NUR 2101 Final Exam 2025| 100 Questions and
Verified Answers (100% Correct Answers for
Guaranteed Pass)
A nurse in a clinic is interviewing a client who will undergo diagnostic testing. The nurse should
ask about a client's potential allergies during which phase of the nursing process?
Options:
A. Planning
B. Evaluation
C. Assessment
D. Implementation
Answer: C. Assessment
Explanation:
Assessment is the first step of the nursing process, where the nurse collects data, including
allergies, to identify potential risks before any interventions are planned or implemented.
A nurse is caring for an older adult patient who states, "I am afraid that I may fall while walking
to the bathroom during the night." Which of the following actions should the nurse take?
Options:
A. Limit the patient's fluid intake in the evening
B. Obtain a bedside commode for the patient's use
C. Leave a nightlight on in the patient's room
D. Put the side rails up and tell the patient to call the nurse before voiding
Answer: C. Leave a nightlight on in the patient's room
Explanation:
A nightlight improves visibility and reduces fall risk, whereas limiting fluids could lead to
dehydration, and side rails may increase the risk of injury if the patient attempts to climb over
them.
A nurse is caring for a client who is at risk for falls. Which of the following actions should the
nurse take? (Select All That Apply.)
Options:
A. Keep the client's room dark at night
B. Teach the client to use the call light
,C. Keep the client's bed in the lowest position
D. Place a fall risk identification band on the client's wrist
E. Assess the client every 4 hours
Answer:
B. Teach the client to use the call light
C. Keep the client's bed in the lowest position
D. Place a fall risk identification band on the client's wrist
Explanation:
These interventions help prevent falls by promoting safety awareness, easy access to assistance,
and proper bed positioning. A dark room increases fall risk, and assessing every 4 hours is
insufficient for high-risk patients.
A nurse is completing a client's history and physical examination. Which of the following
information should the nurse consider subjective data?
Options:
A. Blood pressure
B. Cyanosis
C. Nausea
D. Petechiae
Answer: C. Nausea
Explanation:
Subjective data are symptoms reported by the patient (e.g., nausea), whereas objective data (A,
B, D) are measurable or observable by the nurse.
A nurse is reviewing information about HIPAA with a newly licensed nurse. Which statement by
the nurse indicates a need for further teaching?
Options:
A. "Information about a patient can be disclosed to a family member at any time."
B. "HIPAA established regulations for individually identifiable health information in verbal,
electronic, or written form."
C. "A patient's address would be an example of personally identifiable information."
D. "HIPAA is a federal law, not a state law."
Answer: A. "Information about a patient can be disclosed to a family member at any time."
,Explanation:
HIPAA requires patient consent before disclosing protected health information (PHI) to family
members, except in emergencies or when the patient is incapacitated.
A nurse is giving a presentation about patient confidentiality. Which action is an example of a
violation of confidentiality?
Options:
A. Discussing a patient's surgical procedure with the nurse manager
B. Notifying the provider of physical examination findings
C. Identifying the patient by name when making a referral for home health services
D. Reporting laboratory findings to a member of the patient's family
Answer: D. Reporting laboratory findings to a member of the patient's family
Explanation:
Sharing lab results with family without patient consent violates HIPAA. A, B, and C are
permissible under HIPAA for care coordination.
A nurse anticipates which activity first when using the nursing process?
Options:
A. Critically analyze patient data to determine priorities
B. Collect and organize patient data
C. Set patient-centered, measurable, and realistic goals
D. Determine effectiveness of interventions
Answer: B. Collect and organize patient data
Explanation:
Assessment (data collection) is the first step of the nursing process before diagnosis, planning,
implementation, or evaluation.
A nurse is caring for a group of patients. Which situations require gloves? (Select All That
Apply.)
Options:
A. Emptying urine from an indwelling urine collection bag
B. Providing oral care
C. Changing an ostomy pouch
D. Delivering a food tray to a patient who has AIDS
E. Placing oral medication tablets into a patient's hand
Answer:
, A. Emptying urine from an indwelling urine collection bag
B. Providing oral care
C. Changing an ostomy pouch
Explanation:
Gloves are required for contact with bodily fluids (A, B, C). Delivering food (D) and handling
oral medications (E) do not typically require gloves.
A nurse is caring for a patient with an infection. Which strategy prevents transmission?
Options:
A. Changing the patient's bed linens each day
B. Encouraging the patient to consume a high-protein diet
C. Performing hand hygiene before, during, and after direct contact with the patient
D. Placing the patient in a room with positive-pressure airflow
Answer: C. Performing hand hygiene before, during, and after direct contact with the patient
Explanation:
Hand hygiene is the most effective way to prevent infection transmission. Positive-pressure
airflow (D) is used for immunocompromised patients, not infection control.
A nurse instructs a young adult about sleep habits. Which statement indicates a need for further
teaching?
Options:
A. "I don’t take naps throughout the day."
B. "I go to bed and get up routinely at the same time each day."
C. "I have a small snack and take a bath before going to bed each day."
D. "I watch television until I fall asleep at night."
Answer: D. "I watch television until I fall asleep at night."
Explanation:
Screen time before bed disrupts sleep. A, B, and C promote healthy sleep hygiene.
A nurse is teaching a patient with constipation. Which factors cause constipation? (Select All
That Apply.)
Options:
A. Excessive laxative use
B. Ignoring the urge to defecate
Verified Answers (100% Correct Answers for
Guaranteed Pass)
A nurse in a clinic is interviewing a client who will undergo diagnostic testing. The nurse should
ask about a client's potential allergies during which phase of the nursing process?
Options:
A. Planning
B. Evaluation
C. Assessment
D. Implementation
Answer: C. Assessment
Explanation:
Assessment is the first step of the nursing process, where the nurse collects data, including
allergies, to identify potential risks before any interventions are planned or implemented.
A nurse is caring for an older adult patient who states, "I am afraid that I may fall while walking
to the bathroom during the night." Which of the following actions should the nurse take?
Options:
A. Limit the patient's fluid intake in the evening
B. Obtain a bedside commode for the patient's use
C. Leave a nightlight on in the patient's room
D. Put the side rails up and tell the patient to call the nurse before voiding
Answer: C. Leave a nightlight on in the patient's room
Explanation:
A nightlight improves visibility and reduces fall risk, whereas limiting fluids could lead to
dehydration, and side rails may increase the risk of injury if the patient attempts to climb over
them.
A nurse is caring for a client who is at risk for falls. Which of the following actions should the
nurse take? (Select All That Apply.)
Options:
A. Keep the client's room dark at night
B. Teach the client to use the call light
,C. Keep the client's bed in the lowest position
D. Place a fall risk identification band on the client's wrist
E. Assess the client every 4 hours
Answer:
B. Teach the client to use the call light
C. Keep the client's bed in the lowest position
D. Place a fall risk identification band on the client's wrist
Explanation:
These interventions help prevent falls by promoting safety awareness, easy access to assistance,
and proper bed positioning. A dark room increases fall risk, and assessing every 4 hours is
insufficient for high-risk patients.
A nurse is completing a client's history and physical examination. Which of the following
information should the nurse consider subjective data?
Options:
A. Blood pressure
B. Cyanosis
C. Nausea
D. Petechiae
Answer: C. Nausea
Explanation:
Subjective data are symptoms reported by the patient (e.g., nausea), whereas objective data (A,
B, D) are measurable or observable by the nurse.
A nurse is reviewing information about HIPAA with a newly licensed nurse. Which statement by
the nurse indicates a need for further teaching?
Options:
A. "Information about a patient can be disclosed to a family member at any time."
B. "HIPAA established regulations for individually identifiable health information in verbal,
electronic, or written form."
C. "A patient's address would be an example of personally identifiable information."
D. "HIPAA is a federal law, not a state law."
Answer: A. "Information about a patient can be disclosed to a family member at any time."
,Explanation:
HIPAA requires patient consent before disclosing protected health information (PHI) to family
members, except in emergencies or when the patient is incapacitated.
A nurse is giving a presentation about patient confidentiality. Which action is an example of a
violation of confidentiality?
Options:
A. Discussing a patient's surgical procedure with the nurse manager
B. Notifying the provider of physical examination findings
C. Identifying the patient by name when making a referral for home health services
D. Reporting laboratory findings to a member of the patient's family
Answer: D. Reporting laboratory findings to a member of the patient's family
Explanation:
Sharing lab results with family without patient consent violates HIPAA. A, B, and C are
permissible under HIPAA for care coordination.
A nurse anticipates which activity first when using the nursing process?
Options:
A. Critically analyze patient data to determine priorities
B. Collect and organize patient data
C. Set patient-centered, measurable, and realistic goals
D. Determine effectiveness of interventions
Answer: B. Collect and organize patient data
Explanation:
Assessment (data collection) is the first step of the nursing process before diagnosis, planning,
implementation, or evaluation.
A nurse is caring for a group of patients. Which situations require gloves? (Select All That
Apply.)
Options:
A. Emptying urine from an indwelling urine collection bag
B. Providing oral care
C. Changing an ostomy pouch
D. Delivering a food tray to a patient who has AIDS
E. Placing oral medication tablets into a patient's hand
Answer:
, A. Emptying urine from an indwelling urine collection bag
B. Providing oral care
C. Changing an ostomy pouch
Explanation:
Gloves are required for contact with bodily fluids (A, B, C). Delivering food (D) and handling
oral medications (E) do not typically require gloves.
A nurse is caring for a patient with an infection. Which strategy prevents transmission?
Options:
A. Changing the patient's bed linens each day
B. Encouraging the patient to consume a high-protein diet
C. Performing hand hygiene before, during, and after direct contact with the patient
D. Placing the patient in a room with positive-pressure airflow
Answer: C. Performing hand hygiene before, during, and after direct contact with the patient
Explanation:
Hand hygiene is the most effective way to prevent infection transmission. Positive-pressure
airflow (D) is used for immunocompromised patients, not infection control.
A nurse instructs a young adult about sleep habits. Which statement indicates a need for further
teaching?
Options:
A. "I don’t take naps throughout the day."
B. "I go to bed and get up routinely at the same time each day."
C. "I have a small snack and take a bath before going to bed each day."
D. "I watch television until I fall asleep at night."
Answer: D. "I watch television until I fall asleep at night."
Explanation:
Screen time before bed disrupts sleep. A, B, and C promote healthy sleep hygiene.
A nurse is teaching a patient with constipation. Which factors cause constipation? (Select All
That Apply.)
Options:
A. Excessive laxative use
B. Ignoring the urge to defecate
