NUR104 Exam 2 – Foundations of Nursing
Comprehensive Study Guide
1. Nursing Process
Question: Which step of the nursing process involves setting measurable goals and outcomes
for the patient?
Answer: Planning
Rationale: Planning is where nurses establish priorities, set patient‑centered goals, and outline
interventions.
2. Vital Signs
Question: A patient’s blood pressure is 88/56 mmHg. How should the nurse document this
finding?
Answer: Hypotension
Rationale: Normal adult blood pressure is around 120/80 mmHg. Anything significantly lower is
considered hypotension.
3. Infection Control
Question: What is the most effective method to prevent the spread of infection?
Answer: Hand hygiene
Rationale: Proper handwashing or use of alcohol‑based sanitizer is the single most effective
infection control measure.
4. Patient Safety
Question: A nurse finds a patient confused and trying to get out of bed unassisted. What is the
priority action?
Answer: Ensure patient safety by using bed alarms or calling for assistance
Rationale: Preventing falls is a top priority in patient safety.
5. Therapeutic Communication
Question: A patient says, “I’m scared about my surgery.” What is the most therapeutic
response?
Answer: “Tell me more about what you’re feeling.”
Rationale: Open‑ended questions encourage patients to express concerns and show
empathy.
6. Maslow’s Hierarchy
Question: Which level of Maslow’s hierarchy includes food, water, and shelter?
Answer: Physiological needs
Rationale: These are the most basic survival needs.
7. Nursing Ethics
Question: Respecting a patient’s right to refuse treatment demonstrates which ethical principle?
Answer: Autonomy
Rationale: Autonomy means honoring the patient’s right to make decisions.
8. Delegation
Question: Which task can be delegated to a nursing assistant?
, Answer: Assisting with bathing
Rationale: Routine, non‑complex tasks can be delegated; assessment and teaching cannot.
9. Documentation
Question: What is the most important rule for charting?
Answer: Accuracy and timeliness
Rationale: Documentation must be factual, objective, and recorded promptly.
10. Patient Education
Question: A nurse teaches a patient to self‑administer insulin. Which domain of learning is this?
Answer: Psychomotor
Rationale: Psychomotor involves physical skills and practice.
11. Pain Assessment
Question: A patient rates pain as 8/10. What is the nurse’s priority?
Answer: Administer prescribed pain medication
Rationale: Severe pain requires prompt intervention.
12. Cultural Competence
Question: A patient refuses pork due to religious beliefs. What should the nurse do?
Answer: Respect dietary restrictions and provide alternatives
Rationale: Cultural sensitivity is essential in care.
13. Legal Issues
Question: Performing a procedure without consent may result in what charge?
Answer: Battery
Rationale: Battery is intentional touching without consent.
14. Safety Precautions
Question: What is the best way to prevent patient falls?
Answer: Keep call light within reach
Rationale: Encourages patients to ask for help before moving.
15. Communication Styles
Question: Which statement is therapeutic?
Answer: “I understand this is difficult for you.”
Rationale: Shows empathy and support.
16. Vital Signs
Question: Normal adult respiratory rate is:
Answer: 12–20 breaths per minute
Rationale: Anything outside this range indicates abnormal breathing.
17. Infection Control
Question: Gloves should be worn when:
Answer: Contact with blood or body fluids is possible
Rationale: Standard precautions protect both patient and nurse.
18. Nutrition
Question: Which nutrient is the body’s primary energy source?
Answer: Carbohydrates
Comprehensive Study Guide
1. Nursing Process
Question: Which step of the nursing process involves setting measurable goals and outcomes
for the patient?
Answer: Planning
Rationale: Planning is where nurses establish priorities, set patient‑centered goals, and outline
interventions.
2. Vital Signs
Question: A patient’s blood pressure is 88/56 mmHg. How should the nurse document this
finding?
Answer: Hypotension
Rationale: Normal adult blood pressure is around 120/80 mmHg. Anything significantly lower is
considered hypotension.
3. Infection Control
Question: What is the most effective method to prevent the spread of infection?
Answer: Hand hygiene
Rationale: Proper handwashing or use of alcohol‑based sanitizer is the single most effective
infection control measure.
4. Patient Safety
Question: A nurse finds a patient confused and trying to get out of bed unassisted. What is the
priority action?
Answer: Ensure patient safety by using bed alarms or calling for assistance
Rationale: Preventing falls is a top priority in patient safety.
5. Therapeutic Communication
Question: A patient says, “I’m scared about my surgery.” What is the most therapeutic
response?
Answer: “Tell me more about what you’re feeling.”
Rationale: Open‑ended questions encourage patients to express concerns and show
empathy.
6. Maslow’s Hierarchy
Question: Which level of Maslow’s hierarchy includes food, water, and shelter?
Answer: Physiological needs
Rationale: These are the most basic survival needs.
7. Nursing Ethics
Question: Respecting a patient’s right to refuse treatment demonstrates which ethical principle?
Answer: Autonomy
Rationale: Autonomy means honoring the patient’s right to make decisions.
8. Delegation
Question: Which task can be delegated to a nursing assistant?
, Answer: Assisting with bathing
Rationale: Routine, non‑complex tasks can be delegated; assessment and teaching cannot.
9. Documentation
Question: What is the most important rule for charting?
Answer: Accuracy and timeliness
Rationale: Documentation must be factual, objective, and recorded promptly.
10. Patient Education
Question: A nurse teaches a patient to self‑administer insulin. Which domain of learning is this?
Answer: Psychomotor
Rationale: Psychomotor involves physical skills and practice.
11. Pain Assessment
Question: A patient rates pain as 8/10. What is the nurse’s priority?
Answer: Administer prescribed pain medication
Rationale: Severe pain requires prompt intervention.
12. Cultural Competence
Question: A patient refuses pork due to religious beliefs. What should the nurse do?
Answer: Respect dietary restrictions and provide alternatives
Rationale: Cultural sensitivity is essential in care.
13. Legal Issues
Question: Performing a procedure without consent may result in what charge?
Answer: Battery
Rationale: Battery is intentional touching without consent.
14. Safety Precautions
Question: What is the best way to prevent patient falls?
Answer: Keep call light within reach
Rationale: Encourages patients to ask for help before moving.
15. Communication Styles
Question: Which statement is therapeutic?
Answer: “I understand this is difficult for you.”
Rationale: Shows empathy and support.
16. Vital Signs
Question: Normal adult respiratory rate is:
Answer: 12–20 breaths per minute
Rationale: Anything outside this range indicates abnormal breathing.
17. Infection Control
Question: Gloves should be worn when:
Answer: Contact with blood or body fluids is possible
Rationale: Standard precautions protect both patient and nurse.
18. Nutrition
Question: Which nutrient is the body’s primary energy source?
Answer: Carbohydrates
