NURS 100 Fundamentals of
Nursing Assessment 5 WCU
Questions and Answers
Verified Solutions Latest Update
,NURS 100 Fundamentals of Nursing Assessment 5 WCU
Verified Questions and Answers Latest Version
1. A nurse is creating a plan of care for a client. Which of the following phases of
the nursing process involves establishing client-centered goals and expected
outcomes?
A. Assessment
B. Planning
C. Implementation
D. Evaluation
Answer: B
Rationale: The planning phase involves the nurse collaborating with the client and family
to set priorities, establish goals, and determine expected outcomes.
2. A nurse is caring for a client with Clostridium difficile (C. diff). Which hand
hygiene method is mandatory after providing care?
A. Alcohol-based hand rub
B. Washing with soap and water
C. Chlorhexidine scrub
D. Wearing gloves only
Answer: B
Rationale: Alcohol-based rubs are ineffective against C. diff spores; therefore, mechanical
scrubbing with soap and water is required to remove them.
, 3. Which ethical principle refers to the nurse’s obligation to do no harm to the
patient?
A. Beneficence
B. Autonomy
C. Non-maleficence
D. Justice
Answer: C
Rationale: Non-maleficence is the ethical duty to avoid causing harm or hurt to the patient.
4. When assessing a patient’s blood pressure, the nurse notes that the cuff is
too small for the patient’s arm. What impact will this have on the reading?
A. The reading will be falsely low
B. The reading will be falsely high
C. The reading will not be affected
D. The diastolic reading only will be high
Answer: B
Rationale: Using a blood pressure cuff that is too small or too narrow for the limb will
result in a falsely elevated (high) reading.
5. A nurse is assessing a client’s risk for pressure injuries using the Braden Scale.
Which score range indicates the highest risk?
A. 19-23
B. 6-9
C. 13-14
D. 15-18
Answer: B
Rationale: In the Braden Scale, a lower score indicates a higher risk for pressure injury
development. Scores range from 6 to 23.
Nursing Assessment 5 WCU
Questions and Answers
Verified Solutions Latest Update
,NURS 100 Fundamentals of Nursing Assessment 5 WCU
Verified Questions and Answers Latest Version
1. A nurse is creating a plan of care for a client. Which of the following phases of
the nursing process involves establishing client-centered goals and expected
outcomes?
A. Assessment
B. Planning
C. Implementation
D. Evaluation
Answer: B
Rationale: The planning phase involves the nurse collaborating with the client and family
to set priorities, establish goals, and determine expected outcomes.
2. A nurse is caring for a client with Clostridium difficile (C. diff). Which hand
hygiene method is mandatory after providing care?
A. Alcohol-based hand rub
B. Washing with soap and water
C. Chlorhexidine scrub
D. Wearing gloves only
Answer: B
Rationale: Alcohol-based rubs are ineffective against C. diff spores; therefore, mechanical
scrubbing with soap and water is required to remove them.
, 3. Which ethical principle refers to the nurse’s obligation to do no harm to the
patient?
A. Beneficence
B. Autonomy
C. Non-maleficence
D. Justice
Answer: C
Rationale: Non-maleficence is the ethical duty to avoid causing harm or hurt to the patient.
4. When assessing a patient’s blood pressure, the nurse notes that the cuff is
too small for the patient’s arm. What impact will this have on the reading?
A. The reading will be falsely low
B. The reading will be falsely high
C. The reading will not be affected
D. The diastolic reading only will be high
Answer: B
Rationale: Using a blood pressure cuff that is too small or too narrow for the limb will
result in a falsely elevated (high) reading.
5. A nurse is assessing a client’s risk for pressure injuries using the Braden Scale.
Which score range indicates the highest risk?
A. 19-23
B. 6-9
C. 13-14
D. 15-18
Answer: B
Rationale: In the Braden Scale, a lower score indicates a higher risk for pressure injury
development. Scores range from 6 to 23.
