NUR 104/NUR104 Exam 1 V2 | Foundations of
Nursing Q&A with Rationale | Fortis College
1. A nurse is conducting the assessment phase of the nursing process. Which activity is the
nurse primarily engaged in?
A. Formulating a nursing diagnosis based on data.
B. Setting measurable goals for patient outcomes.
C. Collecting and organizing patient health data.
D. Evaluating the effectiveness of nursing interventions.
Correct Answer: C
Explanation: The assessment phase is the first step of the nursing process and focuses on
data collection. It involves gathering subjective and objective information from various
sources. This phase provides the baseline for all subsequent steps in the nursing process.
2. When applying the principles of Florence Nightingale to modern practice, which
intervention would the nurse prioritize?
A. Ensuring a clean, well-ventilated environment for the patient.
B. Administering pharmacological agents to control pain.
C. Utilizing advanced technology for hemodynamic monitoring.
D. Assisting the physician with surgical procedures.
,Correct Answer: A
Explanation: Florence Nightingale’s Environmental Theory emphasizes the importance of
a patient’s surroundings in the healing process. She believed that fresh air, pure water,
efficient drainage, and light were essential for recovery. Contemporary nursing still
incorporates these principles by maintaining a safe and therapeutic environment.
3. A nurse is communicating with a client who is visibly upset. Which therapeutic
communication technique should the nurse use first?
A. Using active listening and open-ended questions.
B. Changing the subject to something more positive.
C. Giving advice on how to solve the problem.
D. Telling the client everything will be fine.
Correct Answer: A
Explanation: Active listening demonstrates that the nurse is fully present and interested in
the client’s concerns. Open-ended questions allow the client to express their feelings
without being restricted to yes or no answers. These techniques build trust and encourage
the client to share more detailed information.
4. Which ethical principle is the nurse practicing when they keep a promise to return to a
patient’s room in 10 minutes?
A. Autonomy
B. Fidelity
, C. Justice
D. Beneficence
Correct Answer: B
Explanation: Fidelity refers to the concept of faithfulness and keeping one’s promises to
patients. It is a fundamental component of the nurse-patient relationship and builds
professional trust. When a nurse follows through on a commitment, they demonstrate
respect and reliability.
5. The nurse is preparing to take a blood pressure on an adult client. Which action is most
likely to result in an inaccurately high reading?
A. Deflating the cuff at a rate of 2 to 3 mmHg per second.
B. Positioning the client’s arm at the level of the heart.
C. Using a cuff that is too narrow for the arm circumference.
D. Allowing the client to rest for 5 minutes before the measurement.
Correct Answer: C
Explanation: Using a blood pressure cuff that is too small or narrow will result in a false
high reading. The bladder of the cuff should encircle at least 80% of the adult’s arm. Proper
cuff sizing is critical for obtaining valid hemodynamic data.
6. According to Maslow’s Hierarchy of Needs, which patient should the nurse assess first?
A. A patient complaining of difficulty breathing.
Nursing Q&A with Rationale | Fortis College
1. A nurse is conducting the assessment phase of the nursing process. Which activity is the
nurse primarily engaged in?
A. Formulating a nursing diagnosis based on data.
B. Setting measurable goals for patient outcomes.
C. Collecting and organizing patient health data.
D. Evaluating the effectiveness of nursing interventions.
Correct Answer: C
Explanation: The assessment phase is the first step of the nursing process and focuses on
data collection. It involves gathering subjective and objective information from various
sources. This phase provides the baseline for all subsequent steps in the nursing process.
2. When applying the principles of Florence Nightingale to modern practice, which
intervention would the nurse prioritize?
A. Ensuring a clean, well-ventilated environment for the patient.
B. Administering pharmacological agents to control pain.
C. Utilizing advanced technology for hemodynamic monitoring.
D. Assisting the physician with surgical procedures.
,Correct Answer: A
Explanation: Florence Nightingale’s Environmental Theory emphasizes the importance of
a patient’s surroundings in the healing process. She believed that fresh air, pure water,
efficient drainage, and light were essential for recovery. Contemporary nursing still
incorporates these principles by maintaining a safe and therapeutic environment.
3. A nurse is communicating with a client who is visibly upset. Which therapeutic
communication technique should the nurse use first?
A. Using active listening and open-ended questions.
B. Changing the subject to something more positive.
C. Giving advice on how to solve the problem.
D. Telling the client everything will be fine.
Correct Answer: A
Explanation: Active listening demonstrates that the nurse is fully present and interested in
the client’s concerns. Open-ended questions allow the client to express their feelings
without being restricted to yes or no answers. These techniques build trust and encourage
the client to share more detailed information.
4. Which ethical principle is the nurse practicing when they keep a promise to return to a
patient’s room in 10 minutes?
A. Autonomy
B. Fidelity
, C. Justice
D. Beneficence
Correct Answer: B
Explanation: Fidelity refers to the concept of faithfulness and keeping one’s promises to
patients. It is a fundamental component of the nurse-patient relationship and builds
professional trust. When a nurse follows through on a commitment, they demonstrate
respect and reliability.
5. The nurse is preparing to take a blood pressure on an adult client. Which action is most
likely to result in an inaccurately high reading?
A. Deflating the cuff at a rate of 2 to 3 mmHg per second.
B. Positioning the client’s arm at the level of the heart.
C. Using a cuff that is too narrow for the arm circumference.
D. Allowing the client to rest for 5 minutes before the measurement.
Correct Answer: C
Explanation: Using a blood pressure cuff that is too small or narrow will result in a false
high reading. The bladder of the cuff should encircle at least 80% of the adult’s arm. Proper
cuff sizing is critical for obtaining valid hemodynamic data.
6. According to Maslow’s Hierarchy of Needs, which patient should the nurse assess first?
A. A patient complaining of difficulty breathing.
