NR226/NR 226 Exam 1 V1 | Fundamentals of
Patient Care Q&A with Rationale | Chamberlain
University
1. A nurse is preparing to perform a physical assessment on a newly admitted patient. Which
action should the nurse perform first to establish a therapeutic relationship?
A. Introduce self by name and role and explain the purpose of the assessment.
B. Ask the patient to change into a hospital gown immediately.
C. Begin palpating the abdomen to check for tenderness.
D. Review the patient’s medical records at the bedside.
Correct Answer: A
Explanation: Introduction of the nurse and explaining the procedure is a fundamental step
in establishing trust and a therapeutic relationship. This action respects the patient’s
autonomy and reduces anxiety by providing clear expectations for the interaction.
According to the Fundamentals of Nursing, rapport is built through clear communication
and professional presence.
2. When assessing a patient’s radial pulse, the nurse notes that the rhythm is irregular. Which
action should the nurse take next?
A. Measure the apical pulse for one full minute.
B. Document the finding and proceed with the assessment.
,C. Re-assess the radial pulse for 30 seconds and multiply by two.
D. Administer prescribed cardiac medication immediately.
Correct Answer: A
Explanation: The apical pulse is the most accurate site for assessing heart rate and rhythm
when peripheral pulses are irregular. Assessing for a full minute allows the nurse to
identify the specific nature of the irregularity and ensures an accurate heart rate
measurement. This is a critical safety intervention to prevent errors in patient assessment
and subsequent treatment.
3. Which of the following is an example of objective data?
A. The nurse observes the patient’s skin is cool and clammy.
B. The patient states, ‘I have a sharp pain in my hip.’
C. The patient reports feeling nauseated.
D. The patient expresses concern about the upcoming surgery.
Correct Answer: A
Explanation: Objective data are observable and measurable signs that can be seen, heard,
felt, or smelled by the nurse. Observations such as skin temperature and moisture are
factual and not dependent on the patient’s interpretation. In contrast, reports of pain,
nausea, or feelings are subjective data provided by the patient.
, 4. The nurse is caring for a patient who has been diagnosed with Clostridioides difficile (C.
diff). Which infection control measure is mandatory for this patient?
A. Use an alcohol-based hand rub after every contact.
B. Wash hands with soap and water after leaving the room.
C. Wear an N95 respirator mask when entering the room.
D. Maintain a distance of 6 feet from the patient at all times.
Correct Answer: B
Explanation: Hand hygiene with soap and water is required when caring for patients with
C. diff because alcohol-based rubs are ineffective against the spores produced by the
bacteria. Mechanical friction during hand washing helps physically remove the spores from
the hands. This is a standard transmission-based precaution for enteric infections.
5. A nurse is assessing a patient’s risk for falls using the Morse Fall Scale. Which factor would
increase the patient’s score?
A. The patient is alert and oriented to person, place, and time.
B. The patient uses a cane for ambulation.
C. The patient has no history of falling.
D. The patient is receiving intravenous fluids via a pump.
Correct Answer: D
Patient Care Q&A with Rationale | Chamberlain
University
1. A nurse is preparing to perform a physical assessment on a newly admitted patient. Which
action should the nurse perform first to establish a therapeutic relationship?
A. Introduce self by name and role and explain the purpose of the assessment.
B. Ask the patient to change into a hospital gown immediately.
C. Begin palpating the abdomen to check for tenderness.
D. Review the patient’s medical records at the bedside.
Correct Answer: A
Explanation: Introduction of the nurse and explaining the procedure is a fundamental step
in establishing trust and a therapeutic relationship. This action respects the patient’s
autonomy and reduces anxiety by providing clear expectations for the interaction.
According to the Fundamentals of Nursing, rapport is built through clear communication
and professional presence.
2. When assessing a patient’s radial pulse, the nurse notes that the rhythm is irregular. Which
action should the nurse take next?
A. Measure the apical pulse for one full minute.
B. Document the finding and proceed with the assessment.
,C. Re-assess the radial pulse for 30 seconds and multiply by two.
D. Administer prescribed cardiac medication immediately.
Correct Answer: A
Explanation: The apical pulse is the most accurate site for assessing heart rate and rhythm
when peripheral pulses are irregular. Assessing for a full minute allows the nurse to
identify the specific nature of the irregularity and ensures an accurate heart rate
measurement. This is a critical safety intervention to prevent errors in patient assessment
and subsequent treatment.
3. Which of the following is an example of objective data?
A. The nurse observes the patient’s skin is cool and clammy.
B. The patient states, ‘I have a sharp pain in my hip.’
C. The patient reports feeling nauseated.
D. The patient expresses concern about the upcoming surgery.
Correct Answer: A
Explanation: Objective data are observable and measurable signs that can be seen, heard,
felt, or smelled by the nurse. Observations such as skin temperature and moisture are
factual and not dependent on the patient’s interpretation. In contrast, reports of pain,
nausea, or feelings are subjective data provided by the patient.
, 4. The nurse is caring for a patient who has been diagnosed with Clostridioides difficile (C.
diff). Which infection control measure is mandatory for this patient?
A. Use an alcohol-based hand rub after every contact.
B. Wash hands with soap and water after leaving the room.
C. Wear an N95 respirator mask when entering the room.
D. Maintain a distance of 6 feet from the patient at all times.
Correct Answer: B
Explanation: Hand hygiene with soap and water is required when caring for patients with
C. diff because alcohol-based rubs are ineffective against the spores produced by the
bacteria. Mechanical friction during hand washing helps physically remove the spores from
the hands. This is a standard transmission-based precaution for enteric infections.
5. A nurse is assessing a patient’s risk for falls using the Morse Fall Scale. Which factor would
increase the patient’s score?
A. The patient is alert and oriented to person, place, and time.
B. The patient uses a cane for ambulation.
C. The patient has no history of falling.
D. The patient is receiving intravenous fluids via a pump.
Correct Answer: D
