NURS 201: Fundamentals of Nursing Prep with
Detailed Rationales
Course Code: NURS 201
Course Name: Fundamentals of Nursing
Topic: Clinical Nursing Procedures, Pharmacology Calculations, Legal Standards,
and Patient Safety
Academic Year: 2026/2027
1. Question
A 45-year-old client with renal insufficiency and hypertension is prescribed a
low-sodium, low-protein diet. During a 24-hour dietary recall, which food choices
indicate to the nurse that the client has been noncompliant? (Select all that apply.)
A. Potato chips and diet soda.
B. Tuna fish sandwich, carrot sticks, and fresh fruit.
C. Bacon, eggs, toast, and coffee.
D. Vegetable lasagna, tossed salad, and sherbet.
E. Crackers and milk.
CORRECT ANSWER: A, B, C, E
RATIONALE: Potato chips, bacon, and crackers contain exceptionally high
levels of sodium, which exacerbates hypertension and fluid retention in patients
with kidney dysfunction. Tuna fish is extremely high in protein, which increases
the metabolic workload on failing kidneys. Only the vegetable lasagna meal
(Choice D) adheres properly to the low-sodium, low-protein dietary restriction.
2. Question
A nurse is formulating a plan of care for a client requiring an Unna's paste boot to
treat severe lower extremity stasis ulcers from chronic venous insufficiency. Which
intervention is a priority for the nurse to include?
A. Check the capillary refill of the toes on the affected lower extremity.
B. Apply a thick gauze dressing to the wound before applying the boot.
,C. Wrap the paste bandage starting from the knee down toward the foot.
D. Remove the entire paste boot every 8 hours to evaluate wound healing.
CORRECT ANSWER: A
RATIONALE: An Unna's paste boot dries into a firm, rigid molded cast over
the lower extremity. It is essential to check capillary refill distally to ensure the
wrap is not overly constrictive and impairing arterial blood flow. The boot should
be wrapped starting at the foot and moving upward toward the knee to promote
venous return. It serves as a sterile dressing and is typically left in place for up to a
week, making 8-hour removals contraindicated.
3. Question
A 75-year-old client with end-stage renal failure and advanced lung cancer recently
suffered a stroke. The provider discontinues dialysis treatments because death is
impending. The client is disoriented and cannot sign a Do Not Resuscitate (DNR)
directive. Which action is the priority nursing intervention?
A. Review the client’s most recent serum creatinine and BUN laboratory reports.
B. Request an immediate referral for the client and family to receive outpatient
hospice care.
C. Contact the hospital ethics committee to resolve the immediate treatment
disagreement.
D. Determine who is legally empowered to make healthcare decisions for the
client.
CORRECT ANSWER: D
RATIONALE: When a client is disoriented and death is impending, the
immediate priority is to determine the legal decision-maker (such as a durable
power of attorney or legal guardian) to guide life-sustaining interventions.
Reviewing laboratory values is non-urgent as dialysis has already been stopped.
Referrals to hospice and ethics committee consultations are appropriate secondary
steps if the legal decision-maker cannot be determined or family conflicts arise.
4. Question
A charge nurse assigns a complex clinical nursing procedure to a new staff nurse
who has never performed the task before. According to state Nurse Practice Acts,
, what is the most important action for the new staff nurse to take?
A. Read through the step-by-step instructions in the agency's procedure manual.
B. Ask a coworker to stand nearby and assist while implementing the procedure.
C. Follow the agency's standard written policy and procedure guidelines.
D. Refuse to perform the task because it is beyond the nurse's current
experience.
CORRECT ANSWER: D
RATIONALE: According to legal regulations, a nurse must function safely
within their specific scope of competency. Safe practice dictates an initial refusal
to perform a procedure when there is a complete lack of experience or
proficiency. Reviewing manuals, following policy, or asking a peer for assistance
do not substitute for formal training and verified competence when patient safety is
at stake.
5. Question
A nurse assesses an adverse change in a client's status and decides to withhold a
scheduled medication. After consulting with the healthcare provider, the dose is
modified and administered one hour later than originally scheduled. What action
should the nurse implement next?
A. Notify the charge nurse immediately that a medication error has occurred.
B. Complete and submit a medication variance/incident report to the supervisor.
C. Document the exact sequence of events clearly in the client's nurses' notes.
D. Discard the original medication administration record to protect the facility.
CORRECT ANSWER: C
RATIONALE: The nurse utilized correct clinical judgment by withholding a
medication due to a change in patient clinical condition, consulting the provider,
and administering the updated prescription. This constitutes appropriate nursing
care rather than an error or variance, meaning that documenting the sequence of
events in the chart is the only requirement. The medication administration record
must never be discarded.
6. Question
Detailed Rationales
Course Code: NURS 201
Course Name: Fundamentals of Nursing
Topic: Clinical Nursing Procedures, Pharmacology Calculations, Legal Standards,
and Patient Safety
Academic Year: 2026/2027
1. Question
A 45-year-old client with renal insufficiency and hypertension is prescribed a
low-sodium, low-protein diet. During a 24-hour dietary recall, which food choices
indicate to the nurse that the client has been noncompliant? (Select all that apply.)
A. Potato chips and diet soda.
B. Tuna fish sandwich, carrot sticks, and fresh fruit.
C. Bacon, eggs, toast, and coffee.
D. Vegetable lasagna, tossed salad, and sherbet.
E. Crackers and milk.
CORRECT ANSWER: A, B, C, E
RATIONALE: Potato chips, bacon, and crackers contain exceptionally high
levels of sodium, which exacerbates hypertension and fluid retention in patients
with kidney dysfunction. Tuna fish is extremely high in protein, which increases
the metabolic workload on failing kidneys. Only the vegetable lasagna meal
(Choice D) adheres properly to the low-sodium, low-protein dietary restriction.
2. Question
A nurse is formulating a plan of care for a client requiring an Unna's paste boot to
treat severe lower extremity stasis ulcers from chronic venous insufficiency. Which
intervention is a priority for the nurse to include?
A. Check the capillary refill of the toes on the affected lower extremity.
B. Apply a thick gauze dressing to the wound before applying the boot.
,C. Wrap the paste bandage starting from the knee down toward the foot.
D. Remove the entire paste boot every 8 hours to evaluate wound healing.
CORRECT ANSWER: A
RATIONALE: An Unna's paste boot dries into a firm, rigid molded cast over
the lower extremity. It is essential to check capillary refill distally to ensure the
wrap is not overly constrictive and impairing arterial blood flow. The boot should
be wrapped starting at the foot and moving upward toward the knee to promote
venous return. It serves as a sterile dressing and is typically left in place for up to a
week, making 8-hour removals contraindicated.
3. Question
A 75-year-old client with end-stage renal failure and advanced lung cancer recently
suffered a stroke. The provider discontinues dialysis treatments because death is
impending. The client is disoriented and cannot sign a Do Not Resuscitate (DNR)
directive. Which action is the priority nursing intervention?
A. Review the client’s most recent serum creatinine and BUN laboratory reports.
B. Request an immediate referral for the client and family to receive outpatient
hospice care.
C. Contact the hospital ethics committee to resolve the immediate treatment
disagreement.
D. Determine who is legally empowered to make healthcare decisions for the
client.
CORRECT ANSWER: D
RATIONALE: When a client is disoriented and death is impending, the
immediate priority is to determine the legal decision-maker (such as a durable
power of attorney or legal guardian) to guide life-sustaining interventions.
Reviewing laboratory values is non-urgent as dialysis has already been stopped.
Referrals to hospice and ethics committee consultations are appropriate secondary
steps if the legal decision-maker cannot be determined or family conflicts arise.
4. Question
A charge nurse assigns a complex clinical nursing procedure to a new staff nurse
who has never performed the task before. According to state Nurse Practice Acts,
, what is the most important action for the new staff nurse to take?
A. Read through the step-by-step instructions in the agency's procedure manual.
B. Ask a coworker to stand nearby and assist while implementing the procedure.
C. Follow the agency's standard written policy and procedure guidelines.
D. Refuse to perform the task because it is beyond the nurse's current
experience.
CORRECT ANSWER: D
RATIONALE: According to legal regulations, a nurse must function safely
within their specific scope of competency. Safe practice dictates an initial refusal
to perform a procedure when there is a complete lack of experience or
proficiency. Reviewing manuals, following policy, or asking a peer for assistance
do not substitute for formal training and verified competence when patient safety is
at stake.
5. Question
A nurse assesses an adverse change in a client's status and decides to withhold a
scheduled medication. After consulting with the healthcare provider, the dose is
modified and administered one hour later than originally scheduled. What action
should the nurse implement next?
A. Notify the charge nurse immediately that a medication error has occurred.
B. Complete and submit a medication variance/incident report to the supervisor.
C. Document the exact sequence of events clearly in the client's nurses' notes.
D. Discard the original medication administration record to protect the facility.
CORRECT ANSWER: C
RATIONALE: The nurse utilized correct clinical judgment by withholding a
medication due to a change in patient clinical condition, consulting the provider,
and administering the updated prescription. This constitutes appropriate nursing
care rather than an error or variance, meaning that documenting the sequence of
events in the chart is the only requirement. The medication administration record
must never be discarded.
6. Question
