NUR 101EXAM GUIDE ON FUNDAMENTALS OF NURSING
Q&A 2026/27
[1] A nurse is caring for a client who suddenly becomes agitated
and tries to remove their IV line. Which action should the nurse
take FIRST?
A. Apply soft wrist restraints
B. Call for a security escort
C. Reassess the client’s immediate needs
D. Administer PRN sedative medication
Correct Answer: C
Explanation: Restraints and sedatives are last resorts. The nurse
must first reassess for reversible causes (e.g., pain, hypoxia, full
bladder). Option C aligns with least restrictive intervention
principles.
[2] A client with a history of falls is using a walker. The nurse
observes the client sliding the walker forward while walking. What
is the most appropriate correction?
A. “Lift the walker slightly and place it down in front of you.”
B. “Keep the walker close to your body at all times.”
C. “Push the walker ahead and then step into it.”
D. “Use only one hand to move the walker for better balance.”
Correct Answer: A
Explanation: Walkers should be lifted slightly and placed forward to
avoid tripping. Sliding can cause instability. Option A is correct;
,options B and D increase fall risk. Option C describes a rollator, not
a standard walker.
[3] Which nursing intervention best reduces the risk of ventilator-
associated pneumonia (VAP) in an intubated client?
A. Changing the ventilator circuit daily
B. Elevating the head of the bed to 30–45 degrees
C. Suctioning the oropharynx every 2 hours
D. Administering prophylactic antibiotics
Correct Answer: B
*Explanation: Semirecumbent positioning (30–45°) reduces
aspiration risk, a key VAP cause. Daily circuit changes are not
recommended; over-suctioning can cause mucosal damage.
Antibiotics are not prophylactic for VAP.*
[4] A nurse is calculating intake and output. The client drank 240
mL of water, 120 mL of coffee, and received 500 mL of IV fluids.
Urine output was 400 mL, and emesis was 150 mL. What is the net
fluid balance?
A. +310 mL
B. +190 mL
C. +410 mL
D. −10 mL
Correct Answer: A
*Explanation: Total intake = 240+120+500 = 860 mL. Total output
= 400+150 = 550 mL. Balance = 860−550 = +310 mL (positive).*
,[5] A client with type 2 diabetes mellitus is NPO for surgery. The
morning blood glucose is 180 mg/dL. Which action should the
nurse take FIRST?
A. Administer insulin per sliding scale
B. Notify the provider
C. Hold all diabetes medications
D. Check capillary blood glucose again
Correct Answer: B
Explanation: Hyperglycemia in NPO status may require provider
guidance for insulin adjustment. Holding all medications (C) could
worsen glucose. Rechecking (D) delays care. Sliding scale (A)
requires an order; notifying provider is first.
[6] The nurse is preparing to insert an indwelling urinary catheter.
Which technique demonstrates correct sterile technique?
A. Opening the sterile kit facing away from the client
B. Placing the sterile drape with the non-dominant hand wearing
sterile gloves
C. Pouring sterile solution into the sterile basin from 6 inches
above
D. Using clean gloves to handle the catheter after sterile gloves
are applied
Correct Answer: C
*Explanation: Pouring from 6 inches prevents splashing
contamination. Opening the kit should face the nurse (A). Sterile
, drape is placed with sterile-gloved hand (B). Clean gloves cannot
touch sterile catheter (D).*
[7] Which client is at highest risk for developing a pressure injury?
A. A 22-year-old with a fractured tibia in a cast
B. A 45-year-old with urinary incontinence on bedrest
C. A 70-year-old with controlled hypertension who ambulates
daily
D. A 60-year-old with hip surgery using a trapeze bar
independently
Correct Answer: B
Explanation: Incontinence plus immobility (bedrest) creates
moisture and shear, high risk. Age alone (C) is lower risk than
combined factors. Fracture cast (A) is localized. Trapeze use (D)
reduces pressure risk.
[8] The nurse hears a new murmur in a client with infective
endocarditis. What is the priority nursing action?
A. Document the finding and recheck in 4 hours
B. Notify the healthcare provider immediately
C. Elevate the head of the bed to 90 degrees
D. Administer PRN acetaminophen for possible pain
Correct Answer: B
Explanation: A new murmur in endocarditis suggests valve
vegetation or rupture, a life-threatening complication requiring
Q&A 2026/27
[1] A nurse is caring for a client who suddenly becomes agitated
and tries to remove their IV line. Which action should the nurse
take FIRST?
A. Apply soft wrist restraints
B. Call for a security escort
C. Reassess the client’s immediate needs
D. Administer PRN sedative medication
Correct Answer: C
Explanation: Restraints and sedatives are last resorts. The nurse
must first reassess for reversible causes (e.g., pain, hypoxia, full
bladder). Option C aligns with least restrictive intervention
principles.
[2] A client with a history of falls is using a walker. The nurse
observes the client sliding the walker forward while walking. What
is the most appropriate correction?
A. “Lift the walker slightly and place it down in front of you.”
B. “Keep the walker close to your body at all times.”
C. “Push the walker ahead and then step into it.”
D. “Use only one hand to move the walker for better balance.”
Correct Answer: A
Explanation: Walkers should be lifted slightly and placed forward to
avoid tripping. Sliding can cause instability. Option A is correct;
,options B and D increase fall risk. Option C describes a rollator, not
a standard walker.
[3] Which nursing intervention best reduces the risk of ventilator-
associated pneumonia (VAP) in an intubated client?
A. Changing the ventilator circuit daily
B. Elevating the head of the bed to 30–45 degrees
C. Suctioning the oropharynx every 2 hours
D. Administering prophylactic antibiotics
Correct Answer: B
*Explanation: Semirecumbent positioning (30–45°) reduces
aspiration risk, a key VAP cause. Daily circuit changes are not
recommended; over-suctioning can cause mucosal damage.
Antibiotics are not prophylactic for VAP.*
[4] A nurse is calculating intake and output. The client drank 240
mL of water, 120 mL of coffee, and received 500 mL of IV fluids.
Urine output was 400 mL, and emesis was 150 mL. What is the net
fluid balance?
A. +310 mL
B. +190 mL
C. +410 mL
D. −10 mL
Correct Answer: A
*Explanation: Total intake = 240+120+500 = 860 mL. Total output
= 400+150 = 550 mL. Balance = 860−550 = +310 mL (positive).*
,[5] A client with type 2 diabetes mellitus is NPO for surgery. The
morning blood glucose is 180 mg/dL. Which action should the
nurse take FIRST?
A. Administer insulin per sliding scale
B. Notify the provider
C. Hold all diabetes medications
D. Check capillary blood glucose again
Correct Answer: B
Explanation: Hyperglycemia in NPO status may require provider
guidance for insulin adjustment. Holding all medications (C) could
worsen glucose. Rechecking (D) delays care. Sliding scale (A)
requires an order; notifying provider is first.
[6] The nurse is preparing to insert an indwelling urinary catheter.
Which technique demonstrates correct sterile technique?
A. Opening the sterile kit facing away from the client
B. Placing the sterile drape with the non-dominant hand wearing
sterile gloves
C. Pouring sterile solution into the sterile basin from 6 inches
above
D. Using clean gloves to handle the catheter after sterile gloves
are applied
Correct Answer: C
*Explanation: Pouring from 6 inches prevents splashing
contamination. Opening the kit should face the nurse (A). Sterile
, drape is placed with sterile-gloved hand (B). Clean gloves cannot
touch sterile catheter (D).*
[7] Which client is at highest risk for developing a pressure injury?
A. A 22-year-old with a fractured tibia in a cast
B. A 45-year-old with urinary incontinence on bedrest
C. A 70-year-old with controlled hypertension who ambulates
daily
D. A 60-year-old with hip surgery using a trapeze bar
independently
Correct Answer: B
Explanation: Incontinence plus immobility (bedrest) creates
moisture and shear, high risk. Age alone (C) is lower risk than
combined factors. Fracture cast (A) is localized. Trapeze use (D)
reduces pressure risk.
[8] The nurse hears a new murmur in a client with infective
endocarditis. What is the priority nursing action?
A. Document the finding and recheck in 4 hours
B. Notify the healthcare provider immediately
C. Elevate the head of the bed to 90 degrees
D. Administer PRN acetaminophen for possible pain
Correct Answer: B
Explanation: A new murmur in endocarditis suggests valve
vegetation or rupture, a life-threatening complication requiring
