NR226/NR 226 Exam 1 V2 | Fundamentals of
Patient Care Q&A with Rationale | Chamberlain
University
1. A nurse is collecting subjective data during an initial assessment. Which of the following
statements by the patient should the nurse document as subjective data?
A. The patient reports feeling nauseated after breakfast.
B. The patient’s surgical incision is red and swollen.
C. The patient’s blood pressure is 142/90 mmHg.
D. The patient has a clear liquid diet ordered.
Correct Answer: A
Explanation: Subjective data consists of information provided by the patient that cannot
be independently measured by the nurse. This includes the patient’s feelings, perceptions,
and self-reported symptoms like nausea. In contrast, objective data includes observable
and measurable findings such as vital signs or physical examination results.
2. A nurse is performing hand hygiene before entering a patient’s room. Which action is the
most effective way to prevent the spread of microorganisms?
A. Rinsing hands with cold water for 5 seconds.
B. Applying hand lotion immediately after washing.
C. Drying hands with a shared cloth towel.
,D. Using friction while washing with soap and water.
Correct Answer: D
Explanation: Friction is the most essential component of handwashing because it
physically removes transient microorganisms from the skin. The nurse should scrub all
surfaces of the hands for at least 15 to 20 seconds to ensure cleanliness. Following proper
hand hygiene protocols is the single most effective way to break the chain of infection in a
clinical setting.
3. According to the Nursing Process, which phase involves the nurse establishing patient-
centered goals and expected outcomes?
A. Assessment
B. Diagnosis
C. Implementation
D. Planning
Correct Answer: D
Explanation: The planning phase is dedicated to prioritizing nursing diagnoses and setting
SMART goals for the patient. These goals must be specific, measurable, attainable, realistic,
and timed to effectively guide nursing care. Once the plan is established, the nurse can then
proceed to the implementation phase to carry out the interventions.
, 4. A nurse is caring for a patient who is on contact precautions. Which of the following
personal protective equipment (PPE) is required when providing direct care?
A. N95 respirator and goggles
B. Surgical mask and shoe covers
C. Gown and gloves
D. No PPE is required unless splashing is expected
Correct Answer: C
Explanation: Contact precautions are implemented to prevent the transmission of
infectious agents through direct or indirect contact. The nurse must wear a gown and
gloves to protect their clothing and skin from contamination during patient care. It is also
vital to remove these items and perform hand hygiene before leaving the patient’s room to
prevent cross-contamination.
5. When measuring a patient’s blood pressure, the nurse uses a cuff that is too small for the
patient’s arm. What effect will this have on the reading?
A. The reading will be falsely low.
B. The reading will be falsely high.
C. The reading will be accurate regardless of size.
D. The diastolic pressure will be accurate, but systolic will be low.
Correct Answer: B
Patient Care Q&A with Rationale | Chamberlain
University
1. A nurse is collecting subjective data during an initial assessment. Which of the following
statements by the patient should the nurse document as subjective data?
A. The patient reports feeling nauseated after breakfast.
B. The patient’s surgical incision is red and swollen.
C. The patient’s blood pressure is 142/90 mmHg.
D. The patient has a clear liquid diet ordered.
Correct Answer: A
Explanation: Subjective data consists of information provided by the patient that cannot
be independently measured by the nurse. This includes the patient’s feelings, perceptions,
and self-reported symptoms like nausea. In contrast, objective data includes observable
and measurable findings such as vital signs or physical examination results.
2. A nurse is performing hand hygiene before entering a patient’s room. Which action is the
most effective way to prevent the spread of microorganisms?
A. Rinsing hands with cold water for 5 seconds.
B. Applying hand lotion immediately after washing.
C. Drying hands with a shared cloth towel.
,D. Using friction while washing with soap and water.
Correct Answer: D
Explanation: Friction is the most essential component of handwashing because it
physically removes transient microorganisms from the skin. The nurse should scrub all
surfaces of the hands for at least 15 to 20 seconds to ensure cleanliness. Following proper
hand hygiene protocols is the single most effective way to break the chain of infection in a
clinical setting.
3. According to the Nursing Process, which phase involves the nurse establishing patient-
centered goals and expected outcomes?
A. Assessment
B. Diagnosis
C. Implementation
D. Planning
Correct Answer: D
Explanation: The planning phase is dedicated to prioritizing nursing diagnoses and setting
SMART goals for the patient. These goals must be specific, measurable, attainable, realistic,
and timed to effectively guide nursing care. Once the plan is established, the nurse can then
proceed to the implementation phase to carry out the interventions.
, 4. A nurse is caring for a patient who is on contact precautions. Which of the following
personal protective equipment (PPE) is required when providing direct care?
A. N95 respirator and goggles
B. Surgical mask and shoe covers
C. Gown and gloves
D. No PPE is required unless splashing is expected
Correct Answer: C
Explanation: Contact precautions are implemented to prevent the transmission of
infectious agents through direct or indirect contact. The nurse must wear a gown and
gloves to protect their clothing and skin from contamination during patient care. It is also
vital to remove these items and perform hand hygiene before leaving the patient’s room to
prevent cross-contamination.
5. When measuring a patient’s blood pressure, the nurse uses a cuff that is too small for the
patient’s arm. What effect will this have on the reading?
A. The reading will be falsely low.
B. The reading will be falsely high.
C. The reading will be accurate regardless of size.
D. The diastolic pressure will be accurate, but systolic will be low.
Correct Answer: B
