West Coast University NURS 100 Exam 1 (pdf) | 2026/2027 |
Fundamentals Q&A | Nursing
1. A nurse is preparing to perform palpation on a client during a physical
assessment. Which of the following is the nurse assessing during palpation?
A) Unexpected sounds made by tapping on the client's skin
B) Skin temperature, moisture, or unexpected findings
C) Heart sounds, lung sounds, and bowel sounds
D) The client's cleanliness and grooming
Correct Answer: Skin temperature, moisture, or unexpected findings
Rationale: Palpation is used to assess skin temperature, moisture, texture,
and unexpected findings such as lumps and deformities [7†L7-L14].
Auscultation is used for heart, lung, and bowel sounds. Tapping (percussion)
is used to assess sounds, and inspection is used for cleanliness and
grooming.
2. A nurse is preparing to irrigate a client's leg wound. Which pieces of
personal protective equipment (PPE) should the nurse wear? (Select all that
apply)
A) N95 mask
B) Surgical cap
C) Gloves
D) Gown
E) Goggles
Correct Answer: Gloves, Gown, Goggles
Rationale: During wound irrigation, the nurse should wear gloves, a gown,
and goggles (or a face shield) to prevent contact with blood, bodily fluids,
,and splashes [7†L15-L23]. An N95 mask and surgical cap are not required for
standard wound irrigation unless specific isolation precautions are indicated.
3. The nurse is completing documentation in a client's medical record. Which
of the following entries displays proper documentation by the nurse?
A) "The client is feeling better"
B) "The client's abdomen is soft and non-distended"
C) "The client's status is unchanged"
D) "The client appears in pain"
Correct Answer: "The client's abdomen is soft and non-distended"
Rationale: Documentation should include factual, accurate, and objective
information [7†L24-L35]. Subjective terms like "feeling better," "unchanged,"
or "appears" should be replaced with objective, measurable data [7†L28-
L33]. A soft, non-distended abdomen is an objective assessment finding.
4. A nurse in the emergency department has received report on a child who
has a laceration to the right calf. Which step of the nursing process should
the nurse perform first?
A) Assessment
B) Analysis
C) Evaluation
D) Planning
Correct Answer: Assessment
Rationale: The first step of the nursing process is assessment [0†L6-L8]
[7†L36-L41]. During this step, the nurse gathers information by performing a
physical exam, interviewing the client, and observing the client.
,5. A nurse has just received report on a newly admitted client who speaks a
different language than the nurse. Which action should the nurse take to
assist with effective communication during the initial assessment?
A) Enlist the aid of the client's school-age child to interpret
B) Ask the client's best friend to interpret for the nurse and client
C) Use jokes and laughter to make the client feel more at ease
D) Request assistance from a professional interpreter
Correct Answer: Request assistance from a professional interpreter
Rationale: The nurse should enlist a professional interpreter if the client
speaks a different language [7†L42-L50]. Using family members or friends is
not appropriate as they may not provide accurate translations and may not
maintain confidentiality.
6. Which organization played a key role in standardizing the nursing process
framework used in modern nursing practice?
A) Centers for Disease Control and Prevention (CDC)
B) American Nurses Association (ANA)
C) World Health Organization (WHO)
D) National Council of State Boards of Nursing (NCSBN)
Correct Answer: American Nurses Association (ANA)
Rationale: The American Nurses Association (ANA) helped standardize the
nursing process, which includes assessment, diagnosis, planning,
implementation, and evaluation [8†L23-L26][11†L27-L35]. The CDC focuses
on disease control, WHO on global health, and NCSBN on licensure.
, 7. During which phase of the nursing process does the nurse formulate
S.M.A.R.T. goals with the patient?
A) Assessment
B) Planning
C) Implementation
D) Evaluation
Correct Answer: Planning
Rationale: During the planning phase, the nurse collaborates with the patient
to set specific, measurable, attainable, realistic, and time-bound (S.M.A.R.T.)
goals [11†L36-L42]. Assessment involves data collection, implementation is
carrying out interventions, and evaluation determines if goals were met.
8. After administering a pain medication, the nurse reassesses the client's
pain level 30 minutes later. This action reflects which step of the nursing
process?
A) Assessment
B) Planning
C) Implementation
D) Evaluation
Correct Answer: Evaluation
Rationale: Reassessing the client's pain level after an intervention is part of
the evaluation phase of the nursing process, which determines whether the
goals have been met [11†L42-L44]. Assessment is the initial data collection,
planning involves goal setting, and implementation is carrying out the
intervention.
Fundamentals Q&A | Nursing
1. A nurse is preparing to perform palpation on a client during a physical
assessment. Which of the following is the nurse assessing during palpation?
A) Unexpected sounds made by tapping on the client's skin
B) Skin temperature, moisture, or unexpected findings
C) Heart sounds, lung sounds, and bowel sounds
D) The client's cleanliness and grooming
Correct Answer: Skin temperature, moisture, or unexpected findings
Rationale: Palpation is used to assess skin temperature, moisture, texture,
and unexpected findings such as lumps and deformities [7†L7-L14].
Auscultation is used for heart, lung, and bowel sounds. Tapping (percussion)
is used to assess sounds, and inspection is used for cleanliness and
grooming.
2. A nurse is preparing to irrigate a client's leg wound. Which pieces of
personal protective equipment (PPE) should the nurse wear? (Select all that
apply)
A) N95 mask
B) Surgical cap
C) Gloves
D) Gown
E) Goggles
Correct Answer: Gloves, Gown, Goggles
Rationale: During wound irrigation, the nurse should wear gloves, a gown,
and goggles (or a face shield) to prevent contact with blood, bodily fluids,
,and splashes [7†L15-L23]. An N95 mask and surgical cap are not required for
standard wound irrigation unless specific isolation precautions are indicated.
3. The nurse is completing documentation in a client's medical record. Which
of the following entries displays proper documentation by the nurse?
A) "The client is feeling better"
B) "The client's abdomen is soft and non-distended"
C) "The client's status is unchanged"
D) "The client appears in pain"
Correct Answer: "The client's abdomen is soft and non-distended"
Rationale: Documentation should include factual, accurate, and objective
information [7†L24-L35]. Subjective terms like "feeling better," "unchanged,"
or "appears" should be replaced with objective, measurable data [7†L28-
L33]. A soft, non-distended abdomen is an objective assessment finding.
4. A nurse in the emergency department has received report on a child who
has a laceration to the right calf. Which step of the nursing process should
the nurse perform first?
A) Assessment
B) Analysis
C) Evaluation
D) Planning
Correct Answer: Assessment
Rationale: The first step of the nursing process is assessment [0†L6-L8]
[7†L36-L41]. During this step, the nurse gathers information by performing a
physical exam, interviewing the client, and observing the client.
,5. A nurse has just received report on a newly admitted client who speaks a
different language than the nurse. Which action should the nurse take to
assist with effective communication during the initial assessment?
A) Enlist the aid of the client's school-age child to interpret
B) Ask the client's best friend to interpret for the nurse and client
C) Use jokes and laughter to make the client feel more at ease
D) Request assistance from a professional interpreter
Correct Answer: Request assistance from a professional interpreter
Rationale: The nurse should enlist a professional interpreter if the client
speaks a different language [7†L42-L50]. Using family members or friends is
not appropriate as they may not provide accurate translations and may not
maintain confidentiality.
6. Which organization played a key role in standardizing the nursing process
framework used in modern nursing practice?
A) Centers for Disease Control and Prevention (CDC)
B) American Nurses Association (ANA)
C) World Health Organization (WHO)
D) National Council of State Boards of Nursing (NCSBN)
Correct Answer: American Nurses Association (ANA)
Rationale: The American Nurses Association (ANA) helped standardize the
nursing process, which includes assessment, diagnosis, planning,
implementation, and evaluation [8†L23-L26][11†L27-L35]. The CDC focuses
on disease control, WHO on global health, and NCSBN on licensure.
, 7. During which phase of the nursing process does the nurse formulate
S.M.A.R.T. goals with the patient?
A) Assessment
B) Planning
C) Implementation
D) Evaluation
Correct Answer: Planning
Rationale: During the planning phase, the nurse collaborates with the patient
to set specific, measurable, attainable, realistic, and time-bound (S.M.A.R.T.)
goals [11†L36-L42]. Assessment involves data collection, implementation is
carrying out interventions, and evaluation determines if goals were met.
8. After administering a pain medication, the nurse reassesses the client's
pain level 30 minutes later. This action reflects which step of the nursing
process?
A) Assessment
B) Planning
C) Implementation
D) Evaluation
Correct Answer: Evaluation
Rationale: Reassessing the client's pain level after an intervention is part of
the evaluation phase of the nursing process, which determines whether the
goals have been met [11†L42-L44]. Assessment is the initial data collection,
planning involves goal setting, and implementation is carrying out the
intervention.
