NUR 215 Exam 1: Fundamentals V3 - Arizona College
Updated and Latest Questions and Correct Answers with
Rationale
1. A nurse is performing a physical assessment on a client and notes a blood pressure of 150/94 mmHg.
Which step of the nursing process is the nurse currently engaged in?
A. Implementation
B. Diagnosis
C. Assessment
D. Planning
Ans: C
Explanation: Assessment is the initial phase of the nursing process involving data collection. The nurse
gathers objective information such as vital signs during this stage. These findings serve as the basis for
clinical decision-making. Documentation of these findings is essential for tracking patient progress. This
step must be continuous and systematic throughout patient care.
2. When preparing to perform a sterile procedure, which action by the nurse would violate the principles of
surgical asepsis?
A. Keeping sterile gloved hands above the waist level
B. Opening the outermost flap of a sterile kit away from the body
C. Turning one’s back to the sterile field to grab more supplies
D. Placing sterile items in the center of the sterile field
Ans: C
,Explanation: A sterile field is considered contaminated if it is out of the nurse’s range of vision. Turning
your back on the field prevents you from monitoring its sterility. Objects must always be kept within the
line of sight to ensure they remain uncontaminated. Maintaining a sterile field requires constant vigilance
and adherence to strict protocols. If a field is unattended or unseen, it must be discarded and replaced.
3. A nurse is caring for an older adult client with a high risk of falls. Which intervention is the highest priority
for ensuring safety?
A. Keeping all four side rails in the upright position
B. Encouraging the client to walk to the bathroom alone
C. Placing the call light within the client’s reach
D. Applying physical restraints to prevent the client from getting up
Ans: C
Explanation: Ensuring the call light is accessible allows the patient to request help safely. This simple
intervention empowers the patient and reduces the risk of unassisted mobility. Keeping all four side rails
up can actually increase injury risk and is considered a restraint. Physical restraints should only be used
as a last resort after other measures fail. Safety protocols emphasize using the least restrictive
environment possible for the patient.
4. Which ethical principle is the nurse upholding when they respect a client’s right to refuse a recommended
medical treatment?
A. Justice
B. Nonmaleficence
C. Autonomy
D. Beneficence
, Ans: C
Explanation: Autonomy refers to the right of patients to make their own healthcare decisions. This
principle mandates that nurses respect the choices made by competent individuals. Even if the nurse
disagrees with the choice, the patient’s self-determination is paramount. Informed consent is a practical
application of the principle of autonomy. Nurses act as advocates by ensuring patients have the
information needed to decide.
5. A nurse is documenting in a client’s electronic health record. Which entry is the most objective and
accurate?
A. The client seems very angry and uncooperative this morning.
B. The client drank an adequate amount of water today.
C. The client’s skin is warm and dry with a 2 cm reddened area on the sacrum.
D. The client’s surgical wound is healing quite nicely.
Ans: C
Explanation: Objective documentation focuses on facts that can be measured or observed. Statements
about ‘anger’ or ‘healing well’ are subjective and open to interpretation. Quantifying findings, like the 2
cm measurement, provides a clear baseline for other staff. Professional documentation should avoid
biased language or vague generalizations. Clear, descriptive facts ensure the continuity and safety of
patient care.
6. While measuring a client’s blood pressure, the nurse notes that the cuff is too small for the client’s arm.
What is the likely result of using this cuff?
A. The systolic reading will be low and the diastolic will be high
B. A falsely low reading
Updated and Latest Questions and Correct Answers with
Rationale
1. A nurse is performing a physical assessment on a client and notes a blood pressure of 150/94 mmHg.
Which step of the nursing process is the nurse currently engaged in?
A. Implementation
B. Diagnosis
C. Assessment
D. Planning
Ans: C
Explanation: Assessment is the initial phase of the nursing process involving data collection. The nurse
gathers objective information such as vital signs during this stage. These findings serve as the basis for
clinical decision-making. Documentation of these findings is essential for tracking patient progress. This
step must be continuous and systematic throughout patient care.
2. When preparing to perform a sterile procedure, which action by the nurse would violate the principles of
surgical asepsis?
A. Keeping sterile gloved hands above the waist level
B. Opening the outermost flap of a sterile kit away from the body
C. Turning one’s back to the sterile field to grab more supplies
D. Placing sterile items in the center of the sterile field
Ans: C
,Explanation: A sterile field is considered contaminated if it is out of the nurse’s range of vision. Turning
your back on the field prevents you from monitoring its sterility. Objects must always be kept within the
line of sight to ensure they remain uncontaminated. Maintaining a sterile field requires constant vigilance
and adherence to strict protocols. If a field is unattended or unseen, it must be discarded and replaced.
3. A nurse is caring for an older adult client with a high risk of falls. Which intervention is the highest priority
for ensuring safety?
A. Keeping all four side rails in the upright position
B. Encouraging the client to walk to the bathroom alone
C. Placing the call light within the client’s reach
D. Applying physical restraints to prevent the client from getting up
Ans: C
Explanation: Ensuring the call light is accessible allows the patient to request help safely. This simple
intervention empowers the patient and reduces the risk of unassisted mobility. Keeping all four side rails
up can actually increase injury risk and is considered a restraint. Physical restraints should only be used
as a last resort after other measures fail. Safety protocols emphasize using the least restrictive
environment possible for the patient.
4. Which ethical principle is the nurse upholding when they respect a client’s right to refuse a recommended
medical treatment?
A. Justice
B. Nonmaleficence
C. Autonomy
D. Beneficence
, Ans: C
Explanation: Autonomy refers to the right of patients to make their own healthcare decisions. This
principle mandates that nurses respect the choices made by competent individuals. Even if the nurse
disagrees with the choice, the patient’s self-determination is paramount. Informed consent is a practical
application of the principle of autonomy. Nurses act as advocates by ensuring patients have the
information needed to decide.
5. A nurse is documenting in a client’s electronic health record. Which entry is the most objective and
accurate?
A. The client seems very angry and uncooperative this morning.
B. The client drank an adequate amount of water today.
C. The client’s skin is warm and dry with a 2 cm reddened area on the sacrum.
D. The client’s surgical wound is healing quite nicely.
Ans: C
Explanation: Objective documentation focuses on facts that can be measured or observed. Statements
about ‘anger’ or ‘healing well’ are subjective and open to interpretation. Quantifying findings, like the 2
cm measurement, provides a clear baseline for other staff. Professional documentation should avoid
biased language or vague generalizations. Clear, descriptive facts ensure the continuity and safety of
patient care.
6. While measuring a client’s blood pressure, the nurse notes that the cuff is too small for the client’s arm.
What is the likely result of using this cuff?
A. The systolic reading will be low and the diastolic will be high
B. A falsely low reading
