NURS 100 | NURS100 Final Exam: Nursing
Fundamentals - WCU Updated and Latest
Questions and Correct Answers with Rationale
1. Which action is considered the most effective method for preventing the transmission of
healthcare-associated infections?
A. Performing meticulous hand hygiene before and after patient contact
B. Wearing gloves at all times when in a patient room
C. Administering prophylactic antibiotics to all admitted patients
D. Keeping the patient in a private room regardless of diagnosis
Correct Answer: A
Rationale: Hand hygiene is universally recognized as the single most important practice to
reduce the spread of pathogens. Nurses must perform hand hygiene before touching a
patient and after any body fluid exposure risk. Alcohol-based hand sanitizers are effective
for most clinical situations except when hands are visibly soiled. Soap and water are
specifically required when dealing with spore-forming organisms like Clostridioides
difficile. Consistent adherence to this practice protects both the healthcare provider and
the patient population.
2. A nurse is collecting data during the assessment phase of the nursing process. Which of the
following is an example of objective data?
A. The patient reports feeling nauseated after breakfast
B. The patient states their pain level is a 6 out of 10
C. The patient’s blood pressure is 142/88 mmHg
D. The patient complains of feeling dizzy when standing
Correct Answer: C
Rationale: Objective data are measurable and observable findings obtained through
physical examination and diagnostic testing. Blood pressure readings provide a concrete
numerical value that can be verified by another observer. Subjective data, conversely,
consist of the patient’s personal perceptions and feelings such as pain or nausea. Accurate
documentation requires the nurse to distinguish clearly between what the patient says and
what the nurse observes. This distinction is vital for developing an evidence-based plan of
care for the individual.
3. A patient is placed on Contact Precautions for a wound infection. Which personal
protective equipment (PPE) should the nurse don before entering the room?
A. Gloves only
,B. N95 respirator and goggles
C. Surgical mask and shoe covers
D. Gown and gloves
Correct Answer: D
Rationale: Contact precautions are implemented to prevent the transmission of infectious
agents through direct or indirect touch. The required PPE for these precautions includes a
gown and gloves for all interactions involving the patient or their environment. These
items must be donned before entering the room and removed before exiting to prevent
cross-contamination. Standard precautions are still maintained in addition to these specific
transmission-based precautions. Proper disposal of used PPE is essential to maintain the
integrity of the isolation environment.
4. Which phase of the nursing process involves the nurse prioritizing diagnoses and setting
SMART goals?
A. Assessment
B. Implementation
C. Evaluation
D. Planning
Correct Answer: D
Rationale: The planning phase is the stage where the nurse develops a roadmap for
patient care based on identified needs. During this step, the nurse collaborates with the
patient to establish measurable and realistic goals. SMART goals ensure that outcomes are
specific, measurable, attainable, relevant, and time-bound. This phase also involves
selecting appropriate nursing interventions to help the patient reach these goals. Effective
planning provides a clear direction for the subsequent implementation and evaluation
phases.
5. When transferring a patient from a bed to a chair, which principle of body mechanics
should the nurse apply to prevent injury?
A. Keep the feet close together to maintain a narrow base of support
B. Maintain a wide base of support and bend at the knees
C. Twist the torso while lifting to move the patient quickly
D. Bend at the waist to reach the patient more easily
Correct Answer: B
Rationale: Proper body mechanics are essential for protecting the nurse from
musculoskeletal strain and injury. Maintaining a wide base of support provides stability
, and balance during heavy lifting or transfers. Nurses should use the large muscles of the
legs rather than the smaller muscles of the back. It is critical to avoid twisting the spine and
instead pivot the entire body when changing direction. Using assistive devices whenever
available further enhances safety for both the nurse and the patient.
6. The nurse is preparing to administer an intramuscular injection. Which of the following is
the first action to ensure medication safety?
A. Verify the patient’s identity using two identifiers
B. Clean the injection site with an alcohol swab
C. Check the medication label against the medication administration record (MAR)
D. Select the correct needle size for the patient’s muscle mass
Correct Answer: C
Rationale: Medication safety begins with the first check of the six rights of medication
administration. The nurse must compare the medication label with the provider’s orders or
the MAR before preparation. This initial step helps prevent errors related to incorrect
medication, dosage, or route. Identifying the patient is also a critical ‘right’ but occurs
immediately before administration at the bedside. Following a systematic checking process
ensures that any discrepancies are caught before the drug reaches the patient.
7. A nurse is caring for an older adult patient at high risk for falls. Which intervention is the
highest priority for safety?
A. Keep all four side rails in the upright position
B. Administer a sedative to keep the patient in bed
C. Place the call bell within the patient’s reach
D. Instruct the patient to stay in bed until the morning
Correct Answer: C
Rationale: Ensuring the call bell is within reach empowers the patient to ask for assistance
when needed for mobility. This simple intervention is a standard component of universal
fall precautions in all healthcare settings. Keeping all four side rails up is often considered a
physical restraint and can increase the risk of injury if the patient tries to climb over.
Sedation should never be used as a primary method for fall prevention as it increases
confusion and instability. Regular rounding and environmental safety checks are additional
strategies to mitigate fall risks effectively.
8. Which therapeutic communication technique is being used when the nurse says, ‘Can you
tell me more about what you mean by that?’
A. Clarifying
B. Summarizing
Fundamentals - WCU Updated and Latest
Questions and Correct Answers with Rationale
1. Which action is considered the most effective method for preventing the transmission of
healthcare-associated infections?
A. Performing meticulous hand hygiene before and after patient contact
B. Wearing gloves at all times when in a patient room
C. Administering prophylactic antibiotics to all admitted patients
D. Keeping the patient in a private room regardless of diagnosis
Correct Answer: A
Rationale: Hand hygiene is universally recognized as the single most important practice to
reduce the spread of pathogens. Nurses must perform hand hygiene before touching a
patient and after any body fluid exposure risk. Alcohol-based hand sanitizers are effective
for most clinical situations except when hands are visibly soiled. Soap and water are
specifically required when dealing with spore-forming organisms like Clostridioides
difficile. Consistent adherence to this practice protects both the healthcare provider and
the patient population.
2. A nurse is collecting data during the assessment phase of the nursing process. Which of the
following is an example of objective data?
A. The patient reports feeling nauseated after breakfast
B. The patient states their pain level is a 6 out of 10
C. The patient’s blood pressure is 142/88 mmHg
D. The patient complains of feeling dizzy when standing
Correct Answer: C
Rationale: Objective data are measurable and observable findings obtained through
physical examination and diagnostic testing. Blood pressure readings provide a concrete
numerical value that can be verified by another observer. Subjective data, conversely,
consist of the patient’s personal perceptions and feelings such as pain or nausea. Accurate
documentation requires the nurse to distinguish clearly between what the patient says and
what the nurse observes. This distinction is vital for developing an evidence-based plan of
care for the individual.
3. A patient is placed on Contact Precautions for a wound infection. Which personal
protective equipment (PPE) should the nurse don before entering the room?
A. Gloves only
,B. N95 respirator and goggles
C. Surgical mask and shoe covers
D. Gown and gloves
Correct Answer: D
Rationale: Contact precautions are implemented to prevent the transmission of infectious
agents through direct or indirect touch. The required PPE for these precautions includes a
gown and gloves for all interactions involving the patient or their environment. These
items must be donned before entering the room and removed before exiting to prevent
cross-contamination. Standard precautions are still maintained in addition to these specific
transmission-based precautions. Proper disposal of used PPE is essential to maintain the
integrity of the isolation environment.
4. Which phase of the nursing process involves the nurse prioritizing diagnoses and setting
SMART goals?
A. Assessment
B. Implementation
C. Evaluation
D. Planning
Correct Answer: D
Rationale: The planning phase is the stage where the nurse develops a roadmap for
patient care based on identified needs. During this step, the nurse collaborates with the
patient to establish measurable and realistic goals. SMART goals ensure that outcomes are
specific, measurable, attainable, relevant, and time-bound. This phase also involves
selecting appropriate nursing interventions to help the patient reach these goals. Effective
planning provides a clear direction for the subsequent implementation and evaluation
phases.
5. When transferring a patient from a bed to a chair, which principle of body mechanics
should the nurse apply to prevent injury?
A. Keep the feet close together to maintain a narrow base of support
B. Maintain a wide base of support and bend at the knees
C. Twist the torso while lifting to move the patient quickly
D. Bend at the waist to reach the patient more easily
Correct Answer: B
Rationale: Proper body mechanics are essential for protecting the nurse from
musculoskeletal strain and injury. Maintaining a wide base of support provides stability
, and balance during heavy lifting or transfers. Nurses should use the large muscles of the
legs rather than the smaller muscles of the back. It is critical to avoid twisting the spine and
instead pivot the entire body when changing direction. Using assistive devices whenever
available further enhances safety for both the nurse and the patient.
6. The nurse is preparing to administer an intramuscular injection. Which of the following is
the first action to ensure medication safety?
A. Verify the patient’s identity using two identifiers
B. Clean the injection site with an alcohol swab
C. Check the medication label against the medication administration record (MAR)
D. Select the correct needle size for the patient’s muscle mass
Correct Answer: C
Rationale: Medication safety begins with the first check of the six rights of medication
administration. The nurse must compare the medication label with the provider’s orders or
the MAR before preparation. This initial step helps prevent errors related to incorrect
medication, dosage, or route. Identifying the patient is also a critical ‘right’ but occurs
immediately before administration at the bedside. Following a systematic checking process
ensures that any discrepancies are caught before the drug reaches the patient.
7. A nurse is caring for an older adult patient at high risk for falls. Which intervention is the
highest priority for safety?
A. Keep all four side rails in the upright position
B. Administer a sedative to keep the patient in bed
C. Place the call bell within the patient’s reach
D. Instruct the patient to stay in bed until the morning
Correct Answer: C
Rationale: Ensuring the call bell is within reach empowers the patient to ask for assistance
when needed for mobility. This simple intervention is a standard component of universal
fall precautions in all healthcare settings. Keeping all four side rails up is often considered a
physical restraint and can increase the risk of injury if the patient tries to climb over.
Sedation should never be used as a primary method for fall prevention as it increases
confusion and instability. Regular rounding and environmental safety checks are additional
strategies to mitigate fall risks effectively.
8. Which therapeutic communication technique is being used when the nurse says, ‘Can you
tell me more about what you mean by that?’
A. Clarifying
B. Summarizing
