PNR 106/PNR106 Final Exam V3 |
Foundations of Nursing Q&A with
Rationale | Fortis College
1. A nurse is preparing to perform a physical assessment on a newly admitted client. Which
step of the nursing process is the nurse currently performing?
A. Implementation
B. Assessment
C. Evaluation
D. Planning
Correct Answer: B
Expert Explanation: Assessment is the initial step of the nursing process where the nurse
collects subjective and objective data. This phase involves systematic data collection
through observation, interviews, and physical examinations. Accurate assessment is
foundational for the development of a nursing diagnosis and a tailored plan of care.
2. Which of the following is considered a subjective finding during a patient assessment?
A. The patient’s blood pressure is 140/90 mmHg.
B. The patient’s temperature is 101.2 degrees Fahrenheit.
C. The patient has a skin rash on their upper chest.
D. The patient states, ‘I feel very dizzy when I stand up.’
,Correct Answer: D
Expert Explanation: Subjective data consists of information that the patient reports and
cannot be independently verified by the nurse. In this case, the feeling of dizziness is a
personal experience reported by the patient. Objective data, on the other hand, refers to
measurable signs like blood pressure and temperature.
3. A nurse is caring for a client who is on contact precautions. Which personal protective
equipment (PPE) should the nurse don before entering the room?
A. N95 respirator and gloves
B. Gown and gloves
C. Surgical mask and eye protection
D. Gloves and goggles only
Correct Answer: B
Expert Explanation: Contact precautions are used for pathogens spread by direct or
indirect contact with the patient or their environment. The nurse must wear a gown and
gloves to prevent the transmission of microorganisms to their skin or clothing. Proper
donning and doffing techniques are essential to maintain infection control standards.
4. According to Maslow’s Hierarchy of Needs, which of the following patient needs should the
nurse address first?
A. The patient’s need for oxygen and hydration
B. The patient’s need for self-esteem
, C. The patient’s need for social interaction
D. The patient’s need for safety and security
Correct Answer: A
Expert Explanation: Maslow’s Hierarchy prioritizes physiological needs, such as
breathing, food, and water, over all other needs. These are essential for survival and must
be met before a patient can progress to higher-level needs like safety or self-actualization.
Prioritizing these needs ensures the patient’s immediate stabilization and well-being.
5. A nurse is assessing a client’s pulse and finds it to be irregular. What is the nurse’s next
best action?
A. Document the finding and recheck in 4 hours.
B. Administer heart medication immediately.
C. Count the apical pulse for one full minute.
D. Notify the physician of a medical emergency.
Correct Answer: C
Expert Explanation: When a peripheral pulse is found to be irregular, the apical pulse
must be assessed for one full minute to obtain the most accurate heart rate and rhythm.
This helps identify discrepancies between the heart’s contraction and the peripheral pulse,
known as a pulse deficit. This measurement provides critical data for the physician to
determine the appropriate intervention.
Foundations of Nursing Q&A with
Rationale | Fortis College
1. A nurse is preparing to perform a physical assessment on a newly admitted client. Which
step of the nursing process is the nurse currently performing?
A. Implementation
B. Assessment
C. Evaluation
D. Planning
Correct Answer: B
Expert Explanation: Assessment is the initial step of the nursing process where the nurse
collects subjective and objective data. This phase involves systematic data collection
through observation, interviews, and physical examinations. Accurate assessment is
foundational for the development of a nursing diagnosis and a tailored plan of care.
2. Which of the following is considered a subjective finding during a patient assessment?
A. The patient’s blood pressure is 140/90 mmHg.
B. The patient’s temperature is 101.2 degrees Fahrenheit.
C. The patient has a skin rash on their upper chest.
D. The patient states, ‘I feel very dizzy when I stand up.’
,Correct Answer: D
Expert Explanation: Subjective data consists of information that the patient reports and
cannot be independently verified by the nurse. In this case, the feeling of dizziness is a
personal experience reported by the patient. Objective data, on the other hand, refers to
measurable signs like blood pressure and temperature.
3. A nurse is caring for a client who is on contact precautions. Which personal protective
equipment (PPE) should the nurse don before entering the room?
A. N95 respirator and gloves
B. Gown and gloves
C. Surgical mask and eye protection
D. Gloves and goggles only
Correct Answer: B
Expert Explanation: Contact precautions are used for pathogens spread by direct or
indirect contact with the patient or their environment. The nurse must wear a gown and
gloves to prevent the transmission of microorganisms to their skin or clothing. Proper
donning and doffing techniques are essential to maintain infection control standards.
4. According to Maslow’s Hierarchy of Needs, which of the following patient needs should the
nurse address first?
A. The patient’s need for oxygen and hydration
B. The patient’s need for self-esteem
, C. The patient’s need for social interaction
D. The patient’s need for safety and security
Correct Answer: A
Expert Explanation: Maslow’s Hierarchy prioritizes physiological needs, such as
breathing, food, and water, over all other needs. These are essential for survival and must
be met before a patient can progress to higher-level needs like safety or self-actualization.
Prioritizing these needs ensures the patient’s immediate stabilization and well-being.
5. A nurse is assessing a client’s pulse and finds it to be irregular. What is the nurse’s next
best action?
A. Document the finding and recheck in 4 hours.
B. Administer heart medication immediately.
C. Count the apical pulse for one full minute.
D. Notify the physician of a medical emergency.
Correct Answer: C
Expert Explanation: When a peripheral pulse is found to be irregular, the apical pulse
must be assessed for one full minute to obtain the most accurate heart rate and rhythm.
This helps identify discrepancies between the heart’s contraction and the peripheral pulse,
known as a pulse deficit. This measurement provides critical data for the physician to
determine the appropriate intervention.
