NURS 100 | NURS100 Exam 4: Nursing
Fundamentals - WCU Updated and Latest
Questions and Correct Answers with Rationale
1. A nurse is caring for a patient who decides to stop all medical treatment for terminal
cancer. Which ethical principle is the nurse supporting by respecting this decision?
A. Autonomy
B. Non-maleficence
C. Beneficence
D. Justice
Correct Answer: A
Rationale: Autonomy refers to the right of patients to make their own healthcare decisions
without coercion. The nurse respects the individual’s self-determination even when the
decision conflicts with medical advice. This principle requires that the patient is fully
informed of the risks and benefits. Supporting a terminal patient’s right to refuse treatment
is a primary application of this concept. It ensures the patient’s values and preferences
remain central to their plan of care.
2. When performing hand hygiene with an alcohol-based hand rub, which action should the
nurse take to ensure effectiveness?
A. Rinse hands with water after applying the rub
B. Rub hands together until the solution is dry
C. Wipe the excess solution off with a paper towel
D. Only apply the solution to the palms of the hands
Correct Answer: B
Rationale: Hand hygiene is the most effective way to prevent the spread of healthcare-
associated infections. Alcohol-based rubs must be rubbed over all surfaces of the hands
including fingers and nails. The friction should continue until the hands are completely dry
for maximum efficacy. Rinsing or wiping off the solution prevents it from working as
intended. This practice is recommended by the CDC for routine decontamination when
hands are not visibly soiled.
3. A nurse is assessing a patient for orthostatic hypotension. Which finding would indicate a
positive result?
A. A decrease in systolic blood pressure of 10 mmHg when standing
B. An increase in diastolic blood pressure of 5 mmHg when standing
,C. A decrease in heart rate of 10 beats per minute when standing
D. A decrease in systolic blood pressure of 20 mmHg when standing
Correct Answer: D
Rationale: Orthostatic hypotension is defined by a significant drop in blood pressure when
moving to an upright position. A decrease in systolic pressure by at least 20 mmHg is a
standard diagnostic criterion. Alternatively, a drop in diastolic pressure of 10 mmHg or
more within three minutes of standing is significant. This condition often results in
dizziness or syncope, posing a high fall risk for patients. Monitoring these changes helps
nurses implement appropriate safety measures for patient mobility.
4. Which ethical principle is the nurse following when they provide the same quality of care
to a homeless patient as they do to a wealthy patient?
A. Fidelity
B. Beneficence
C. Veracity
D. Justice
Correct Answer: D
Rationale: Justice in nursing ethics involves the fair and equitable distribution of resources
and care. It dictates that all patients should receive the same standard of treatment
regardless of socioeconomic status. This principle prevents bias from influencing the
quality of nursing interventions provided. Nurses must advocate for fairness to ensure that
vulnerable populations are not marginalized. Equal treatment is a fundamental right of
every patient entering the healthcare system.
5. A nurse is caring for a non-English speaking patient. What is the most appropriate action to
ensure effective communication regarding care?
A. Ask a family member to interpret the medical information
B. Use a certified medical interpreter
C. Speak slowly and loudly in English
D. Use hand gestures to explain the treatment plan
Correct Answer: B
Rationale: Effective communication is essential for providing safe and patient-centered
care to diverse populations. Certified medical interpreters are trained to accurately
translate complex medical terminology and concepts. Using family members can lead to
misinterpretation or the omission of sensitive information. Clear communication ensures
the patient can provide truly informed consent for procedures. This approach respects the
patient’s primary language and promotes health literacy.
, 6. Which of the following is a primary intervention to prevent falls in an older adult patient in
a hospital setting?
A. Keeping all four side rails in the up position
B. Applying physical restraints at night
C. Keeping the bed in the highest position
D. Providing non-skid footwear
Correct Answer: D
Rationale: Fall prevention is a critical component of safety in clinical nursing practice.
Non-skid footwear provides better traction and stability when the patient is ambulating.
Keeping the bed in the lowest position is also a standard safety protocol. Using four side
rails is often considered a form of restraint and can increase the risk of injury. Nurses must
assess fall risk regularly to tailor interventions to the patient’s specific needs.
7. The nurse tells a patient that they will return in 15 minutes to reassess their pain. The
nurse returns exactly 15 minutes later. Which ethical principle does this reflect?
A. Autonomy
B. Fidelity
C. Beneficence
D. Non-maleficence
Correct Answer: B
Rationale: Fidelity refers to the nurse’s obligation to be faithful to commitments and
promises made to patients. By returning at the promised time, the nurse builds trust and a
strong therapeutic relationship. This principle is vital for maintaining the integrity of the
nursing profession. Failing to follow through can cause patient anxiety and decrease their
confidence in the care team. Consistent reliability is a key behavior in demonstrating
professional fidelity.
8. A nurse is preparing to perform a sterile dressing change. Which action would contaminate
the sterile field?
A. Opening the sterile package away from the body
B. Keeping the sterile field within eyesight at all times
C. Dropping sterile gauze onto the field from 6 inches above
D. Reaching over the sterile field to pick up an instrument
Correct Answer: D
Fundamentals - WCU Updated and Latest
Questions and Correct Answers with Rationale
1. A nurse is caring for a patient who decides to stop all medical treatment for terminal
cancer. Which ethical principle is the nurse supporting by respecting this decision?
A. Autonomy
B. Non-maleficence
C. Beneficence
D. Justice
Correct Answer: A
Rationale: Autonomy refers to the right of patients to make their own healthcare decisions
without coercion. The nurse respects the individual’s self-determination even when the
decision conflicts with medical advice. This principle requires that the patient is fully
informed of the risks and benefits. Supporting a terminal patient’s right to refuse treatment
is a primary application of this concept. It ensures the patient’s values and preferences
remain central to their plan of care.
2. When performing hand hygiene with an alcohol-based hand rub, which action should the
nurse take to ensure effectiveness?
A. Rinse hands with water after applying the rub
B. Rub hands together until the solution is dry
C. Wipe the excess solution off with a paper towel
D. Only apply the solution to the palms of the hands
Correct Answer: B
Rationale: Hand hygiene is the most effective way to prevent the spread of healthcare-
associated infections. Alcohol-based rubs must be rubbed over all surfaces of the hands
including fingers and nails. The friction should continue until the hands are completely dry
for maximum efficacy. Rinsing or wiping off the solution prevents it from working as
intended. This practice is recommended by the CDC for routine decontamination when
hands are not visibly soiled.
3. A nurse is assessing a patient for orthostatic hypotension. Which finding would indicate a
positive result?
A. A decrease in systolic blood pressure of 10 mmHg when standing
B. An increase in diastolic blood pressure of 5 mmHg when standing
,C. A decrease in heart rate of 10 beats per minute when standing
D. A decrease in systolic blood pressure of 20 mmHg when standing
Correct Answer: D
Rationale: Orthostatic hypotension is defined by a significant drop in blood pressure when
moving to an upright position. A decrease in systolic pressure by at least 20 mmHg is a
standard diagnostic criterion. Alternatively, a drop in diastolic pressure of 10 mmHg or
more within three minutes of standing is significant. This condition often results in
dizziness or syncope, posing a high fall risk for patients. Monitoring these changes helps
nurses implement appropriate safety measures for patient mobility.
4. Which ethical principle is the nurse following when they provide the same quality of care
to a homeless patient as they do to a wealthy patient?
A. Fidelity
B. Beneficence
C. Veracity
D. Justice
Correct Answer: D
Rationale: Justice in nursing ethics involves the fair and equitable distribution of resources
and care. It dictates that all patients should receive the same standard of treatment
regardless of socioeconomic status. This principle prevents bias from influencing the
quality of nursing interventions provided. Nurses must advocate for fairness to ensure that
vulnerable populations are not marginalized. Equal treatment is a fundamental right of
every patient entering the healthcare system.
5. A nurse is caring for a non-English speaking patient. What is the most appropriate action to
ensure effective communication regarding care?
A. Ask a family member to interpret the medical information
B. Use a certified medical interpreter
C. Speak slowly and loudly in English
D. Use hand gestures to explain the treatment plan
Correct Answer: B
Rationale: Effective communication is essential for providing safe and patient-centered
care to diverse populations. Certified medical interpreters are trained to accurately
translate complex medical terminology and concepts. Using family members can lead to
misinterpretation or the omission of sensitive information. Clear communication ensures
the patient can provide truly informed consent for procedures. This approach respects the
patient’s primary language and promotes health literacy.
, 6. Which of the following is a primary intervention to prevent falls in an older adult patient in
a hospital setting?
A. Keeping all four side rails in the up position
B. Applying physical restraints at night
C. Keeping the bed in the highest position
D. Providing non-skid footwear
Correct Answer: D
Rationale: Fall prevention is a critical component of safety in clinical nursing practice.
Non-skid footwear provides better traction and stability when the patient is ambulating.
Keeping the bed in the lowest position is also a standard safety protocol. Using four side
rails is often considered a form of restraint and can increase the risk of injury. Nurses must
assess fall risk regularly to tailor interventions to the patient’s specific needs.
7. The nurse tells a patient that they will return in 15 minutes to reassess their pain. The
nurse returns exactly 15 minutes later. Which ethical principle does this reflect?
A. Autonomy
B. Fidelity
C. Beneficence
D. Non-maleficence
Correct Answer: B
Rationale: Fidelity refers to the nurse’s obligation to be faithful to commitments and
promises made to patients. By returning at the promised time, the nurse builds trust and a
strong therapeutic relationship. This principle is vital for maintaining the integrity of the
nursing profession. Failing to follow through can cause patient anxiety and decrease their
confidence in the care team. Consistent reliability is a key behavior in demonstrating
professional fidelity.
8. A nurse is preparing to perform a sterile dressing change. Which action would contaminate
the sterile field?
A. Opening the sterile package away from the body
B. Keeping the sterile field within eyesight at all times
C. Dropping sterile gauze onto the field from 6 inches above
D. Reaching over the sterile field to pick up an instrument
Correct Answer: D
