NUR 101: Comprehensive Nursing
Fundamentals Prep with Detailed Rationales
Course Code: NUR 101
Course Name: Comprehensive Nursing Fundamentals
Topic: Core Principles, Nursing Process, Infection Control, Mobility, and
Physical Assessment
Academic Year: 2026/2027
1. A patient diagnosed with an aggressive intra-abdominal abscess is scheduled
for an emergent surgical debridement. While setting up the central venous
catheter insertion tray, the surgical nurse notices a colleague sneezes
directly over the uncovered sterile field from a distance of two feet. Which
action by the nurse is the immediate priority to guarantee patient safety?
A. Spray the surface of the tray with an approved high-level chemical
disinfectant.
B. Immediately discard the entire sterile field as contaminated and re-
establish a new sterile field with new equipment.
C. Proceed with the procedure as long as the items do not appear physically
damp.
D. Wipe down the outer boundary borders of the tray using sterile gauze
soaked in normal saline.
CORRECT ANSWER: B
RATIONALE: In surgical asepsis, an item or field is considered sterile
only when it is completely free of all microorganisms. If a sterile field is
exposed to a sneeze, it is immediately contaminated by airborne respiratory
droplets. The nurse must immediately discard the entire field as
contaminated and re-establish sterility using fresh, unopened kits.
Wiping, spraying, or ignoring the exposure violates basic aseptic techniques
and places the patient at a severe risk for an iatrogenic infection.
2. An older adult patient who is fully immobilized following a severe
cerebrovascular accident (CVA) is admitted to the medical-surgical unit.
During the initial head-to-toe physical assessment, the nurse notes a new,
non-blanchable reddened blister on the patient's right heel. How should
, the nurse systematically categorize and manage this finding?
A. Classify it as a typical age-related vascular change and apply a warm
compress.
B. Document it as a normal response to immobility and reassess the area in
48 hours.
C. Identify and report it as a new pressure injury, and initiate a turning
schedule every 2 hours.
D. Cleanse the area with rubbing alcohol and leave it open to room air to dry
out.
CORRECT ANSWER: C
RATIONALE: A new, reddened blister on the heel indicates a
pressure injury resulting from prolonged immobility and localized tissue
hypoxia. The nurse's priority action is to implement pressure-relieving
interventions, such as position changes every 2 hours, floating the heels,
and documenting the assessment accurately. Leaving the area unmanaged or
applying heat/friction will accelerate skin breakdown.
3. A patient with a history of chronic hypertension is being evaluated for
episodic syncope. The nurse obtains blood pressure readings across multiple
positions. The patient's blood pressure drops from 142/88 mmHg while
supine to 118/74 mmHg immediately upon standing, accompanied by a
complaint of severe dizziness. The nurse identifies this presentation as:
A. Paradoxical blood pressure fluctuation
B. Orthostatic hypotension indicating volume depletion or autonomic
dysfunction.
C. An expected physiologic response to gravitational changes
D. Secondary rebound hypertension
CORRECT ANSWER: B
RATIONALE: Orthostatic hypotension is defined as a significant drop
in blood pressure when changing positions (a decrease in systolic blood
pressure ≥ 20 mmHg or a diastolic blood pressure ≥ 10 mmHg within 3
minutes of sitting or standing). This finding indicates volume depletion or
autonomic dysfunction, predisposing the patient to falls. Care must include
teaching the patient to rise slowly and dangling their legs at the bedside
before standing.
, 4. A nurse receives an order to collect a midstream urine specimen for culture
and sensitivity from an adult patient suspected of having an acute urinary
tract infection (UTI). Immediately after collecting the specimen at the
bedside, what is the most appropriate action for the nurse to perform?
A. Place the unlabeled container on the utility desk and request the unit clerk
fill out the paperwork.
B. Label the container directly at the bedside with the patient's name,
date, time of collection, and the nurse's initials.
C. Store the sample inside the clean utility room refrigerator for 12 hours
prior to labeling.
D. Apply a label directly onto the removable lid of the specimen container
using a water-soluble pen.
CORRECT ANSWER: B
RATIONALE: To prevent specimen misidentification errors, all
diagnostic samples must be labeled directly at the bedside in the presence
of the patient. The label must contain at least two unique patient
identifiers (full name and date of birth), the exact date and time of
collection, and the collecting nurse's initials. Labels must be adhered to
the body of the container, not the removable lid
5. A nurse prepares to perform a comprehensive physical assessment on a
newly admitted patient. Which technique must the nurse utilize first for
every body system under review?
A. Palpation
B. Inspection
C. Percussion
D. Auscultation
CORRECT ANSWER: B
RATIONALE: The correct structural sequence of physical examination
techniques is Inspection → Palpation → Percussion → Auscultation.
Inspection involves visual observation and must always be performed first to
gather baseline information before touching or manipulating the tissues.
6. The nurse is checking vital signs for an adult patient and notes a significant
discrepancy in blood pressure readings between the left and right arms. If the
Fundamentals Prep with Detailed Rationales
Course Code: NUR 101
Course Name: Comprehensive Nursing Fundamentals
Topic: Core Principles, Nursing Process, Infection Control, Mobility, and
Physical Assessment
Academic Year: 2026/2027
1. A patient diagnosed with an aggressive intra-abdominal abscess is scheduled
for an emergent surgical debridement. While setting up the central venous
catheter insertion tray, the surgical nurse notices a colleague sneezes
directly over the uncovered sterile field from a distance of two feet. Which
action by the nurse is the immediate priority to guarantee patient safety?
A. Spray the surface of the tray with an approved high-level chemical
disinfectant.
B. Immediately discard the entire sterile field as contaminated and re-
establish a new sterile field with new equipment.
C. Proceed with the procedure as long as the items do not appear physically
damp.
D. Wipe down the outer boundary borders of the tray using sterile gauze
soaked in normal saline.
CORRECT ANSWER: B
RATIONALE: In surgical asepsis, an item or field is considered sterile
only when it is completely free of all microorganisms. If a sterile field is
exposed to a sneeze, it is immediately contaminated by airborne respiratory
droplets. The nurse must immediately discard the entire field as
contaminated and re-establish sterility using fresh, unopened kits.
Wiping, spraying, or ignoring the exposure violates basic aseptic techniques
and places the patient at a severe risk for an iatrogenic infection.
2. An older adult patient who is fully immobilized following a severe
cerebrovascular accident (CVA) is admitted to the medical-surgical unit.
During the initial head-to-toe physical assessment, the nurse notes a new,
non-blanchable reddened blister on the patient's right heel. How should
, the nurse systematically categorize and manage this finding?
A. Classify it as a typical age-related vascular change and apply a warm
compress.
B. Document it as a normal response to immobility and reassess the area in
48 hours.
C. Identify and report it as a new pressure injury, and initiate a turning
schedule every 2 hours.
D. Cleanse the area with rubbing alcohol and leave it open to room air to dry
out.
CORRECT ANSWER: C
RATIONALE: A new, reddened blister on the heel indicates a
pressure injury resulting from prolonged immobility and localized tissue
hypoxia. The nurse's priority action is to implement pressure-relieving
interventions, such as position changes every 2 hours, floating the heels,
and documenting the assessment accurately. Leaving the area unmanaged or
applying heat/friction will accelerate skin breakdown.
3. A patient with a history of chronic hypertension is being evaluated for
episodic syncope. The nurse obtains blood pressure readings across multiple
positions. The patient's blood pressure drops from 142/88 mmHg while
supine to 118/74 mmHg immediately upon standing, accompanied by a
complaint of severe dizziness. The nurse identifies this presentation as:
A. Paradoxical blood pressure fluctuation
B. Orthostatic hypotension indicating volume depletion or autonomic
dysfunction.
C. An expected physiologic response to gravitational changes
D. Secondary rebound hypertension
CORRECT ANSWER: B
RATIONALE: Orthostatic hypotension is defined as a significant drop
in blood pressure when changing positions (a decrease in systolic blood
pressure ≥ 20 mmHg or a diastolic blood pressure ≥ 10 mmHg within 3
minutes of sitting or standing). This finding indicates volume depletion or
autonomic dysfunction, predisposing the patient to falls. Care must include
teaching the patient to rise slowly and dangling their legs at the bedside
before standing.
, 4. A nurse receives an order to collect a midstream urine specimen for culture
and sensitivity from an adult patient suspected of having an acute urinary
tract infection (UTI). Immediately after collecting the specimen at the
bedside, what is the most appropriate action for the nurse to perform?
A. Place the unlabeled container on the utility desk and request the unit clerk
fill out the paperwork.
B. Label the container directly at the bedside with the patient's name,
date, time of collection, and the nurse's initials.
C. Store the sample inside the clean utility room refrigerator for 12 hours
prior to labeling.
D. Apply a label directly onto the removable lid of the specimen container
using a water-soluble pen.
CORRECT ANSWER: B
RATIONALE: To prevent specimen misidentification errors, all
diagnostic samples must be labeled directly at the bedside in the presence
of the patient. The label must contain at least two unique patient
identifiers (full name and date of birth), the exact date and time of
collection, and the collecting nurse's initials. Labels must be adhered to
the body of the container, not the removable lid
5. A nurse prepares to perform a comprehensive physical assessment on a
newly admitted patient. Which technique must the nurse utilize first for
every body system under review?
A. Palpation
B. Inspection
C. Percussion
D. Auscultation
CORRECT ANSWER: B
RATIONALE: The correct structural sequence of physical examination
techniques is Inspection → Palpation → Percussion → Auscultation.
Inspection involves visual observation and must always be performed first to
gather baseline information before touching or manipulating the tissues.
6. The nurse is checking vital signs for an adult patient and notes a significant
discrepancy in blood pressure readings between the left and right arms. If the
