PNR 106/PNR106 Final Exam V1 |
Foundations of Nursing Q&A with
Rationale | Fortis College
1. A nurse is preparing to provide oral care for an unconscious client. Which of the following
actions should the nurse take first?
A. Rinse the client’s mouth with a large amount of water.
B. Place the client in a side-lying position.
C. Brush the client’s teeth with a hard-bristled toothbrush.
D. Apply petroleum jelly to the client’s lips.
Correct Answer: B
Expert Explanation: The nurse should first place the client in a side-lying position with
the head turned toward the side to prevent aspiration. This position allows secretions to
drain from the mouth by gravity rather than being inhaled into the lungs. Safety is the
priority when providing care to a client who cannot protect their own airway.
2. When assessing a client’s blood pressure, the nurse notes that the cuff is too small for the
client’s arm. Which of the following results should the nurse expect?
A. The reading will be lower than the actual pressure.
B. The diastolic pressure will be impossible to hear.
C. The reading will be unaffected by the cuff size.
,D. The reading will be higher than the actual pressure.
Correct Answer: D
Expert Explanation: Using a blood pressure cuff that is too small or too narrow for the
client’s arm will result in an erroneously high blood pressure reading. The cuff must be the
appropriate size, covering about 40% of the arm circumference, to ensure accurate
pressure distribution. Proper equipment selection is a fundamental nursing competency
for obtaining reliable vital signs.
3. A nurse is caring for a client who is on contact precautions. Which of the following pieces of
personal protective equipment (PPE) is required when entering the room?
A. N95 respirator and goggles
B. Surgical mask and shoe covers
C. Gown and gloves
D. Hair cover and face shield
Correct Answer: C
Expert Explanation: Contact precautions require the use of a gown and gloves to prevent
the transmission of infectious agents through direct or indirect contact with the client or
their environment. The nurse should don this PPE before entering the room and remove it
before leaving. This standard of practice is essential for infection control and preventing
healthcare-associated infections.
, 4. Which of the following describes the ethical principle of ‘Autonomy’ in nursing practice?
A. The duty to do good for the client.
B. The commitment to tell the truth.
C. The right of the client to make their own decisions.
D. The obligation to treat all clients fairly and equally.
Correct Answer: C
Expert Explanation: Autonomy refers to the nurse’s respect for the client’s right to make
their own healthcare decisions without coercion. It involves providing the client with
necessary information to make an informed choice. Respecting autonomy is a cornerstone
of ethical nursing and patient-centered care.
5. A nurse is teaching a client about the use of a cane. On which side should the client hold
the cane?
A. On the weaker side of the body.
B. On the stronger side of the body.
C. On whichever side feels more comfortable.
D. On both sides using two canes.
Correct Answer: B
Expert Explanation: The client should hold the cane on the stronger or unaffected side of
the body to provide maximum support and balance. When walking, the cane moves
Foundations of Nursing Q&A with
Rationale | Fortis College
1. A nurse is preparing to provide oral care for an unconscious client. Which of the following
actions should the nurse take first?
A. Rinse the client’s mouth with a large amount of water.
B. Place the client in a side-lying position.
C. Brush the client’s teeth with a hard-bristled toothbrush.
D. Apply petroleum jelly to the client’s lips.
Correct Answer: B
Expert Explanation: The nurse should first place the client in a side-lying position with
the head turned toward the side to prevent aspiration. This position allows secretions to
drain from the mouth by gravity rather than being inhaled into the lungs. Safety is the
priority when providing care to a client who cannot protect their own airway.
2. When assessing a client’s blood pressure, the nurse notes that the cuff is too small for the
client’s arm. Which of the following results should the nurse expect?
A. The reading will be lower than the actual pressure.
B. The diastolic pressure will be impossible to hear.
C. The reading will be unaffected by the cuff size.
,D. The reading will be higher than the actual pressure.
Correct Answer: D
Expert Explanation: Using a blood pressure cuff that is too small or too narrow for the
client’s arm will result in an erroneously high blood pressure reading. The cuff must be the
appropriate size, covering about 40% of the arm circumference, to ensure accurate
pressure distribution. Proper equipment selection is a fundamental nursing competency
for obtaining reliable vital signs.
3. A nurse is caring for a client who is on contact precautions. Which of the following pieces of
personal protective equipment (PPE) is required when entering the room?
A. N95 respirator and goggles
B. Surgical mask and shoe covers
C. Gown and gloves
D. Hair cover and face shield
Correct Answer: C
Expert Explanation: Contact precautions require the use of a gown and gloves to prevent
the transmission of infectious agents through direct or indirect contact with the client or
their environment. The nurse should don this PPE before entering the room and remove it
before leaving. This standard of practice is essential for infection control and preventing
healthcare-associated infections.
, 4. Which of the following describes the ethical principle of ‘Autonomy’ in nursing practice?
A. The duty to do good for the client.
B. The commitment to tell the truth.
C. The right of the client to make their own decisions.
D. The obligation to treat all clients fairly and equally.
Correct Answer: C
Expert Explanation: Autonomy refers to the nurse’s respect for the client’s right to make
their own healthcare decisions without coercion. It involves providing the client with
necessary information to make an informed choice. Respecting autonomy is a cornerstone
of ethical nursing and patient-centered care.
5. A nurse is teaching a client about the use of a cane. On which side should the client hold
the cane?
A. On the weaker side of the body.
B. On the stronger side of the body.
C. On whichever side feels more comfortable.
D. On both sides using two canes.
Correct Answer: B
Expert Explanation: The client should hold the cane on the stronger or unaffected side of
the body to provide maximum support and balance. When walking, the cane moves
