Page |1
FUNDAMENTALS OF NURSING — PRACTICE Q&A | Questions
with Answers & Rationales
1. The nurse is caring for a client who is at risk for falls. Which
intervention is the highest priority?
A. Keep the bed in the lowest position and place the call light
within reach
B. Raise all four side rails at all times
C. Restrain the client to prevent falls
D. Keep the room dark to encourage rest
Answer: A
Rationale: Keeping the bed low and the call light accessible are
standard fall prevention measures. Restraints are a last resort,
and raising all side rails may be considered a restraint.
2. Which action by the nurse is the most effective way to
prevent the spread of infection?
A. Wearing gloves for all client contact
B. Performing hand hygiene before and after client care
C. Using alcohol-based hand rub on visibly soiled hands
D. Wearing a mask in all client rooms
Answer: B
Rationale: Hand hygiene is the single most important practice
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to reduce infection. Alcohol-based rubs are not used on visibly
soiled hands.
3. A nurse is preparing to assess a client’s abdomen. What is the
correct order of assessment?
A. Inspection, auscultation, palpation, percussion
B. Inspection, palpation, percussion, auscultation
C. Auscultation, inspection, palpation, percussion
D. Palpation, auscultation, inspection, percussion
Answer: A
Rationale: Inspect first, then auscultate before palpation and
percussion because percussion and palpation can alter bowel
sounds.
4. The nurse documents that a client has "purulent drainage"
from a wound. What does this indicate?
A. Serous drainage
B. Infection or inflammation
C. Normal healing
D. Sanguineous drainage
Answer: B
Rationale: Purulent drainage is thick, yellow, green, or white
and indicates infection.
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5. Which of the following is a sign of a localized infection?
A. Fever and chills
B. Redness, warmth, swelling, and pain at the wound site
C. Generalized body aches
D. Fatigue and malaise only
Answer: B
Rationale: Localized infection signs are at the site: redness,
warmth, swelling, pain, and possibly purulent drainage.
6. A client has a stage 2 pressure injury. What does the nurse
expect to find?
A. Non-blanchable erythema of intact skin
B. Partial-thickness skin loss with a red-pink wound bed or
intact blister
C. Full-thickness tissue loss with exposed bone
D. Unstageable slough or eschar
Answer: B
Rationale: Stage 2 pressure injury involves partial-thickness skin
loss, often a shallow open ulcer or intact blister.
7. Which finding is a stage 1 pressure injury?
A. Non-blanchable erythema of intact skin
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B. Shallow open ulcer
C. Full-thickness loss with visible fat
D. Deep crater with undermining
Answer: A
Rationale: Stage 1 is non-blanchable redness of intact skin.
8. A client has a stage 4 pressure injury. The nurse expects to
find:
A. Full-thickness tissue loss with exposed bone, tendon, or
muscle
B. Partial-thickness skin loss
C. Non-blanchable erythema
D. An intact blood-filled blister only
Answer: A
Rationale: Stage 4 involves full-thickness loss with exposed
deep structures.
9. A nurse is repositioning an immobile client. How often should
the client be repositioned?
A. At least every 2 hours
B. Every 4 hours
C. Every 8 hours
D. Once per shift
FUNDAMENTALS OF NURSING — PRACTICE Q&A | Questions
with Answers & Rationales
1. The nurse is caring for a client who is at risk for falls. Which
intervention is the highest priority?
A. Keep the bed in the lowest position and place the call light
within reach
B. Raise all four side rails at all times
C. Restrain the client to prevent falls
D. Keep the room dark to encourage rest
Answer: A
Rationale: Keeping the bed low and the call light accessible are
standard fall prevention measures. Restraints are a last resort,
and raising all side rails may be considered a restraint.
2. Which action by the nurse is the most effective way to
prevent the spread of infection?
A. Wearing gloves for all client contact
B. Performing hand hygiene before and after client care
C. Using alcohol-based hand rub on visibly soiled hands
D. Wearing a mask in all client rooms
Answer: B
Rationale: Hand hygiene is the single most important practice
, Page |2
to reduce infection. Alcohol-based rubs are not used on visibly
soiled hands.
3. A nurse is preparing to assess a client’s abdomen. What is the
correct order of assessment?
A. Inspection, auscultation, palpation, percussion
B. Inspection, palpation, percussion, auscultation
C. Auscultation, inspection, palpation, percussion
D. Palpation, auscultation, inspection, percussion
Answer: A
Rationale: Inspect first, then auscultate before palpation and
percussion because percussion and palpation can alter bowel
sounds.
4. The nurse documents that a client has "purulent drainage"
from a wound. What does this indicate?
A. Serous drainage
B. Infection or inflammation
C. Normal healing
D. Sanguineous drainage
Answer: B
Rationale: Purulent drainage is thick, yellow, green, or white
and indicates infection.
, Page |3
5. Which of the following is a sign of a localized infection?
A. Fever and chills
B. Redness, warmth, swelling, and pain at the wound site
C. Generalized body aches
D. Fatigue and malaise only
Answer: B
Rationale: Localized infection signs are at the site: redness,
warmth, swelling, pain, and possibly purulent drainage.
6. A client has a stage 2 pressure injury. What does the nurse
expect to find?
A. Non-blanchable erythema of intact skin
B. Partial-thickness skin loss with a red-pink wound bed or
intact blister
C. Full-thickness tissue loss with exposed bone
D. Unstageable slough or eschar
Answer: B
Rationale: Stage 2 pressure injury involves partial-thickness skin
loss, often a shallow open ulcer or intact blister.
7. Which finding is a stage 1 pressure injury?
A. Non-blanchable erythema of intact skin
, Page |4
B. Shallow open ulcer
C. Full-thickness loss with visible fat
D. Deep crater with undermining
Answer: A
Rationale: Stage 1 is non-blanchable redness of intact skin.
8. A client has a stage 4 pressure injury. The nurse expects to
find:
A. Full-thickness tissue loss with exposed bone, tendon, or
muscle
B. Partial-thickness skin loss
C. Non-blanchable erythema
D. An intact blood-filled blister only
Answer: A
Rationale: Stage 4 involves full-thickness loss with exposed
deep structures.
9. A nurse is repositioning an immobile client. How often should
the client be repositioned?
A. At least every 2 hours
B. Every 4 hours
C. Every 8 hours
D. Once per shift
