Excelsior College NUR 109 - Nursing Fundamentals
Exam Questions | Verified Practice Questions with
Answers & Detailed Rationales | Updated 2026
Edition | Comprehensive Study Guide for Nursing
Students & NCLEX Preparation
Question 1
A patient is admitted with shortness of breath. What is the priority nursing
assessment?
A) Vital signs
B) Respiratory assessment (Correct Option)
C) Neurological assessment
D) Gastrointestinal assessment
Rationale: Assessing respiratory status is crucial for patients with shortness of breath
to determine the severity and underlying cause.
Question 2
Which of the following is a primary responsibility of a nurse in patient education?
A) To provide all medical treatments
B) To ensure the patient understands their care (Correct Option)
C) To perform all diagnostic tests
D) To make decisions without patient input
Rationale: Nurses play a critical role in educating patients about their health,
treatments, and self-care to promote understanding and compliance.
Question 3
A nurse is preparing to administer medication to a patient. What is the first step in
the medication administration process?
A) Checking the patient's allergy history
B) Verifying the medication order (Correct Option)
C) Preparing the medication
D) Ensuring the correct route of administration
Rationale: The first step in medication administration is to verify the medication order
to ensure accuracy and safety.
Question 4
During a routine assessment, a nurse finds that a patient’s blood pressure is 150/95
mmHg. What should the nurse do next?
A) Notify the physician immediately
B) Recheck the blood pressure after a few minutes (Correct Option)
,C) Document the finding and continue with the assessment
D) Administer antihypertensive medication
Rationale: Rechecking the blood pressure allows for confirmation of the initial reading
before taking further action.
Question 5
A patient with diabetes is experiencing hypoglycemia. Which symptom would the
nurse expect to observe?
A) Increased thirst
B) Tremors and sweating (Correct Option)
C) Blurred vision
D) Frequent urination
Rationale: Hypoglycemia commonly presents with symptoms such as tremors,
sweating, and confusion due to low blood sugar levels.
Question 6
What is the most effective way for a nurse to prevent the spread of infection in a
healthcare setting?
A) Wearing gloves only
B) Hand hygiene (Correct Option)
C) Using antiseptic wipes
D) Isolating infected patients
Rationale: Hand hygiene is the most effective method for preventing the transmission
of infections.
Question 7
A nurse is assessing a patient who has just returned from surgery. What is the
priority assessment?
A) Pain level
B) Airway patency (Correct Option)
C) Surgical site
D) Nutritional status
Rationale: Ensuring airway patency is crucial to prevent respiratory complications
following surgery.
Question 8
When teaching a patient about dietary modifications for hypertension, which food
should the nurse encourage the patient to increase?
,A) Processed foods
B) Fruits and vegetables (Correct Option)
C) Red meat
D) Salty snacks
Rationale: Increasing fruits and vegetables can help lower blood pressure and improve
overall heart health.
Question 9
A nurse is caring for a patient with heart failure. What is the most important daily
assessment?
A) Temperature
B) Weight (Correct Option)
C) Blood glucose
D) Respiratory rate
Rationale: Daily weight monitoring is essential for patients with heart failure to assess
fluid retention and manage their condition.
Question 10
What is the primary purpose of documentation in nursing?
A) To fulfill legal requirements
B) To ensure continuity of care (Correct Option)
C) To prevent lawsuits
D) To improve hospital ratings
Rationale: Accurate documentation is vital for ensuring continuity of care among
healthcare providers.
Question 11
A nurse teaching a patient about a prescribed anticoagulant should include which
of the following points?
A) Avoid all physical activity
B) Report any unusual bleeding (Correct Option)
C) Take the medication only when symptoms occur
D) Discontinue the medication if feeling well
Rationale: Patients on anticoagulants must be informed about the risk of bleeding and
the importance of reporting any unusual bleeding or bruising.
Question 12
During a health assessment, the nurse notes a patient has a temperature of 101°F.
, What is the appropriate nursing action?
A) Administer antipyretics immediately
B) Continue with the assessment (Correct Option)
C) Notify the physician right away
D) Document it without further action
Rationale: Continuing the assessment allows the nurse to gather more information
before taking action based on the temperature.
Question 13
What should a nurse do if a patient refuses medication?
A) Document the refusal and reason (Correct Option)
B) Force the patient to take it
C) Ignore the refusal
D) Notify the physician immediately
Rationale: Documenting the refusal and any reasons provided ensures that proper
records are kept and that the healthcare team is informed.
Question 14
A nurse is preparing to educate a patient about a new diagnosis of hypertension.
Which teaching strategy is most effective?
A) Lecturing the patient
B) Using teach-back methods (Correct Option)
C) Providing written information only
D) Discussing in a loud voice
Rationale: Teach-back methods ensure that the patient understands the information by
asking them to repeat it in their own words.
Question 15
A patient is experiencing anxiety before surgery. What is the best nursing
intervention?
A) Provide reassurance and information (Correct Option)
B) Ignore the patient's concerns
C) Tell the patient to relax
D) Discuss the surgery in detail
Rationale: Providing reassurance and clear information can help alleviate anxiety and
improve the patient’s emotional state before surgery.
Exam Questions | Verified Practice Questions with
Answers & Detailed Rationales | Updated 2026
Edition | Comprehensive Study Guide for Nursing
Students & NCLEX Preparation
Question 1
A patient is admitted with shortness of breath. What is the priority nursing
assessment?
A) Vital signs
B) Respiratory assessment (Correct Option)
C) Neurological assessment
D) Gastrointestinal assessment
Rationale: Assessing respiratory status is crucial for patients with shortness of breath
to determine the severity and underlying cause.
Question 2
Which of the following is a primary responsibility of a nurse in patient education?
A) To provide all medical treatments
B) To ensure the patient understands their care (Correct Option)
C) To perform all diagnostic tests
D) To make decisions without patient input
Rationale: Nurses play a critical role in educating patients about their health,
treatments, and self-care to promote understanding and compliance.
Question 3
A nurse is preparing to administer medication to a patient. What is the first step in
the medication administration process?
A) Checking the patient's allergy history
B) Verifying the medication order (Correct Option)
C) Preparing the medication
D) Ensuring the correct route of administration
Rationale: The first step in medication administration is to verify the medication order
to ensure accuracy and safety.
Question 4
During a routine assessment, a nurse finds that a patient’s blood pressure is 150/95
mmHg. What should the nurse do next?
A) Notify the physician immediately
B) Recheck the blood pressure after a few minutes (Correct Option)
,C) Document the finding and continue with the assessment
D) Administer antihypertensive medication
Rationale: Rechecking the blood pressure allows for confirmation of the initial reading
before taking further action.
Question 5
A patient with diabetes is experiencing hypoglycemia. Which symptom would the
nurse expect to observe?
A) Increased thirst
B) Tremors and sweating (Correct Option)
C) Blurred vision
D) Frequent urination
Rationale: Hypoglycemia commonly presents with symptoms such as tremors,
sweating, and confusion due to low blood sugar levels.
Question 6
What is the most effective way for a nurse to prevent the spread of infection in a
healthcare setting?
A) Wearing gloves only
B) Hand hygiene (Correct Option)
C) Using antiseptic wipes
D) Isolating infected patients
Rationale: Hand hygiene is the most effective method for preventing the transmission
of infections.
Question 7
A nurse is assessing a patient who has just returned from surgery. What is the
priority assessment?
A) Pain level
B) Airway patency (Correct Option)
C) Surgical site
D) Nutritional status
Rationale: Ensuring airway patency is crucial to prevent respiratory complications
following surgery.
Question 8
When teaching a patient about dietary modifications for hypertension, which food
should the nurse encourage the patient to increase?
,A) Processed foods
B) Fruits and vegetables (Correct Option)
C) Red meat
D) Salty snacks
Rationale: Increasing fruits and vegetables can help lower blood pressure and improve
overall heart health.
Question 9
A nurse is caring for a patient with heart failure. What is the most important daily
assessment?
A) Temperature
B) Weight (Correct Option)
C) Blood glucose
D) Respiratory rate
Rationale: Daily weight monitoring is essential for patients with heart failure to assess
fluid retention and manage their condition.
Question 10
What is the primary purpose of documentation in nursing?
A) To fulfill legal requirements
B) To ensure continuity of care (Correct Option)
C) To prevent lawsuits
D) To improve hospital ratings
Rationale: Accurate documentation is vital for ensuring continuity of care among
healthcare providers.
Question 11
A nurse teaching a patient about a prescribed anticoagulant should include which
of the following points?
A) Avoid all physical activity
B) Report any unusual bleeding (Correct Option)
C) Take the medication only when symptoms occur
D) Discontinue the medication if feeling well
Rationale: Patients on anticoagulants must be informed about the risk of bleeding and
the importance of reporting any unusual bleeding or bruising.
Question 12
During a health assessment, the nurse notes a patient has a temperature of 101°F.
, What is the appropriate nursing action?
A) Administer antipyretics immediately
B) Continue with the assessment (Correct Option)
C) Notify the physician right away
D) Document it without further action
Rationale: Continuing the assessment allows the nurse to gather more information
before taking action based on the temperature.
Question 13
What should a nurse do if a patient refuses medication?
A) Document the refusal and reason (Correct Option)
B) Force the patient to take it
C) Ignore the refusal
D) Notify the physician immediately
Rationale: Documenting the refusal and any reasons provided ensures that proper
records are kept and that the healthcare team is informed.
Question 14
A nurse is preparing to educate a patient about a new diagnosis of hypertension.
Which teaching strategy is most effective?
A) Lecturing the patient
B) Using teach-back methods (Correct Option)
C) Providing written information only
D) Discussing in a loud voice
Rationale: Teach-back methods ensure that the patient understands the information by
asking them to repeat it in their own words.
Question 15
A patient is experiencing anxiety before surgery. What is the best nursing
intervention?
A) Provide reassurance and information (Correct Option)
B) Ignore the patient's concerns
C) Tell the patient to relax
D) Discuss the surgery in detail
Rationale: Providing reassurance and clear information can help alleviate anxiety and
improve the patient’s emotional state before surgery.
