NUR 215 Exam 1–3 (Arizona College of Nursing) |300
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EXAM 1: FOUNDATIONS OF NURSING PRACTICE
(Questions 1–100)
1. A nurse is preparing to perform a physical assessment on a newly admitted patient. Which action
should the nurse perform FIRST?
A) Gather all necessary equipment
B) Perform hand hygiene
C) Introduce themselves to the patient
D) Wash hands and introduce themselves simultaneously
Wait — let me correct this properly:
A) Gather all necessary equipment B) Perform hand hygiene (correct answer) C) Review the patient's
chart D) Obtain the patient's vital signs
Rationale: Hand hygiene is the single most important measure to prevent the spread of infection. It must
be performed before any patient contact, as per CDC and Joint Commission standards.
2. The nurse understands that the primary purpose of the nursing process is to:
A) Provide a framework for documentation
B) Provide individualized, goal-directed nursing care (correct answer)
C) Establish medical diagnoses for patients
D) Delegate tasks to unlicensed personnel
Rationale: The nursing process (ADPIE: Assessment, Diagnosis, Planning, Implementation, Evaluation)
is a systematic, patient-centered framework designed to provide individualized and goal-directed care.
,3. A nurse is collecting data during a patient assessment. Which finding is considered objective
data?
A) The patient reports feeling nauseated
B) The patient states they have a headache
C) The patient's blood pressure is 148/92 mmHg (correct answer)
D) The patient says they feel anxious
Rationale: Objective data are measurable, observable facts obtained through physical examination or
diagnostic testing. A blood pressure reading is objective. Subjective data are what the patient reports
(nausea, headache, anxiety).
4. Which nursing diagnosis is correctly written according to PES format?
A) Risk for infection related to surgical incision B) Impaired skin integrity related to prolonged
immobility as evidenced by a 2 cm sacral pressure ulcer (correct answer) C) Patient has a wound on
the sacrum D) Alteration in nutrition related to poor appetite
Rationale: The PES format includes the Problem, Etiology (related to), and Signs/Symptoms (as
evidenced by). Only option B contains all three components correctly.
5. A patient is admitted with dehydration. Which assessment finding is the nurse most likely to
observe?
A) Bounding pulse
B) Increased urinary output
C) Decreased skin turgor (correct answer)
D) Hypertension
Rationale: Decreased skin turgor (tenting) is a classic sign of dehydration. Dehydration causes reduced
fluid in the interstitial spaces, leading to loss of skin elasticity.
6. The nurse is planning care for a patient. Which step of the nursing process involves setting
measurable goals?
,A) Assessment B) Diagnosis C) Planning (correct answer) D) Evaluation
Rationale: The Planning phase of the nursing process involves establishing priorities and setting
measurable, patient-centered goals or outcomes that guide nursing interventions.
7. Which action by the nurse demonstrates the ethical principle of autonomy?
A) Administering pain medication to a patient without asking
B) Withholding information to prevent patient distress
C) Allowing a competent patient to refuse treatment (correct answer)
D) Restraining a patient for their own safety without consent
Rationale: Autonomy refers to the patient's right to make their own healthcare decisions. Allowing a
competent patient to refuse treatment respects this ethical principle.
8. A nurse is preparing to administer medication. Which of the "rights" of medication
administration should be checked FIRST?
A) Right dose
B) Right route
C) Right patient (correct answer)
D) Right time
Rationale: Verifying the right patient is always the first step to prevent medication errors. Nurses use two
patient identifiers (name and date of birth or medical record number) before administering any
medication.
9. Which vital sign value should the nurse report to the healthcare provider immediately?
A) Blood pressure of 118/76 mmHg B) Respiratory rate of 16 breaths/min C) Oxygen saturation of 88%
on room air (correct answer) D) Temperature of 37.2°C (99°F)
Rationale: A SpO2 of 88% is below the normal range of 95–100% and indicates hypoxemia. This
requires immediate intervention and provider notification to prevent respiratory compromise.
, 10. A nurse is documenting patient care. Which entry reflects proper charting technique?
A) "Patient seemed uncomfortable all day"
B) "Patient was uncooperative during morning care"
C) "Patient verbalized pain as 7/10, grimacing noted, position changed, reassessment in 30
minutes" (correct answer)
D) "Wound looks worse than yesterday"
Rationale: Accurate, objective, and specific documentation is essential. Option C includes objective
observations, the patient's self-report, the intervention, and a plan for reassessment — all components of
quality documentation.
11. A patient tells the nurse, "I'm scared about my surgery tomorrow." Which response by the
nurse is MOST therapeutic?
A) "Don't worry, everything will be fine." B) "Your surgeon is very experienced." C) "It sounds like
you're feeling anxious. Can you tell me more about your concerns?" (correct answer) D) "Many
patients feel that way before surgery."
Rationale: Therapeutic communication involves acknowledging the patient's feelings and encouraging
them to express themselves. Reflecting and open-ended questions validate the patient's emotions and
promote trust.
12. Which position should the nurse place a patient in who is experiencing respiratory distress?
A) Supine B) Prone C) Trendelenburg D) High Fowler's (90 degrees) (correct answer)
Rationale: High Fowler's position maximizes lung expansion by allowing the diaphragm to descend,
reducing the work of breathing. It is the priority position for patients with respiratory distress.
13. A nurse notes that a patient's urine is dark amber and concentrated. Which intervention is
MOST appropriate?
A) Notify the healthcare provider immediately B) Restrict fluid intake C) Encourage oral fluid intake
(correct answer) D) Insert a urinary catheter
Rationale: Dark amber, concentrated urine is a sign of inadequate fluid intake or dehydration. The first
intervention is to encourage oral fluids if the patient is not restricted.
Practice MCQs | Fundamentals of Nursing questions ,
answers & rationales | latest update | instant download
EXAM 1: FOUNDATIONS OF NURSING PRACTICE
(Questions 1–100)
1. A nurse is preparing to perform a physical assessment on a newly admitted patient. Which action
should the nurse perform FIRST?
A) Gather all necessary equipment
B) Perform hand hygiene
C) Introduce themselves to the patient
D) Wash hands and introduce themselves simultaneously
Wait — let me correct this properly:
A) Gather all necessary equipment B) Perform hand hygiene (correct answer) C) Review the patient's
chart D) Obtain the patient's vital signs
Rationale: Hand hygiene is the single most important measure to prevent the spread of infection. It must
be performed before any patient contact, as per CDC and Joint Commission standards.
2. The nurse understands that the primary purpose of the nursing process is to:
A) Provide a framework for documentation
B) Provide individualized, goal-directed nursing care (correct answer)
C) Establish medical diagnoses for patients
D) Delegate tasks to unlicensed personnel
Rationale: The nursing process (ADPIE: Assessment, Diagnosis, Planning, Implementation, Evaluation)
is a systematic, patient-centered framework designed to provide individualized and goal-directed care.
,3. A nurse is collecting data during a patient assessment. Which finding is considered objective
data?
A) The patient reports feeling nauseated
B) The patient states they have a headache
C) The patient's blood pressure is 148/92 mmHg (correct answer)
D) The patient says they feel anxious
Rationale: Objective data are measurable, observable facts obtained through physical examination or
diagnostic testing. A blood pressure reading is objective. Subjective data are what the patient reports
(nausea, headache, anxiety).
4. Which nursing diagnosis is correctly written according to PES format?
A) Risk for infection related to surgical incision B) Impaired skin integrity related to prolonged
immobility as evidenced by a 2 cm sacral pressure ulcer (correct answer) C) Patient has a wound on
the sacrum D) Alteration in nutrition related to poor appetite
Rationale: The PES format includes the Problem, Etiology (related to), and Signs/Symptoms (as
evidenced by). Only option B contains all three components correctly.
5. A patient is admitted with dehydration. Which assessment finding is the nurse most likely to
observe?
A) Bounding pulse
B) Increased urinary output
C) Decreased skin turgor (correct answer)
D) Hypertension
Rationale: Decreased skin turgor (tenting) is a classic sign of dehydration. Dehydration causes reduced
fluid in the interstitial spaces, leading to loss of skin elasticity.
6. The nurse is planning care for a patient. Which step of the nursing process involves setting
measurable goals?
,A) Assessment B) Diagnosis C) Planning (correct answer) D) Evaluation
Rationale: The Planning phase of the nursing process involves establishing priorities and setting
measurable, patient-centered goals or outcomes that guide nursing interventions.
7. Which action by the nurse demonstrates the ethical principle of autonomy?
A) Administering pain medication to a patient without asking
B) Withholding information to prevent patient distress
C) Allowing a competent patient to refuse treatment (correct answer)
D) Restraining a patient for their own safety without consent
Rationale: Autonomy refers to the patient's right to make their own healthcare decisions. Allowing a
competent patient to refuse treatment respects this ethical principle.
8. A nurse is preparing to administer medication. Which of the "rights" of medication
administration should be checked FIRST?
A) Right dose
B) Right route
C) Right patient (correct answer)
D) Right time
Rationale: Verifying the right patient is always the first step to prevent medication errors. Nurses use two
patient identifiers (name and date of birth or medical record number) before administering any
medication.
9. Which vital sign value should the nurse report to the healthcare provider immediately?
A) Blood pressure of 118/76 mmHg B) Respiratory rate of 16 breaths/min C) Oxygen saturation of 88%
on room air (correct answer) D) Temperature of 37.2°C (99°F)
Rationale: A SpO2 of 88% is below the normal range of 95–100% and indicates hypoxemia. This
requires immediate intervention and provider notification to prevent respiratory compromise.
, 10. A nurse is documenting patient care. Which entry reflects proper charting technique?
A) "Patient seemed uncomfortable all day"
B) "Patient was uncooperative during morning care"
C) "Patient verbalized pain as 7/10, grimacing noted, position changed, reassessment in 30
minutes" (correct answer)
D) "Wound looks worse than yesterday"
Rationale: Accurate, objective, and specific documentation is essential. Option C includes objective
observations, the patient's self-report, the intervention, and a plan for reassessment — all components of
quality documentation.
11. A patient tells the nurse, "I'm scared about my surgery tomorrow." Which response by the
nurse is MOST therapeutic?
A) "Don't worry, everything will be fine." B) "Your surgeon is very experienced." C) "It sounds like
you're feeling anxious. Can you tell me more about your concerns?" (correct answer) D) "Many
patients feel that way before surgery."
Rationale: Therapeutic communication involves acknowledging the patient's feelings and encouraging
them to express themselves. Reflecting and open-ended questions validate the patient's emotions and
promote trust.
12. Which position should the nurse place a patient in who is experiencing respiratory distress?
A) Supine B) Prone C) Trendelenburg D) High Fowler's (90 degrees) (correct answer)
Rationale: High Fowler's position maximizes lung expansion by allowing the diaphragm to descend,
reducing the work of breathing. It is the priority position for patients with respiratory distress.
13. A nurse notes that a patient's urine is dark amber and concentrated. Which intervention is
MOST appropriate?
A) Notify the healthcare provider immediately B) Restrict fluid intake C) Encourage oral fluid intake
(correct answer) D) Insert a urinary catheter
Rationale: Dark amber, concentrated urine is a sign of inadequate fluid intake or dehydration. The first
intervention is to encourage oral fluids if the patient is not restricted.
