NUR 104/NUR104 Final Exam V3 | Foundations of
Nursing Q&A with Rationale | Fortis College
1. A nurse is performing a physical assessment on a newly admitted client. Which action by
the nurse represents the assessment phase of the nursing process?
A. Documenting the client’s response to pain medication.
B. Administering an intravenous antibiotic as ordered.
C. Auscultating the client’s lung sounds for wheezing.
D. Establishing a goal for the client to walk 50 feet.
Correct Answer: C
Explanation: Assessment involves the systematic collection of data through observation,
physical examination, and interviewing. Auscultating lung sounds is a direct method of
gathering objective data about the client’s respiratory status. This phase is critical because
it provides the foundation for identifying nursing diagnoses and planning subsequent care.
2. Which intervention is the most effective method for preventing the transmission of
healthcare-associated infections (HAIs)?
A. Wearing clean gloves for all client interactions.
B. Restricting visitors with respiratory symptoms.
C. Performing consistent and thorough hand hygiene.
D. Administering prophylactic antibiotics to all clients.
,Correct Answer: C
Explanation: Hand hygiene is recognized globally as the single most important practice to
reduce the spread of pathogens in healthcare settings. It should be performed before and
after client contact, as well as after contact with body fluids or contaminated surfaces.
Failure to adhere to hand hygiene protocols significantly increases the risk of cross-
contamination between clients and staff.
3. A nurse is preparing to transfer a client from the bed to a chair. Which principle of body
mechanics should the nurse apply to ensure safety?
A. Keep the feet close together to maintain a narrow base of support.
B. Bend at the waist while lifting to utilize back muscles.
C. Twist the torso while moving to change directions quickly.
D. Keep the client as close to the nurse’s body as possible.
Correct Answer: D
Explanation: Keeping the weight close to the body’s center of gravity reduces the strain on
the back and improves stability during a transfer. The nurse should maintain a wide base of
support with feet apart and use the large muscles of the legs rather than the back. Proper
body mechanics are essential for preventing musculoskeletal injuries among nursing
personnel.
, 4. A nurse is caring for an older adult client who is at high risk for skin breakdown. Which
nursing intervention is a priority for this client?
A. Massaging reddened bony prominences every 4 hours.
B. Limiting fluid intake to prevent incontinence episodes.
C. Applying powder to skin folds to reduce moisture.
D. Repositioning the client at least every 2 hours.
Correct Answer: D
Explanation: Frequent repositioning relieves pressure on tissues, particularly over bony
prominences, which is the primary cause of pressure injuries. Massaging reddened areas
should be avoided as it can cause further tissue damage to fragile capillaries. Maintaining
skin integrity in older adults requires a proactive approach that includes pressure relief
and adequate nutrition/hydration.
5. When documenting in a client’s medical record, which entry by the nurse follows the
principles of legal documentation?
A. Client had a good day and appeared to be in a better mood.
B. The physician was late and did not return the nurse’s call.
C. 0830: Client’s surgical dressing is clean, dry, and intact.
D. Medication was given even though the client seemed confused.
Correct Answer: C
Nursing Q&A with Rationale | Fortis College
1. A nurse is performing a physical assessment on a newly admitted client. Which action by
the nurse represents the assessment phase of the nursing process?
A. Documenting the client’s response to pain medication.
B. Administering an intravenous antibiotic as ordered.
C. Auscultating the client’s lung sounds for wheezing.
D. Establishing a goal for the client to walk 50 feet.
Correct Answer: C
Explanation: Assessment involves the systematic collection of data through observation,
physical examination, and interviewing. Auscultating lung sounds is a direct method of
gathering objective data about the client’s respiratory status. This phase is critical because
it provides the foundation for identifying nursing diagnoses and planning subsequent care.
2. Which intervention is the most effective method for preventing the transmission of
healthcare-associated infections (HAIs)?
A. Wearing clean gloves for all client interactions.
B. Restricting visitors with respiratory symptoms.
C. Performing consistent and thorough hand hygiene.
D. Administering prophylactic antibiotics to all clients.
,Correct Answer: C
Explanation: Hand hygiene is recognized globally as the single most important practice to
reduce the spread of pathogens in healthcare settings. It should be performed before and
after client contact, as well as after contact with body fluids or contaminated surfaces.
Failure to adhere to hand hygiene protocols significantly increases the risk of cross-
contamination between clients and staff.
3. A nurse is preparing to transfer a client from the bed to a chair. Which principle of body
mechanics should the nurse apply to ensure safety?
A. Keep the feet close together to maintain a narrow base of support.
B. Bend at the waist while lifting to utilize back muscles.
C. Twist the torso while moving to change directions quickly.
D. Keep the client as close to the nurse’s body as possible.
Correct Answer: D
Explanation: Keeping the weight close to the body’s center of gravity reduces the strain on
the back and improves stability during a transfer. The nurse should maintain a wide base of
support with feet apart and use the large muscles of the legs rather than the back. Proper
body mechanics are essential for preventing musculoskeletal injuries among nursing
personnel.
, 4. A nurse is caring for an older adult client who is at high risk for skin breakdown. Which
nursing intervention is a priority for this client?
A. Massaging reddened bony prominences every 4 hours.
B. Limiting fluid intake to prevent incontinence episodes.
C. Applying powder to skin folds to reduce moisture.
D. Repositioning the client at least every 2 hours.
Correct Answer: D
Explanation: Frequent repositioning relieves pressure on tissues, particularly over bony
prominences, which is the primary cause of pressure injuries. Massaging reddened areas
should be avoided as it can cause further tissue damage to fragile capillaries. Maintaining
skin integrity in older adults requires a proactive approach that includes pressure relief
and adequate nutrition/hydration.
5. When documenting in a client’s medical record, which entry by the nurse follows the
principles of legal documentation?
A. Client had a good day and appeared to be in a better mood.
B. The physician was late and did not return the nurse’s call.
C. 0830: Client’s surgical dressing is clean, dry, and intact.
D. Medication was given even though the client seemed confused.
Correct Answer: C
