2 M A X E • S L AT N E M A D N U F
★ ★
Nursing Fundamentals Assessment
N Comprehensive Examination — Exam 2
EST. 2026
E XC E L L E N C E I N N U RS I N G E D U C AT I O N
Nursing Fundamentals — Exam 2
D E L E G AT I O N , CO M M U N I C AT I O N , M O B I L I T Y, W O U N D C A R E & S A F E T Y
INSTITUTION Nursing Fundamentals Assessment COURSE CODE Nursing Fundamentals — Exam 2
PROGRAM Practical Nursing (PN) / Associate Degree ACADEMIC YEAR
in Nursing (ADN)
EXAM TITLE Nursing Fundamentals Exam 2 TOTAL QUESTIONS 50 Questions
COURSE TITLE Fundamentals of Nursing FORMAT Multiple Choice — Select the Single Best
Answer
EXAMINATION INSTRUCTIONS
▸ Select the single best answer for each question unless otherwise instructed.
▸ Select all that apply questions are indicated — choose every correct option.
▸ Questions cover delegation, communication, mobility, wound care, safety, and infection control.
▸ Correct answers and clinical rationales appear below each question for review purposes.
▸ All content reflects current evidence-based nursing practice and ANA standards.
SECTION I — FUNDAMENTALS OF NURSING COMPREHENSIVE Questions 1 –
EXAMINATION 50
1. Which of the following tasks should NEVER be delegated by the registered nurse?
A. Ambulating a stable patient.
B. Assessment, teaching, evaluation, and planning.
C. Measuring vital signs.
D. Assisting with bathing.
CORRECT ANSWER B — Assessment, teaching, evaluation, and planning.
RATIONALE The RN must never delegate tasks that require complex assessment, critical thinking, clinical judgment, or
professional nursing knowledge. This includes: initial and ongoing assessments, patient teaching, evaluation
of patient responses, and care planning. These are the core functions of professional nursing that require RN-
level education and licensure. Tasks like ambulation, vital signs (the physical act), and bathing may be
delegated to UAPs when the patient is stable. LPNs may reinforce teaching but cannot perform the initial
teaching.
,2. What are the Five Rights of Delegation?
A. Right Patient, Right Medication, Right Dose, Right Route, Right Time.
B. Right Task, Right Circumstance, Right Direction, Right Person, Right Supervision.
C. Right Assessment, Right Diagnosis, Right Plan, Right Intervention, Right Evaluation.
D. Right to Refuse, Right to Privacy, Right to Information, Right to Safety, Right to Dignity.
CORRECT ANSWER B — Right Task, Right Circumstance, Right Direction, Right Person, Right Supervision.
RATIONALE The Five Rights of Delegation ensure safe and effective assignment of care activities: (1) Right Task —
appropriate for delegation within scope of practice, (2) Right Circumstance — patient is stable and
predictable, (3) Right Direction — clear, specific instructions provided, (4) Right Person — delegatee is
competent and authorized, (5) Right Supervision — RN monitors performance and evaluates outcomes.
Option A describes the rights of medication administration. Delegation does not absolve the RN of
accountability.
3. According to Maslow's Hierarchy of Needs, which patient should the nurse see first?
A. A patient requesting pain medication for incisional pain rated 6/10.
B. A patient who is lonely and requesting to speak with a chaplain.
C. A patient experiencing acute shortness of breath with an SpO₂ of 84%.
D. A patient with low self-esteem related to a new colostomy.
CORRECT ANSWER C — A patient experiencing acute shortness of breath with an SpO₂ of 84%.
RATIONALE Maslow's hierarchy prioritizes physiological needs (airway, breathing, circulation) above all others. Acute
respiratory distress with severe hypoxia represents a life-threatening physiological crisis requiring immediate
intervention per the ABC framework. Pain is a physiological need but is not immediately life-threatening.
Loneliness relates to love/belonging needs (level 3). Self-esteem is level 4. Physiological needs — especially
airway and breathing — always take precedence over higher-level psychosocial needs.
4. The nurse is documenting patient care. Which of the following principles should guide documentation? (Select all
that apply.)
A. Documentation must be factual, objective, accurate, concise, complete, current, and organized.
B. Subjective data should be documented in the patient's own words using quotation marks.
C. Documentation should include medications administered, teaching provided, interventions, and treatments.
D. Vague statements like "patient had a good day" are preferred for brevity.
CORRECT ANSWER A, B, C — Documentation must be factual and complete; Subjective data in quotation marks; Include
medications, teaching, interventions, and treatments.
RATIONALE Documentation must follow FACT principles: Factual, Accurate, Complete, and Timely. Subjective data (what
the patient says) must be recorded in the patient's own words in quotation marks. Documentation should
include: findings, medications administered, correlating signs/symptoms, interventions performed, and
whether the provider was notified. Vague statements like "had a good day" are not objective, not measurable,
and do not communicate meaningful clinical information. Documentation is a legal record of care provided.
, 5. What does HIPAA protect?
A. Only the patient's financial information.
B. Insurance coverage and private patient health information.
C. Hospital staffing ratios.
D. Medication administration schedules.
CORRECT ANSWER B — Insurance coverage and private patient health information.
RATIONALE HIPAA (Health Insurance Portability and Accountability Act) serves dual purposes: (1) protecting health
insurance coverage for workers when they change or lose jobs, and (2) establishing national standards for
protecting the privacy and security of individually identifiable health information. Under HIPAA, nurses must
safeguard all patient information — verbal, written, and electronic. Disclosures require patient authorization.
Violations carry significant civil and criminal penalties. Privacy is physical seclusion; confidentiality is not
disclosing information without consent.
6. Which type of communication technique invites the patient to share more information?
A. Closed-ended questions.
B. Open-ended questions.
C. Giving advice.
D. False reassurance.
CORRECT ANSWER B — Open-ended questions.
RATIONALE Open-ended questions (beginning with "What," "Tell me about," "Describe") encourage the patient to
elaborate and share more information. They cannot be answered with a simple "yes" or "no." Closed-ended
questions elicit specific factual answers but limit discussion. Giving advice takes decision-making autonomy
away from the patient. False reassurance invalidates the patient's feelings. Therapeutic communication
techniques include: open-ended questions, restating, reflection, active listening, summarizing, affirmations,
and motivational interviewing.
7. Which communication technique involves paraphrasing what the patient said to ensure understanding?
A. Challenging.
B. Minimizing.
C. Restating.
D. Dismissing.
CORRECT ANSWER C — Restating.
RATIONALE Restating (paraphrasing) is a therapeutic communication technique where the nurse repeats the essential
content of the patient's message in different words to confirm understanding and encourage further
elaboration. Reflection focuses on the feelings behind the message. Challenging makes the patient defend
their actions. Minimizing dismisses the patient's feelings as invalid. Dismissing fails to acknowledge the
patient's concern. Restating validates that the nurse is listening and accurately interpreting the patient's
communication.
★ ★
Nursing Fundamentals Assessment
N Comprehensive Examination — Exam 2
EST. 2026
E XC E L L E N C E I N N U RS I N G E D U C AT I O N
Nursing Fundamentals — Exam 2
D E L E G AT I O N , CO M M U N I C AT I O N , M O B I L I T Y, W O U N D C A R E & S A F E T Y
INSTITUTION Nursing Fundamentals Assessment COURSE CODE Nursing Fundamentals — Exam 2
PROGRAM Practical Nursing (PN) / Associate Degree ACADEMIC YEAR
in Nursing (ADN)
EXAM TITLE Nursing Fundamentals Exam 2 TOTAL QUESTIONS 50 Questions
COURSE TITLE Fundamentals of Nursing FORMAT Multiple Choice — Select the Single Best
Answer
EXAMINATION INSTRUCTIONS
▸ Select the single best answer for each question unless otherwise instructed.
▸ Select all that apply questions are indicated — choose every correct option.
▸ Questions cover delegation, communication, mobility, wound care, safety, and infection control.
▸ Correct answers and clinical rationales appear below each question for review purposes.
▸ All content reflects current evidence-based nursing practice and ANA standards.
SECTION I — FUNDAMENTALS OF NURSING COMPREHENSIVE Questions 1 –
EXAMINATION 50
1. Which of the following tasks should NEVER be delegated by the registered nurse?
A. Ambulating a stable patient.
B. Assessment, teaching, evaluation, and planning.
C. Measuring vital signs.
D. Assisting with bathing.
CORRECT ANSWER B — Assessment, teaching, evaluation, and planning.
RATIONALE The RN must never delegate tasks that require complex assessment, critical thinking, clinical judgment, or
professional nursing knowledge. This includes: initial and ongoing assessments, patient teaching, evaluation
of patient responses, and care planning. These are the core functions of professional nursing that require RN-
level education and licensure. Tasks like ambulation, vital signs (the physical act), and bathing may be
delegated to UAPs when the patient is stable. LPNs may reinforce teaching but cannot perform the initial
teaching.
,2. What are the Five Rights of Delegation?
A. Right Patient, Right Medication, Right Dose, Right Route, Right Time.
B. Right Task, Right Circumstance, Right Direction, Right Person, Right Supervision.
C. Right Assessment, Right Diagnosis, Right Plan, Right Intervention, Right Evaluation.
D. Right to Refuse, Right to Privacy, Right to Information, Right to Safety, Right to Dignity.
CORRECT ANSWER B — Right Task, Right Circumstance, Right Direction, Right Person, Right Supervision.
RATIONALE The Five Rights of Delegation ensure safe and effective assignment of care activities: (1) Right Task —
appropriate for delegation within scope of practice, (2) Right Circumstance — patient is stable and
predictable, (3) Right Direction — clear, specific instructions provided, (4) Right Person — delegatee is
competent and authorized, (5) Right Supervision — RN monitors performance and evaluates outcomes.
Option A describes the rights of medication administration. Delegation does not absolve the RN of
accountability.
3. According to Maslow's Hierarchy of Needs, which patient should the nurse see first?
A. A patient requesting pain medication for incisional pain rated 6/10.
B. A patient who is lonely and requesting to speak with a chaplain.
C. A patient experiencing acute shortness of breath with an SpO₂ of 84%.
D. A patient with low self-esteem related to a new colostomy.
CORRECT ANSWER C — A patient experiencing acute shortness of breath with an SpO₂ of 84%.
RATIONALE Maslow's hierarchy prioritizes physiological needs (airway, breathing, circulation) above all others. Acute
respiratory distress with severe hypoxia represents a life-threatening physiological crisis requiring immediate
intervention per the ABC framework. Pain is a physiological need but is not immediately life-threatening.
Loneliness relates to love/belonging needs (level 3). Self-esteem is level 4. Physiological needs — especially
airway and breathing — always take precedence over higher-level psychosocial needs.
4. The nurse is documenting patient care. Which of the following principles should guide documentation? (Select all
that apply.)
A. Documentation must be factual, objective, accurate, concise, complete, current, and organized.
B. Subjective data should be documented in the patient's own words using quotation marks.
C. Documentation should include medications administered, teaching provided, interventions, and treatments.
D. Vague statements like "patient had a good day" are preferred for brevity.
CORRECT ANSWER A, B, C — Documentation must be factual and complete; Subjective data in quotation marks; Include
medications, teaching, interventions, and treatments.
RATIONALE Documentation must follow FACT principles: Factual, Accurate, Complete, and Timely. Subjective data (what
the patient says) must be recorded in the patient's own words in quotation marks. Documentation should
include: findings, medications administered, correlating signs/symptoms, interventions performed, and
whether the provider was notified. Vague statements like "had a good day" are not objective, not measurable,
and do not communicate meaningful clinical information. Documentation is a legal record of care provided.
, 5. What does HIPAA protect?
A. Only the patient's financial information.
B. Insurance coverage and private patient health information.
C. Hospital staffing ratios.
D. Medication administration schedules.
CORRECT ANSWER B — Insurance coverage and private patient health information.
RATIONALE HIPAA (Health Insurance Portability and Accountability Act) serves dual purposes: (1) protecting health
insurance coverage for workers when they change or lose jobs, and (2) establishing national standards for
protecting the privacy and security of individually identifiable health information. Under HIPAA, nurses must
safeguard all patient information — verbal, written, and electronic. Disclosures require patient authorization.
Violations carry significant civil and criminal penalties. Privacy is physical seclusion; confidentiality is not
disclosing information without consent.
6. Which type of communication technique invites the patient to share more information?
A. Closed-ended questions.
B. Open-ended questions.
C. Giving advice.
D. False reassurance.
CORRECT ANSWER B — Open-ended questions.
RATIONALE Open-ended questions (beginning with "What," "Tell me about," "Describe") encourage the patient to
elaborate and share more information. They cannot be answered with a simple "yes" or "no." Closed-ended
questions elicit specific factual answers but limit discussion. Giving advice takes decision-making autonomy
away from the patient. False reassurance invalidates the patient's feelings. Therapeutic communication
techniques include: open-ended questions, restating, reflection, active listening, summarizing, affirmations,
and motivational interviewing.
7. Which communication technique involves paraphrasing what the patient said to ensure understanding?
A. Challenging.
B. Minimizing.
C. Restating.
D. Dismissing.
CORRECT ANSWER C — Restating.
RATIONALE Restating (paraphrasing) is a therapeutic communication technique where the nurse repeats the essential
content of the patient's message in different words to confirm understanding and encourage further
elaboration. Reflection focuses on the feelings behind the message. Challenging makes the patient defend
their actions. Minimizing dismisses the patient's feelings as invalid. Dismissing fails to acknowledge the
patient's concern. Restating validates that the nurse is listening and accurately interpreting the patient's
communication.
