NURS 100 Fundamentals of
Nursing Assessment WCU
Questions and Answers
Verified Solutions Latest Update
,NURS 100 Fundamentals of Nursing Assessment WCU
Verified Questions and Answers Latest Version
1. Which phase of the nursing process involves the systematic collection of data
to determine a client’s health status?
A. Planning
B. Implementation
C. Assessment
D. Diagnosis
Answer: C
Rationale: Assessment is the first step of the nursing process, where the nurse collects,
organizes, validates, and documents client data.
2. A nurse is helping a client ambulate and the client begins to fall. Which action
should the nurse take first?
A. Call for help immediately
B. Try to catch the client to prevent the fall
C. Leave the client to get a wheelchair
D. Step behind the client and slide them down their leg to the floor
Answer: D
Rationale: If a client begins to fall during ambulation, the nurse should support the client
and guide them safely to the floor to prevent injury to both the client and the nurse.
, 3. Which of the following is considered subjective data?
A. The client states, ‘I feel nauseated’
B. The client’s surgical incision is red and swollen
C. The client’s blood pressure is 140/90 mmHg
D. The client’s weight is 150 lbs
Answer: A
Rationale: Subjective data are symptoms or sensations described only by the client.
Objective data are observable and measurable signs.
4. The nurse is practicing hand hygiene. What is the minimum recommended
duration for rubbing hands with soap and water?
A. 20 seconds
B. 5 seconds
C. 60 seconds
D. 2 minutes
Answer: A
Rationale: CDC guidelines recommend scrubbing hands for at least 20 seconds to
effectively remove microorganisms.
5. A client has a pulse rate of 110 beats per minute. How should the nurse
document this finding?
A. Tachycardia
B. Eupnea
C. Bradycardia
D. Normal sinus rhythm
Answer: A
Rationale: Tachycardia is defined as an adult heart rate over 100 beats per minute.
Bradycardia is under 60.
Nursing Assessment WCU
Questions and Answers
Verified Solutions Latest Update
,NURS 100 Fundamentals of Nursing Assessment WCU
Verified Questions and Answers Latest Version
1. Which phase of the nursing process involves the systematic collection of data
to determine a client’s health status?
A. Planning
B. Implementation
C. Assessment
D. Diagnosis
Answer: C
Rationale: Assessment is the first step of the nursing process, where the nurse collects,
organizes, validates, and documents client data.
2. A nurse is helping a client ambulate and the client begins to fall. Which action
should the nurse take first?
A. Call for help immediately
B. Try to catch the client to prevent the fall
C. Leave the client to get a wheelchair
D. Step behind the client and slide them down their leg to the floor
Answer: D
Rationale: If a client begins to fall during ambulation, the nurse should support the client
and guide them safely to the floor to prevent injury to both the client and the nurse.
, 3. Which of the following is considered subjective data?
A. The client states, ‘I feel nauseated’
B. The client’s surgical incision is red and swollen
C. The client’s blood pressure is 140/90 mmHg
D. The client’s weight is 150 lbs
Answer: A
Rationale: Subjective data are symptoms or sensations described only by the client.
Objective data are observable and measurable signs.
4. The nurse is practicing hand hygiene. What is the minimum recommended
duration for rubbing hands with soap and water?
A. 20 seconds
B. 5 seconds
C. 60 seconds
D. 2 minutes
Answer: A
Rationale: CDC guidelines recommend scrubbing hands for at least 20 seconds to
effectively remove microorganisms.
5. A client has a pulse rate of 110 beats per minute. How should the nurse
document this finding?
A. Tachycardia
B. Eupnea
C. Bradycardia
D. Normal sinus rhythm
Answer: A
Rationale: Tachycardia is defined as an adult heart rate over 100 beats per minute.
Bradycardia is under 60.
