NUR 104 Midterm Exam Excelsior College
2026/2027 | Complete Exam with 250 Questions
& Correct Answers – Nursing Fundamentals
The NUR 104 Midterm Exam covers fundamental nursing concepts with emphasis on
the nursing process (ADPIE) , patient safety and infection control (including
standard/airborne/contact precautions, fall prevention, restraints, and RACE fire
safety), medication administration (the 10 rights, dosage calculations, insulin, heparin,
and opioid safety), legal/ethical issues (HIPAA, informed consent, advance directives,
refusal of treatment, and incident reports), vital signs and physical assessment (normal
ranges, PQRST pain assessment, abnormal findings), hygiene, mobility, and
positioning (pressure injury prevention, logrolling, hip precautions), oxygenation and
respiratory care (tracheostomy suctioning, pulse oximetry, COPD oxygen targets), fluid
and electrolytes (dehydration, hypokalemia, IV therapy), wound care and surgical
asepsis, elimination (catheters, ostomies, constipation), perioperative care,
and prioritization frameworks (ABCs, Maslow, safety). Additional topics may
include basic geriatric, maternal-newborn, pediatric, mental health, and end-of-life
care. The exam tests both knowledge recall and clinical judgment through prioritization,
delegation, and "best action" questions.
Safety & Infection Control
1. A nurse is preparing to insert an indwelling urinary catheter.
Which technique is required?
• A. Medical asepsis
• B. Surgical asepsis
• C. Clean technique
, • D. Hand hygiene only
Correct Answer: B – Indwelling catheter insertion requires sterile
(surgical) asepsis to prevent introducing bacteria into the bladder.
2. Which action best prevents falls in an older adult patient?
• A. Keeping side rails up at all times
• B. Using restraints at night
• C. Placing the call light within reach
• D. Leaving the bed in the highest position
Correct Answer: C – Ensuring the call light is accessible allows the
patient to ask for help before attempting to get up.
3. A patient on seizure precautions has an aura. What is the
nurse's priority action?
• A. Restrain the patient
• B. Lower the bed to the floor
• C. Place a tongue blade in the mouth
• D. Protect the patient from injury
Correct Answer: D – Protecting from injury (e.g., padding side
rails, lowering bed, clearing area) is priority; never place anything
in the mouth.
4. Which fire safety action is correct for a small trash can fire in a
patient's room (RACE)?
• A. Rescue, Alarm, Contain, Extinguish
• B. Run, Alert, Call, Evacuate
• C. Remove, Ask, Close, Exit
• D. Rescue, Alert, Control, Evacuate
,Correct Answer: A – RACE stands for Rescue (move patient),
Alarm (call 911/pull alarm), Contain (close doors), Extinguish (use
extinguisher).
5. When applying wrist restraints, how many fingers should fit
between the restraint and the patient's skin?
• A. 0 fingers (snug)
• B. 1 finger
• C. 2 fingers
• D. 3 fingers
Correct Answer: C – Two fingers should fit comfortably to
prevent circulation impairment and skin breakdown.
Vital Signs & Assessment
6. A patient's blood pressure is 148/92 mm Hg. The nurse
classifies this as:
• A. Normal
• B. Elevated
• C. Stage 1 hypertension
• D. Hypertensive crisis
Correct Answer: C – According to guidelines, Stage 1
hypertension is 130–139/80–89 mm Hg or higher; 148/92 meets
this.
7. Which pulse site is most commonly used to assess heart rate in
an adult?
• A. Apical
, • B. Carotid
• C. Radial
• D. Brachial
Correct Answer: C – Radial pulse is easily accessible and
commonly used for routine heart rate assessment.
8. The nurse notes a respiratory rate of 28 breaths/min in a
resting adult. This is documented as:
• A. Eupnea
• B. Bradypnea
• C. Tachypnea
• D. Apnea
Correct Answer: C – Tachypnea is an increased respiratory rate
(>20 breaths/min in an adult at rest).
9. Using the PQRST pain assessment method, "P" stands for:
• A. Pain level
• B. Provocation/Palliation
• C. Pulse rate
• D. Pressure area
Correct Answer: B – PQRST: Provocation/Palliation, Quality,
Region/Radiation, Severity, Timing.
10. A tympanic temperature of 99.8°F (37.7°C) is considered:
• A. Hypothermia
• B. Normal
• C. Low-grade fever
• D. Hyperpyrexia
2026/2027 | Complete Exam with 250 Questions
& Correct Answers – Nursing Fundamentals
The NUR 104 Midterm Exam covers fundamental nursing concepts with emphasis on
the nursing process (ADPIE) , patient safety and infection control (including
standard/airborne/contact precautions, fall prevention, restraints, and RACE fire
safety), medication administration (the 10 rights, dosage calculations, insulin, heparin,
and opioid safety), legal/ethical issues (HIPAA, informed consent, advance directives,
refusal of treatment, and incident reports), vital signs and physical assessment (normal
ranges, PQRST pain assessment, abnormal findings), hygiene, mobility, and
positioning (pressure injury prevention, logrolling, hip precautions), oxygenation and
respiratory care (tracheostomy suctioning, pulse oximetry, COPD oxygen targets), fluid
and electrolytes (dehydration, hypokalemia, IV therapy), wound care and surgical
asepsis, elimination (catheters, ostomies, constipation), perioperative care,
and prioritization frameworks (ABCs, Maslow, safety). Additional topics may
include basic geriatric, maternal-newborn, pediatric, mental health, and end-of-life
care. The exam tests both knowledge recall and clinical judgment through prioritization,
delegation, and "best action" questions.
Safety & Infection Control
1. A nurse is preparing to insert an indwelling urinary catheter.
Which technique is required?
• A. Medical asepsis
• B. Surgical asepsis
• C. Clean technique
, • D. Hand hygiene only
Correct Answer: B – Indwelling catheter insertion requires sterile
(surgical) asepsis to prevent introducing bacteria into the bladder.
2. Which action best prevents falls in an older adult patient?
• A. Keeping side rails up at all times
• B. Using restraints at night
• C. Placing the call light within reach
• D. Leaving the bed in the highest position
Correct Answer: C – Ensuring the call light is accessible allows the
patient to ask for help before attempting to get up.
3. A patient on seizure precautions has an aura. What is the
nurse's priority action?
• A. Restrain the patient
• B. Lower the bed to the floor
• C. Place a tongue blade in the mouth
• D. Protect the patient from injury
Correct Answer: D – Protecting from injury (e.g., padding side
rails, lowering bed, clearing area) is priority; never place anything
in the mouth.
4. Which fire safety action is correct for a small trash can fire in a
patient's room (RACE)?
• A. Rescue, Alarm, Contain, Extinguish
• B. Run, Alert, Call, Evacuate
• C. Remove, Ask, Close, Exit
• D. Rescue, Alert, Control, Evacuate
,Correct Answer: A – RACE stands for Rescue (move patient),
Alarm (call 911/pull alarm), Contain (close doors), Extinguish (use
extinguisher).
5. When applying wrist restraints, how many fingers should fit
between the restraint and the patient's skin?
• A. 0 fingers (snug)
• B. 1 finger
• C. 2 fingers
• D. 3 fingers
Correct Answer: C – Two fingers should fit comfortably to
prevent circulation impairment and skin breakdown.
Vital Signs & Assessment
6. A patient's blood pressure is 148/92 mm Hg. The nurse
classifies this as:
• A. Normal
• B. Elevated
• C. Stage 1 hypertension
• D. Hypertensive crisis
Correct Answer: C – According to guidelines, Stage 1
hypertension is 130–139/80–89 mm Hg or higher; 148/92 meets
this.
7. Which pulse site is most commonly used to assess heart rate in
an adult?
• A. Apical
, • B. Carotid
• C. Radial
• D. Brachial
Correct Answer: C – Radial pulse is easily accessible and
commonly used for routine heart rate assessment.
8. The nurse notes a respiratory rate of 28 breaths/min in a
resting adult. This is documented as:
• A. Eupnea
• B. Bradypnea
• C. Tachypnea
• D. Apnea
Correct Answer: C – Tachypnea is an increased respiratory rate
(>20 breaths/min in an adult at rest).
9. Using the PQRST pain assessment method, "P" stands for:
• A. Pain level
• B. Provocation/Palliation
• C. Pulse rate
• D. Pressure area
Correct Answer: B – PQRST: Provocation/Palliation, Quality,
Region/Radiation, Severity, Timing.
10. A tympanic temperature of 99.8°F (37.7°C) is considered:
• A. Hypothermia
• B. Normal
• C. Low-grade fever
• D. Hyperpyrexia
