the level of the heart
C. Use a cuff that covers 40% of the arm’s circumference
D. Inflate the cuff to 50 mmHg above the palpable systolic pressure
Correct Answer: C
Expert Explanation: The bladder of the blood pressure cuff should be approximately 40%
of the circumference of the arm to ensure accuracy. If the cuff is too small, the reading will
be falsely high, and if it is too large, the reading will be falsely low. Proper positioning and
deflation rates are also critical for obtaining a reliable blood pressure measurement.
5. Which of the following describes the ethical principle of autonomy?
A. The duty to do no harm to the client
B. The obligation to be fair and distribute resources equally
C. The duty to tell the truth to the client
D. The right of the client to make their own healthcare decisions
Correct Answer: D
Expert Explanation: Autonomy refers to the client’s right to self-determination and
making informed decisions about their own medical care. Nurses support autonomy by
Foundations of Nursing Q&A with
Rationale | Fortis College
1. A nurse is preparing to perform hand hygiene before caring for a client. Which action is the
most important step in preventing the spread of microorganisms?
A. Using hot water to kill bacteria on the skin
B. Drying hands from the elbows down to the fingertips
C. Applying friction for at least 20 seconds during washing
D. Turning off the faucet with the bare hands after drying
Correct Answer: C
Expert Explanation: Friction is the most effective component of handwashing for
removing transient microorganisms. The CDC recommends scrubbing for at least 20
seconds to ensure adequate cleaning. Proper hand hygiene is the single most important
intervention in preventing healthcare-associated infections.
2. The nurse is caring for a client who is scheduled for surgery. The client expresses concern
about the procedure. Which response by the nurse demonstrates therapeutic
communication?
A. ‘Everything will be fine; the surgeon is very experienced.’
B. ‘Why are you feeling worried about the surgery?’
,C. ‘You should talk to your doctor about these fears.’
D. ‘Tell me more about what is concerning you regarding the procedure.’
Correct Answer: D
Expert Explanation: Using an open-ended statement like ‘Tell me more’ encourages the
client to express their feelings and promotes a therapeutic relationship. Providing false
reassurance or asking ‘why’ questions can block communication and make the client
defensive. This technique allows the nurse to gather more assessment data about the
client’s psychosocial state.
3. Which phase of the nursing process involves the nurse determining if the client’s goals and
outcomes have been met?
A. Assessment
B. Evaluation
C. Planning
D. Implementation
Correct Answer: B
Expert Explanation: Evaluation is the final step of the nursing process where the nurse
compares the client’s current status with the desired outcomes. This phase determines the
effectiveness of the nursing care plan and whether interventions need to be modified. It is a
continuous process that ensures the patient is progressing toward health goals.
, 4. A nurse is assessing a client’s blood pressure for the first time. To ensure an accurate
reading, what should the nurse do?
A. Deflate the cuff at a rate of 10 mmHg per second
B. Position the arm above the level of the heart
C. Use a cuff that covers 40% of the arm’s circumference
D. Inflate the cuff to 50 mmHg above the palpable systolic pressure
Correct Answer: C
Expert Explanation: The bladder of the blood pressure cuff should be approximately 40%
of the circumference of the arm to ensure accuracy. If the cuff is too small, the reading will
be falsely high, and if it is too large, the reading will be falsely low. Proper positioning and
deflation rates are also critical for obtaining a reliable blood pressure measurement.
5. Which of the following describes the ethical principle of autonomy?
A. The duty to do no harm to the client
B. The obligation to be fair and distribute resources equally
C. The duty to tell the truth to the client
D. The right of the client to make their own healthcare decisions
Correct Answer: D
Expert Explanation: Autonomy refers to the client’s right to self-determination and
making informed decisions about their own medical care. Nurses support autonomy by
