NUR 104/NUR104 Final Exam V1 | Foundations of
Nursing Q&A with Rationale | Fortis College
1. A nurse is reviewing the nursing process with a student. Which of the following should the
nurse identify as the first step in providing client-centered care?
A. Planning
B. Evaluation
C. Implementation
D. Assessment
Correct Answer: D
Explanation: Assessment is the first step of the nursing process and involves the
systematic collection of data about the client. This step is crucial because all subsequent
nursing decisions and interventions are based on the data gathered during this phase.
Without a thorough assessment, the nurse cannot accurately identify client needs or
develop an effective plan of care.
2. A nurse is caring for a client who is on contact precautions. Which of the following actions
should the nurse take when entering the client’s room?
A. Wear a surgical mask
B. Don an N95 respirator
C. Wear a gown and gloves
,D. Wear goggles and a hair cover
Correct Answer: C
Explanation: Contact precautions are used to prevent the transmission of infectious agents
that are spread by direct or indirect contact with the client or the client’s environment. The
nurse must wear a gown and gloves to provide a barrier against pathogens such as MRSA
or VRE. These protective measures are essential to maintain a safe environment and
prevent healthcare-associated infections.
3. A nurse is preparing to administer an enema to a client. Which of the following positions
should the nurse place the client in?
A. High-Fowler’s
B. Lithotomy
C. Left Sims’
D. Supine
Correct Answer: C
Explanation: The Left Sims’ position is the most appropriate position for administering an
enema because it allows the solution to flow by gravity into the sigmoid colon and rectum.
In this position, the client lies on the left side with the right knee flexed toward the chest.
This anatomical alignment facilitates the distribution of the fluid and increases the
effectiveness of the procedure.
,4. A nurse is teaching a client about a clear liquid diet. Which of the following food items
should the nurse include in the teaching?
A. Chicken broth
B. Vanilla pudding
C. Orange juice with pulp
D. Low-fat yogurt
Correct Answer: A
Explanation: A clear liquid diet consists of fluids that are transparent and liquid at room
temperature, such as chicken broth, gelatin, and apple juice. Items like orange juice with
pulp, pudding, and yogurt are considered full liquids or solid foods because they are not
transparent and contain solids. Providing the correct items on a clear liquid diet is essential
for clients preparing for diagnostic tests or recovering from surgery.
5. A nurse is assessing a client’s radial pulse and notes that the rhythm is irregular. Which of
the following actions should the nurse take?
A. Document the finding and move to the next assessment
B. Assess the apical pulse for one full minute
C. Reassess the radial pulse for 30 seconds and multiply by 2
D. Notify the provider immediately
Correct Answer: B
, Explanation: When a peripheral pulse is found to be irregular, the most accurate way to
assess the heart rate and rhythm is by auscultating the apical pulse for 60 seconds. This
allows the nurse to identify the specific nature of the irregularity and ensures an accurate
heart rate measurement. Documentation alone is insufficient without further assessment to
ensure client safety.
6. A nurse is preparing to transfer a client from a bed to a chair. Which of the following
actions should the nurse take to maintain proper body mechanics?
A. Bend at the waist to lift the client
B. Keep the feet close together to provide a narrow base of support
C. Twist the torso while moving the client
D. Keep the client close to the nurse’s body
Correct Answer: D
Explanation: Keeping the client close to the nurse’s body shifts the center of gravity and
reduces the strain on the nurse’s back muscles. The nurse should always use a wide base of
support and bend at the knees rather than the waist to prevent injury. Proper body
mechanics are vital in the clinical setting to ensure both nurse and client safety during
transfers.
7. A nurse is caring for a client who is experiencing a seizure. Which of the following is the
nurse’s priority action?
A. Insert a tongue blade into the client’s mouth
Nursing Q&A with Rationale | Fortis College
1. A nurse is reviewing the nursing process with a student. Which of the following should the
nurse identify as the first step in providing client-centered care?
A. Planning
B. Evaluation
C. Implementation
D. Assessment
Correct Answer: D
Explanation: Assessment is the first step of the nursing process and involves the
systematic collection of data about the client. This step is crucial because all subsequent
nursing decisions and interventions are based on the data gathered during this phase.
Without a thorough assessment, the nurse cannot accurately identify client needs or
develop an effective plan of care.
2. A nurse is caring for a client who is on contact precautions. Which of the following actions
should the nurse take when entering the client’s room?
A. Wear a surgical mask
B. Don an N95 respirator
C. Wear a gown and gloves
,D. Wear goggles and a hair cover
Correct Answer: C
Explanation: Contact precautions are used to prevent the transmission of infectious agents
that are spread by direct or indirect contact with the client or the client’s environment. The
nurse must wear a gown and gloves to provide a barrier against pathogens such as MRSA
or VRE. These protective measures are essential to maintain a safe environment and
prevent healthcare-associated infections.
3. A nurse is preparing to administer an enema to a client. Which of the following positions
should the nurse place the client in?
A. High-Fowler’s
B. Lithotomy
C. Left Sims’
D. Supine
Correct Answer: C
Explanation: The Left Sims’ position is the most appropriate position for administering an
enema because it allows the solution to flow by gravity into the sigmoid colon and rectum.
In this position, the client lies on the left side with the right knee flexed toward the chest.
This anatomical alignment facilitates the distribution of the fluid and increases the
effectiveness of the procedure.
,4. A nurse is teaching a client about a clear liquid diet. Which of the following food items
should the nurse include in the teaching?
A. Chicken broth
B. Vanilla pudding
C. Orange juice with pulp
D. Low-fat yogurt
Correct Answer: A
Explanation: A clear liquid diet consists of fluids that are transparent and liquid at room
temperature, such as chicken broth, gelatin, and apple juice. Items like orange juice with
pulp, pudding, and yogurt are considered full liquids or solid foods because they are not
transparent and contain solids. Providing the correct items on a clear liquid diet is essential
for clients preparing for diagnostic tests or recovering from surgery.
5. A nurse is assessing a client’s radial pulse and notes that the rhythm is irregular. Which of
the following actions should the nurse take?
A. Document the finding and move to the next assessment
B. Assess the apical pulse for one full minute
C. Reassess the radial pulse for 30 seconds and multiply by 2
D. Notify the provider immediately
Correct Answer: B
, Explanation: When a peripheral pulse is found to be irregular, the most accurate way to
assess the heart rate and rhythm is by auscultating the apical pulse for 60 seconds. This
allows the nurse to identify the specific nature of the irregularity and ensures an accurate
heart rate measurement. Documentation alone is insufficient without further assessment to
ensure client safety.
6. A nurse is preparing to transfer a client from a bed to a chair. Which of the following
actions should the nurse take to maintain proper body mechanics?
A. Bend at the waist to lift the client
B. Keep the feet close together to provide a narrow base of support
C. Twist the torso while moving the client
D. Keep the client close to the nurse’s body
Correct Answer: D
Explanation: Keeping the client close to the nurse’s body shifts the center of gravity and
reduces the strain on the nurse’s back muscles. The nurse should always use a wide base of
support and bend at the knees rather than the waist to prevent injury. Proper body
mechanics are vital in the clinical setting to ensure both nurse and client safety during
transfers.
7. A nurse is caring for a client who is experiencing a seizure. Which of the following is the
nurse’s priority action?
A. Insert a tongue blade into the client’s mouth
