PNR 106/PNR106 Final Exam V2 |
Foundations of Nursing Q&A with
Rationale | Fortis College
1. Which phase of the nursing process involves the systematic collection of data to determine
the client’s health status?
A. Planning
B. Implementation
C. Assessment
D. Evaluation
Correct Answer: C
Expert Explanation: Assessment is the first step of the nursing process where the nurse
gathers subjective and objective data. This phase is critical because it forms the basis for
the rest of the nursing care plan. Accurate data collection ensures that subsequent nursing
diagnoses and interventions are appropriate for the client’s specific needs.
2. A nurse is caring for a client diagnosed with Clostridium difficile (C. diff). Which hand
hygiene method is most appropriate?
A. Using an alcohol-based hand rub for 15 seconds
B. Applying an antimicrobial foam
C. Wiping hands with a sterile saline cloth
,D. Washing hands with soap and water
Correct Answer: D
Expert Explanation: Hand hygiene with soap and water is mandatory for C. diff because
alcohol-based rubs are ineffective against bacterial spores. The mechanical action of
scrubbing under running water helps to physically remove the spores from the skin
surface. This practice is a standard contact precaution requirement to prevent the spread
of infection within the healthcare environment.
3. When moving a client up in bed, which principle of body mechanics should the nurse
prioritize?
A. Keep the knees straight and bend at the waist
B. Stand with a narrow base of support
C. Raise the bed to a comfortable working height
D. Pull the client using the back muscles
Correct Answer: C
Expert Explanation: Raising the bed to a waist-high level prevents unnecessary strain on
the nurse’s back by allowing for a more ergonomic posture. Proper body mechanics also
include maintaining a wide base of support and using the large muscles of the legs rather
than the back. These techniques significantly reduce the risk of musculoskeletal injuries
during patient handling tasks.
, 4. A nurse is preparing to administer an enema. In which position should the client be placed?
A. High-Fowler’s
B. Supine
C. Prone
D. Left-Sims’
Correct Answer: D
Expert Explanation: The Left-Sims’ position is preferred for enema administration
because it allows the solution to flow by gravity into the sigmoid colon and rectum. This
position involves the client lying on the left side with the right knee flexed. Proper
positioning enhances the effectiveness of the procedure and minimizes discomfort for the
patient.
5. Which of the following is considered ‘subjective’ data during a nursing assessment?
A. The client reports feeling nauseated
B. The client’s skin is warm and dry
C. The client’s blood pressure is 140/90 mmHg
D. The client has a productive cough
Correct Answer: A
Expert Explanation: Subjective data consists of information that the client describes, such
as feelings, perceptions, or symptoms. This data cannot be independently verified by the
Foundations of Nursing Q&A with
Rationale | Fortis College
1. Which phase of the nursing process involves the systematic collection of data to determine
the client’s health status?
A. Planning
B. Implementation
C. Assessment
D. Evaluation
Correct Answer: C
Expert Explanation: Assessment is the first step of the nursing process where the nurse
gathers subjective and objective data. This phase is critical because it forms the basis for
the rest of the nursing care plan. Accurate data collection ensures that subsequent nursing
diagnoses and interventions are appropriate for the client’s specific needs.
2. A nurse is caring for a client diagnosed with Clostridium difficile (C. diff). Which hand
hygiene method is most appropriate?
A. Using an alcohol-based hand rub for 15 seconds
B. Applying an antimicrobial foam
C. Wiping hands with a sterile saline cloth
,D. Washing hands with soap and water
Correct Answer: D
Expert Explanation: Hand hygiene with soap and water is mandatory for C. diff because
alcohol-based rubs are ineffective against bacterial spores. The mechanical action of
scrubbing under running water helps to physically remove the spores from the skin
surface. This practice is a standard contact precaution requirement to prevent the spread
of infection within the healthcare environment.
3. When moving a client up in bed, which principle of body mechanics should the nurse
prioritize?
A. Keep the knees straight and bend at the waist
B. Stand with a narrow base of support
C. Raise the bed to a comfortable working height
D. Pull the client using the back muscles
Correct Answer: C
Expert Explanation: Raising the bed to a waist-high level prevents unnecessary strain on
the nurse’s back by allowing for a more ergonomic posture. Proper body mechanics also
include maintaining a wide base of support and using the large muscles of the legs rather
than the back. These techniques significantly reduce the risk of musculoskeletal injuries
during patient handling tasks.
, 4. A nurse is preparing to administer an enema. In which position should the client be placed?
A. High-Fowler’s
B. Supine
C. Prone
D. Left-Sims’
Correct Answer: D
Expert Explanation: The Left-Sims’ position is preferred for enema administration
because it allows the solution to flow by gravity into the sigmoid colon and rectum. This
position involves the client lying on the left side with the right knee flexed. Proper
positioning enhances the effectiveness of the procedure and minimizes discomfort for the
patient.
5. Which of the following is considered ‘subjective’ data during a nursing assessment?
A. The client reports feeling nauseated
B. The client’s skin is warm and dry
C. The client’s blood pressure is 140/90 mmHg
D. The client has a productive cough
Correct Answer: A
Expert Explanation: Subjective data consists of information that the client describes, such
as feelings, perceptions, or symptoms. This data cannot be independently verified by the
