NUR 104/NUR104 Exam 1 V3 | Foundations of
Nursing Q&A with Rationale | Fortis College
1. A nurse is performing hand hygiene after caring for a client with a known Clostridium
difficile infection. Which action should the nurse take?
A. Wash hands with soap and water for at least 20 seconds.
B. Use an alcohol-based hand rub for 15 seconds.
C. Apply a sterile antiseptic foam to the hands.
D. Rinse hands with hot water and dry with a shared towel.
Correct Answer: A
Explanation: Clostridium difficile spores are resistant to alcohol-based hand rubs.
Washing hands with soap and water provides the mechanical friction necessary to remove
spores from the skin. This is the standard of care recommended by the CDC for this specific
pathogen.
2. Which level of health prevention is a nurse practicing when administering a flu vaccine to a
group of college students?
A. Secondary prevention
B. Tertiary prevention
C. Quaternary prevention
D. Primary prevention
,Correct Answer: D
Explanation: Primary prevention focuses on health promotion and protection against
specific diseases before they occur. Immunizations are a classic example of primary
prevention as they aim to prevent the onset of illness. Secondary prevention involves
screening, while tertiary involves rehabilitation after an illness has occurred.
3. A nurse is assessing a client and notices a fruity odor on their breath. Which vital sign or
assessment should the nurse prioritize next?
A. Blood glucose level
B. Blood pressure
C. Oxygen saturation
D. Deep tendon reflexes
Correct Answer: A
Explanation: A fruity breath odor is often a sign of diabetic ketoacidosis (DKA) due to the
presence of ketones. The nurse should immediately assess the client’s blood glucose level
to determine the severity of hyperglycemia. Early intervention in DKA is critical to prevent
life-threatening complications.
4. According to Maslow’s Hierarchy of Needs, which client should the nurse see first?
A. A client who is requesting information about their medication.
B. A client who is lonely and wants to talk to a family member.
, C. A client who is expressing concern about their body image.
D. A client who is experiencing shortness of breath.
Correct Answer: D
Explanation: Physiological needs, such as breathing and circulation, are at the base of
Maslow’s hierarchy and must be met first. Shortness of breath indicates a compromise in
the respiratory system, which is a high-priority physiological need. Safety, love/belonging,
and self-esteem needs are addressed only after the client is stable physiologically.
5. A nurse is caring for a client who identifies as being from a culture that values non-verbal
communication and direct eye contact is considered disrespectful. How should the nurse
adapt their care?
A. Avoid eye contact and observe the client’s non-verbal cues carefully.
B. Insist the client looks at them when speaking to ensure understanding.
C. Assume the client is not paying attention if they look away.
D. Refer the client to a social worker for behavioral modification.
Correct Answer: A
Explanation: Cultural competence requires the nurse to adapt communication styles to
meet the client’s preferences. Avoiding direct eye contact shows respect for the client’s
cultural norms and fosters a therapeutic relationship. Observing non-verbal cues helps the
nurse gather assessment data without causing discomfort to the client.
Nursing Q&A with Rationale | Fortis College
1. A nurse is performing hand hygiene after caring for a client with a known Clostridium
difficile infection. Which action should the nurse take?
A. Wash hands with soap and water for at least 20 seconds.
B. Use an alcohol-based hand rub for 15 seconds.
C. Apply a sterile antiseptic foam to the hands.
D. Rinse hands with hot water and dry with a shared towel.
Correct Answer: A
Explanation: Clostridium difficile spores are resistant to alcohol-based hand rubs.
Washing hands with soap and water provides the mechanical friction necessary to remove
spores from the skin. This is the standard of care recommended by the CDC for this specific
pathogen.
2. Which level of health prevention is a nurse practicing when administering a flu vaccine to a
group of college students?
A. Secondary prevention
B. Tertiary prevention
C. Quaternary prevention
D. Primary prevention
,Correct Answer: D
Explanation: Primary prevention focuses on health promotion and protection against
specific diseases before they occur. Immunizations are a classic example of primary
prevention as they aim to prevent the onset of illness. Secondary prevention involves
screening, while tertiary involves rehabilitation after an illness has occurred.
3. A nurse is assessing a client and notices a fruity odor on their breath. Which vital sign or
assessment should the nurse prioritize next?
A. Blood glucose level
B. Blood pressure
C. Oxygen saturation
D. Deep tendon reflexes
Correct Answer: A
Explanation: A fruity breath odor is often a sign of diabetic ketoacidosis (DKA) due to the
presence of ketones. The nurse should immediately assess the client’s blood glucose level
to determine the severity of hyperglycemia. Early intervention in DKA is critical to prevent
life-threatening complications.
4. According to Maslow’s Hierarchy of Needs, which client should the nurse see first?
A. A client who is requesting information about their medication.
B. A client who is lonely and wants to talk to a family member.
, C. A client who is expressing concern about their body image.
D. A client who is experiencing shortness of breath.
Correct Answer: D
Explanation: Physiological needs, such as breathing and circulation, are at the base of
Maslow’s hierarchy and must be met first. Shortness of breath indicates a compromise in
the respiratory system, which is a high-priority physiological need. Safety, love/belonging,
and self-esteem needs are addressed only after the client is stable physiologically.
5. A nurse is caring for a client who identifies as being from a culture that values non-verbal
communication and direct eye contact is considered disrespectful. How should the nurse
adapt their care?
A. Avoid eye contact and observe the client’s non-verbal cues carefully.
B. Insist the client looks at them when speaking to ensure understanding.
C. Assume the client is not paying attention if they look away.
D. Refer the client to a social worker for behavioral modification.
Correct Answer: A
Explanation: Cultural competence requires the nurse to adapt communication styles to
meet the client’s preferences. Avoiding direct eye contact shows respect for the client’s
cultural norms and fosters a therapeutic relationship. Observing non-verbal cues helps the
nurse gather assessment data without causing discomfort to the client.
