Assessment 5: Fundamentals of Nursing (NURS 100) 2026 – WCU
1. When assessing a client’s blood pressure, the nurse notes that the cuff used is
too narrow for the client’s arm. What impact will this have on the reading?
A. The reading will be falsely low.
B. The diastolic pressure will be lower than actual.
C. The reading will be unaffected.
D. The reading will be falsely high.
Answer: D
Rationale: A blood pressure cuff that is too narrow or small for the limb will result in a
reading that is falsely high.
2. Which pulse site is considered the most accurate for assessing the heart rate
of an infant?
A. Radial pulse
B. Brachial pulse
C. Apical pulse
D. Carotid pulse
Answer: C
Rationale: The apical pulse is the most reliable site for assessing heart rate in infants and
children up to 2 years of age.
,3. A nurse is performing hand hygiene. According to the CDC, what is the
minimum recommended time for scrubbing hands with soap and water?
A. 10 seconds
B. 60 seconds
C. 45 seconds
D. 20 seconds
Answer: D
Rationale: Effective handwashing requires scrubbing all surfaces of the hands with soap
and water for at least 20 seconds.
4. Which phase of the nursing process involves the nurse prioritizing patient
problems and identifying measurable goals?
A. Assessment
B. Planning
C. Diagnosis
D. Implementation
Answer: B
Rationale: The planning phase involves setting priorities, identifying patient-centered
goals and expected outcomes, and selecting nursing interventions.
5. A patient is identified as having a high risk for falls. Which nursing
intervention is the highest priority?
A. Place the call light within the patient’s reach.
B. Keep all four side rails up at all times.
C. Administer a sedative to keep the patient in bed.
D. Move the patient’s room further from the nurse’s station.
Answer: A
Rationale: Ensuring the call light is within reach is a standard safety intervention; using
four side rails is often considered a restraint and requires specific orders.
, 6. What type of data is represented by a patient’s statement: ‘I feel very short of
breath right now’?
A. Objective data
B. Secondary data
C. Extraneous data
D. Subjective data
Answer: D
Rationale: Subjective data are information from the client’s point of view, including
feelings, perceptions, and concerns.
7. A nurse is caring for a patient with a Stage 2 pressure injury. Which
characteristic is typical of this stage?
A. Non-blanchable erythema of intact skin
B. Partial-thickness skin loss involving the epidermis or dermis
C. Full-thickness skin loss with visible fat
D. Full-thickness tissue loss with exposed bone or tendon
Answer: B
Rationale: Stage 2 pressure injuries involve partial-thickness loss of skin with a visible
ulcer or a serum-filled blister.
8. Which document defines the legal scope of nursing practice within a specific
state?
A. ANA Code of Ethics
B. State Nurse Practice Act
C. Hospital Policy Manual
D. The Joint Commission standards
Answer: B
Rationale: The Nurse Practice Act (NPA) of each state defines the legal boundaries and
scope of nursing practice for that state.
1. When assessing a client’s blood pressure, the nurse notes that the cuff used is
too narrow for the client’s arm. What impact will this have on the reading?
A. The reading will be falsely low.
B. The diastolic pressure will be lower than actual.
C. The reading will be unaffected.
D. The reading will be falsely high.
Answer: D
Rationale: A blood pressure cuff that is too narrow or small for the limb will result in a
reading that is falsely high.
2. Which pulse site is considered the most accurate for assessing the heart rate
of an infant?
A. Radial pulse
B. Brachial pulse
C. Apical pulse
D. Carotid pulse
Answer: C
Rationale: The apical pulse is the most reliable site for assessing heart rate in infants and
children up to 2 years of age.
,3. A nurse is performing hand hygiene. According to the CDC, what is the
minimum recommended time for scrubbing hands with soap and water?
A. 10 seconds
B. 60 seconds
C. 45 seconds
D. 20 seconds
Answer: D
Rationale: Effective handwashing requires scrubbing all surfaces of the hands with soap
and water for at least 20 seconds.
4. Which phase of the nursing process involves the nurse prioritizing patient
problems and identifying measurable goals?
A. Assessment
B. Planning
C. Diagnosis
D. Implementation
Answer: B
Rationale: The planning phase involves setting priorities, identifying patient-centered
goals and expected outcomes, and selecting nursing interventions.
5. A patient is identified as having a high risk for falls. Which nursing
intervention is the highest priority?
A. Place the call light within the patient’s reach.
B. Keep all four side rails up at all times.
C. Administer a sedative to keep the patient in bed.
D. Move the patient’s room further from the nurse’s station.
Answer: A
Rationale: Ensuring the call light is within reach is a standard safety intervention; using
four side rails is often considered a restraint and requires specific orders.
, 6. What type of data is represented by a patient’s statement: ‘I feel very short of
breath right now’?
A. Objective data
B. Secondary data
C. Extraneous data
D. Subjective data
Answer: D
Rationale: Subjective data are information from the client’s point of view, including
feelings, perceptions, and concerns.
7. A nurse is caring for a patient with a Stage 2 pressure injury. Which
characteristic is typical of this stage?
A. Non-blanchable erythema of intact skin
B. Partial-thickness skin loss involving the epidermis or dermis
C. Full-thickness skin loss with visible fat
D. Full-thickness tissue loss with exposed bone or tendon
Answer: B
Rationale: Stage 2 pressure injuries involve partial-thickness loss of skin with a visible
ulcer or a serum-filled blister.
8. Which document defines the legal scope of nursing practice within a specific
state?
A. ANA Code of Ethics
B. State Nurse Practice Act
C. Hospital Policy Manual
D. The Joint Commission standards
Answer: B
Rationale: The Nurse Practice Act (NPA) of each state defines the legal boundaries and
scope of nursing practice for that state.
