NUR 195 Exam 2 Practice Questions with
Answers and Rationales Latest Version
Graded A+
Question 1
A nurse notices a patient attempting to get out of bed without assistance. What should the nurse
do first?
A. Apply restraints
B. Call the provider
C. Assist the patient back to bed safely
D. Document the incident
Correct Answer: C. Assist the patient back to bed safely
Explanation:
The immediate priority is preventing injury. The nurse should safely assist the patient before
completing documentation or considering additional interventions.
Question 2
Which nursing action best demonstrates effective infection prevention?
A. Wearing gloves for every patient interaction
B. Performing hand hygiene before and after patient contact
C. Keeping patient doors closed at all times
D. Using antibiotics routinely
Correct Answer: B. Performing hand hygiene before and after patient contact
Explanation:
Hand hygiene is the most effective method for preventing healthcare-associated infections.
Gloves do not replace proper handwashing.
Question 3
,A nurse is caring for a patient who has a temperature of 39°C (102.2°F). Which intervention is
most appropriate?
A. Apply extra blankets
B. Encourage fluids if not contraindicated
C. Restrict oral intake
D. Keep the room warm
Correct Answer: B. Encourage fluids if not contraindicated
Explanation:
Fever increases fluid loss through sweating and increased metabolism. Fluids help prevent
dehydration and support temperature regulation.
Question 4
The nurse is using the nursing process. Which activity occurs during the assessment phase?
A. Developing nursing diagnoses
B. Collecting patient data
C. Selecting interventions
D. Evaluating outcomes
Correct Answer: B. Collecting patient data
Explanation:
The nursing process follows ADPIE:
• Assessment – collect data
• Diagnosis – identify problems
• Planning – set goals
• Implementation – perform interventions
• Evaluation – determine effectiveness
Question 5
A nurse enters a patient’s room and prepares to perform a physical assessment. Which action
should the nurse perform first?
A. Apply gloves
B. Verify the patient’s identity
,C. Obtain vital signs
D. Document assessment findings
Correct Answer: B. Verify the patient’s identity
Explanation:
Patient identification is the first priority before any procedure or assessment. The nurse should
use at least two identifiers (such as name and date of birth) to ensure safety and prevent errors.
Question 6
Which finding should the nurse report immediately?
A. Blood pressure of 128/78 mmHg
B. Heart rate of 82 beats/min
C. Oxygen saturation of 84%
D. Temperature of 37°C (98.6°F)
Correct Answer: C. Oxygen saturation of 84%
Explanation:
An oxygen saturation below normal levels indicates possible hypoxia and requires immediate
assessment and intervention.
Question 7
A nurse is caring for a patient who states, “I am afraid about my surgery tomorrow.” What is the
best response?
A. “Everything will be fine.”
B. “Don’t worry about it.”
C. “Tell me more about what concerns you.”
D. “You should try not to think about surgery.”
Correct Answer: C. “Tell me more about what concerns you.”
Explanation:
Therapeutic communication encourages expression of feelings and allows the nurse to identify
specific concerns.
, Question 8
Which position is best for a patient experiencing difficulty breathing?
A. Supine
B. Trendelenburg
C. High Fowler’s
D. Prone
Correct Answer: C. High Fowler’s
Explanation:
High Fowler’s position promotes lung expansion and improves ventilation by allowing the
diaphragm to move freely.
Question 9
A nurse documents patient information in the medical record. Which statement is correct?
A. Documentation should include personal opinions
B. Documentation should be completed immediately after care
C. Nurses may erase incorrect entries
D. Documentation can be completed at the end of the week
Correct Answer: B. Documentation should be completed immediately after care
Explanation:
Timely documentation provides accurate communication among healthcare providers and
protects patient safety.
Question 10
Which action demonstrates proper body mechanics when lifting a patient?
A. Bending at the waist
B. Keeping feet close together
C. Using leg muscles to lift
D. Twisting while lifting
Correct Answer: C. Using leg muscles to lift
Answers and Rationales Latest Version
Graded A+
Question 1
A nurse notices a patient attempting to get out of bed without assistance. What should the nurse
do first?
A. Apply restraints
B. Call the provider
C. Assist the patient back to bed safely
D. Document the incident
Correct Answer: C. Assist the patient back to bed safely
Explanation:
The immediate priority is preventing injury. The nurse should safely assist the patient before
completing documentation or considering additional interventions.
Question 2
Which nursing action best demonstrates effective infection prevention?
A. Wearing gloves for every patient interaction
B. Performing hand hygiene before and after patient contact
C. Keeping patient doors closed at all times
D. Using antibiotics routinely
Correct Answer: B. Performing hand hygiene before and after patient contact
Explanation:
Hand hygiene is the most effective method for preventing healthcare-associated infections.
Gloves do not replace proper handwashing.
Question 3
,A nurse is caring for a patient who has a temperature of 39°C (102.2°F). Which intervention is
most appropriate?
A. Apply extra blankets
B. Encourage fluids if not contraindicated
C. Restrict oral intake
D. Keep the room warm
Correct Answer: B. Encourage fluids if not contraindicated
Explanation:
Fever increases fluid loss through sweating and increased metabolism. Fluids help prevent
dehydration and support temperature regulation.
Question 4
The nurse is using the nursing process. Which activity occurs during the assessment phase?
A. Developing nursing diagnoses
B. Collecting patient data
C. Selecting interventions
D. Evaluating outcomes
Correct Answer: B. Collecting patient data
Explanation:
The nursing process follows ADPIE:
• Assessment – collect data
• Diagnosis – identify problems
• Planning – set goals
• Implementation – perform interventions
• Evaluation – determine effectiveness
Question 5
A nurse enters a patient’s room and prepares to perform a physical assessment. Which action
should the nurse perform first?
A. Apply gloves
B. Verify the patient’s identity
,C. Obtain vital signs
D. Document assessment findings
Correct Answer: B. Verify the patient’s identity
Explanation:
Patient identification is the first priority before any procedure or assessment. The nurse should
use at least two identifiers (such as name and date of birth) to ensure safety and prevent errors.
Question 6
Which finding should the nurse report immediately?
A. Blood pressure of 128/78 mmHg
B. Heart rate of 82 beats/min
C. Oxygen saturation of 84%
D. Temperature of 37°C (98.6°F)
Correct Answer: C. Oxygen saturation of 84%
Explanation:
An oxygen saturation below normal levels indicates possible hypoxia and requires immediate
assessment and intervention.
Question 7
A nurse is caring for a patient who states, “I am afraid about my surgery tomorrow.” What is the
best response?
A. “Everything will be fine.”
B. “Don’t worry about it.”
C. “Tell me more about what concerns you.”
D. “You should try not to think about surgery.”
Correct Answer: C. “Tell me more about what concerns you.”
Explanation:
Therapeutic communication encourages expression of feelings and allows the nurse to identify
specific concerns.
, Question 8
Which position is best for a patient experiencing difficulty breathing?
A. Supine
B. Trendelenburg
C. High Fowler’s
D. Prone
Correct Answer: C. High Fowler’s
Explanation:
High Fowler’s position promotes lung expansion and improves ventilation by allowing the
diaphragm to move freely.
Question 9
A nurse documents patient information in the medical record. Which statement is correct?
A. Documentation should include personal opinions
B. Documentation should be completed immediately after care
C. Nurses may erase incorrect entries
D. Documentation can be completed at the end of the week
Correct Answer: B. Documentation should be completed immediately after care
Explanation:
Timely documentation provides accurate communication among healthcare providers and
protects patient safety.
Question 10
Which action demonstrates proper body mechanics when lifting a patient?
A. Bending at the waist
B. Keeping feet close together
C. Using leg muscles to lift
D. Twisting while lifting
Correct Answer: C. Using leg muscles to lift
