FUNDAMENTALS OF NURSING
1
,FUNDAMENTALS OF NURSING
FUNDAMENTALS OF NURSING
ORIGINAL PRACTICE QUESTIONS
Question 1
A nursing student is preparing to perform hand hygiene before entering a patient's room. The
student's hands are not visibly soiled. Which action demonstrates correct technique for hand
hygiene using alcohol-based hand sanitizer?
A. Apply sanitizer to dry hands and rub until completely dry, covering all surfaces
B. Apply sanitizer to wet hands and rub for 10 seconds before rinsing
C. Apply sanitizer to dry hands and rub vigorously for 5 seconds
D. Apply sanitizer to dry hands, rub for 15 seconds, then rinse with water
Correct Answer: A
Rationale:
Alcohol-based hand sanitizer should be applied to dry hands, and the hands should be rubbed
together covering all surfaces until completely dry. This typically takes about 15-20 seconds. The
friction and drying action are essential for the antimicrobial effect. Hands should be dry before
applying sanitizer, not wet (B), and should be rubbed until completely dry, not for a fixed short time
or rinsed afterward (C and D). Rinsing after application would remove the sanitizer before it has
time to work.
Why the other options are incorrect:
• B: Sanitizer should be applied to dry hands, not wet hands. Water dilutes the alcohol
concentration, reducing its effectiveness.
• C: Five seconds is insufficient time for the alcohol to act against microorganisms. The
hands must be rubbed until completely dry to ensure adequate contact time.
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,FUNDAMENTALS OF NURSING
• D: Sanitizer should not be rinsed off with water. Rinsing removes the antimicrobial agent
before it has completed its action.
Cognitive Level: Application
NCLEX Client-Needs Category: Safety and Infection Control
Nursing Process: Implementation
Question 2
A nurse is assessing a 78-year-old patient who was admitted with pneumonia. The patient's vital
signs are: temperature 38.6°C (101.5°F), heart rate 102 beats/min, respiratory rate 24 breaths/min,
blood pressure 138/86 mmHg, and oxygen saturation 91% on room air. Which finding should the
nurse prioritize for immediate intervention?
A. Temperature of 38.6°C
B. Heart rate of 102 beats/min
C. Respiratory rate of 24 breaths/min
D. Oxygen saturation of 91%
Correct Answer: D
Rationale:
Oxygen saturation of 91% indicates hypoxemia and impaired gas exchange, which directly affects
cellular oxygenation. This is the most urgent finding because inadequate oxygenation can lead to
tissue damage and organ dysfunction if not addressed promptly. While the elevated temperature,
tachycardia, and tachypnea are all concerning, they represent the body's compensatory
responses to infection and fever. The low oxygen saturation is the primary threat to physiological
stability and requires immediate intervention such as supplemental oxygen.
Why the other options are incorrect:
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, FUNDAMENTALS OF NURSING
• A: While the elevated temperature indicates infection and requires intervention, it is less
immediately life-threatening than hypoxemia. The body can tolerate fever temporarily while
treatment is initiated.
• B: Tachycardia is a compensatory response to fever, hypoxia, and the stress of illness. It
requires monitoring but is not the priority over addressing oxygenation.
• C: Tachypnea is also a compensatory response. The patient is breathing faster to increase
oxygenation, but the low saturation indicates this compensation is insufficient.
Cognitive Level: Analysis
NCLEX Client-Needs Category: Reduction of Risk Potential
Nursing Process: Assessment
CJMM Focus: Prioritize Hypotheses
Question 3
A nurse is providing care for a patient who is NPO (nothing by mouth) following abdominal surgery.
The patient has a nasogastric tube set to low intermittent suction. Which finding indicates that the
patient is at risk for fluid volume deficit?
A. Urine output of 45 mL over the past 2 hours
B. Blood pressure of 118/72 mmHg
C. Skin turgor that returns to normal immediately
D. Moist mucous membranes
Correct Answer: A
Rationale:
A urine output of 45 mL over 2 hours (approximately 22.5 mL/hour) is below the expected
minimum of 30 mL/hour. This finding suggests inadequate renal perfusion, which can indicate
fluid volume deficit. The patient is NPO and has gastric suction, both of which place the patient at
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1
,FUNDAMENTALS OF NURSING
FUNDAMENTALS OF NURSING
ORIGINAL PRACTICE QUESTIONS
Question 1
A nursing student is preparing to perform hand hygiene before entering a patient's room. The
student's hands are not visibly soiled. Which action demonstrates correct technique for hand
hygiene using alcohol-based hand sanitizer?
A. Apply sanitizer to dry hands and rub until completely dry, covering all surfaces
B. Apply sanitizer to wet hands and rub for 10 seconds before rinsing
C. Apply sanitizer to dry hands and rub vigorously for 5 seconds
D. Apply sanitizer to dry hands, rub for 15 seconds, then rinse with water
Correct Answer: A
Rationale:
Alcohol-based hand sanitizer should be applied to dry hands, and the hands should be rubbed
together covering all surfaces until completely dry. This typically takes about 15-20 seconds. The
friction and drying action are essential for the antimicrobial effect. Hands should be dry before
applying sanitizer, not wet (B), and should be rubbed until completely dry, not for a fixed short time
or rinsed afterward (C and D). Rinsing after application would remove the sanitizer before it has
time to work.
Why the other options are incorrect:
• B: Sanitizer should be applied to dry hands, not wet hands. Water dilutes the alcohol
concentration, reducing its effectiveness.
• C: Five seconds is insufficient time for the alcohol to act against microorganisms. The
hands must be rubbed until completely dry to ensure adequate contact time.
2
,FUNDAMENTALS OF NURSING
• D: Sanitizer should not be rinsed off with water. Rinsing removes the antimicrobial agent
before it has completed its action.
Cognitive Level: Application
NCLEX Client-Needs Category: Safety and Infection Control
Nursing Process: Implementation
Question 2
A nurse is assessing a 78-year-old patient who was admitted with pneumonia. The patient's vital
signs are: temperature 38.6°C (101.5°F), heart rate 102 beats/min, respiratory rate 24 breaths/min,
blood pressure 138/86 mmHg, and oxygen saturation 91% on room air. Which finding should the
nurse prioritize for immediate intervention?
A. Temperature of 38.6°C
B. Heart rate of 102 beats/min
C. Respiratory rate of 24 breaths/min
D. Oxygen saturation of 91%
Correct Answer: D
Rationale:
Oxygen saturation of 91% indicates hypoxemia and impaired gas exchange, which directly affects
cellular oxygenation. This is the most urgent finding because inadequate oxygenation can lead to
tissue damage and organ dysfunction if not addressed promptly. While the elevated temperature,
tachycardia, and tachypnea are all concerning, they represent the body's compensatory
responses to infection and fever. The low oxygen saturation is the primary threat to physiological
stability and requires immediate intervention such as supplemental oxygen.
Why the other options are incorrect:
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, FUNDAMENTALS OF NURSING
• A: While the elevated temperature indicates infection and requires intervention, it is less
immediately life-threatening than hypoxemia. The body can tolerate fever temporarily while
treatment is initiated.
• B: Tachycardia is a compensatory response to fever, hypoxia, and the stress of illness. It
requires monitoring but is not the priority over addressing oxygenation.
• C: Tachypnea is also a compensatory response. The patient is breathing faster to increase
oxygenation, but the low saturation indicates this compensation is insufficient.
Cognitive Level: Analysis
NCLEX Client-Needs Category: Reduction of Risk Potential
Nursing Process: Assessment
CJMM Focus: Prioritize Hypotheses
Question 3
A nurse is providing care for a patient who is NPO (nothing by mouth) following abdominal surgery.
The patient has a nasogastric tube set to low intermittent suction. Which finding indicates that the
patient is at risk for fluid volume deficit?
A. Urine output of 45 mL over the past 2 hours
B. Blood pressure of 118/72 mmHg
C. Skin turgor that returns to normal immediately
D. Moist mucous membranes
Correct Answer: A
Rationale:
A urine output of 45 mL over 2 hours (approximately 22.5 mL/hour) is below the expected
minimum of 30 mL/hour. This finding suggests inadequate renal perfusion, which can indicate
fluid volume deficit. The patient is NPO and has gastric suction, both of which place the patient at
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