,Germanna NSG 100 Exam 2 | Introduction to
Nursing Concepts (2026) Q&A
1. A nurse is implementing fall precautions for a patient with a history of stroke
who takes antihypertensives. Which action is most appropriate?
A) Keep all four side rails up at night
B) Place the bed in the lowest position with locked wheels
C) Encourage the patient to wear non-skid socks only during the day
D) Keep the call light on the bedside table
Correct Answer: Place the bed in the lowest position with locked wheels
Rationale: The bed should be in the lowest position with wheels locked to
reduce injury if a fall occurs. Side rails up are considered a restraint. Non-skid
socks should be worn whenever the patient is out of bed. The call light must be
within easy reach, attached to the gown or pillow, not on the bedside table.
2. A patient uses a cane for ambulation after a right hip replacement. The nurse
should instruct the patient to hold the cane on which side?
A) The weaker side
B) The stronger side
C) The side with most pain
D) The contralateral side to the affected leg
Correct Answer: The stronger side
,Rationale: The cane is held on the stronger side (contralateral to the weak leg)
to widen the base of support and reduce the load on the weak side. Both the
stronger side and the contralateral side describe the same concept.
3. A nurse is educating a patient on home fire safety. Which statement indicates
understanding?
A) "I will use a space heater only when I am sleeping."
B) "I will replace smoke detector batteries every 5 years."
C) "I should have a fire escape plan with two ways out of each room."
D) "I will keep a fire extinguisher in the kitchen only."
Correct Answer: "I should have a fire escape plan with two ways out of each
room."
Rationale: A fire escape plan with two ways out of each room is essential for
home fire safety. Space heaters should not be used while sleeping. Smoke detector
batteries should be replaced at least annually, not every 5 years. Fire extinguishers
should be placed on every level of the home, not just the kitchen.
4. Which patient is at the highest risk for falling?
A) A 45-year-old post-operative day 1 patient
B) A 70-year-old with history of stroke and taking antihypertensives
C) A 30-year-old with a broken ankle using crutches
D) An 80-year-old with mild hearing loss
Correct Answer: A 70-year-old with history of stroke and taking
antihypertensives
, Rationale: This patient has multiple risk factors: advanced age, history of stroke
(hemiparesis/neglect), and antihypertensive medications (orthostatic
hypotension). Hearing loss alone is a lower risk factor.
5. A nurse is preparing to document a patient's care. Which entry is the most
objective?
A) The patient seems very agitated and angry today.
B) The patient's skin is warm, dry, and intact; radial pulse is 82 bpm.
C) The patient ate most of their breakfast and felt better.
D) The patient appears to be in a lot of pain.
Correct Answer: The patient's skin is warm, dry, and intact; radial pulse is 82
bpm.
Rationale: Objective data consists of observable and measurable facts, such as
skin condition and heart rate, rather than interpretations or feelings. The other
options contain subjective interpretations.
6. Which phase of the nursing process involves setting prioritized goals and
expected outcomes?
A) Assessment
B) Planning
C) Diagnosis
D) Implementation
Correct Answer: Planning
Nursing Concepts (2026) Q&A
1. A nurse is implementing fall precautions for a patient with a history of stroke
who takes antihypertensives. Which action is most appropriate?
A) Keep all four side rails up at night
B) Place the bed in the lowest position with locked wheels
C) Encourage the patient to wear non-skid socks only during the day
D) Keep the call light on the bedside table
Correct Answer: Place the bed in the lowest position with locked wheels
Rationale: The bed should be in the lowest position with wheels locked to
reduce injury if a fall occurs. Side rails up are considered a restraint. Non-skid
socks should be worn whenever the patient is out of bed. The call light must be
within easy reach, attached to the gown or pillow, not on the bedside table.
2. A patient uses a cane for ambulation after a right hip replacement. The nurse
should instruct the patient to hold the cane on which side?
A) The weaker side
B) The stronger side
C) The side with most pain
D) The contralateral side to the affected leg
Correct Answer: The stronger side
,Rationale: The cane is held on the stronger side (contralateral to the weak leg)
to widen the base of support and reduce the load on the weak side. Both the
stronger side and the contralateral side describe the same concept.
3. A nurse is educating a patient on home fire safety. Which statement indicates
understanding?
A) "I will use a space heater only when I am sleeping."
B) "I will replace smoke detector batteries every 5 years."
C) "I should have a fire escape plan with two ways out of each room."
D) "I will keep a fire extinguisher in the kitchen only."
Correct Answer: "I should have a fire escape plan with two ways out of each
room."
Rationale: A fire escape plan with two ways out of each room is essential for
home fire safety. Space heaters should not be used while sleeping. Smoke detector
batteries should be replaced at least annually, not every 5 years. Fire extinguishers
should be placed on every level of the home, not just the kitchen.
4. Which patient is at the highest risk for falling?
A) A 45-year-old post-operative day 1 patient
B) A 70-year-old with history of stroke and taking antihypertensives
C) A 30-year-old with a broken ankle using crutches
D) An 80-year-old with mild hearing loss
Correct Answer: A 70-year-old with history of stroke and taking
antihypertensives
, Rationale: This patient has multiple risk factors: advanced age, history of stroke
(hemiparesis/neglect), and antihypertensive medications (orthostatic
hypotension). Hearing loss alone is a lower risk factor.
5. A nurse is preparing to document a patient's care. Which entry is the most
objective?
A) The patient seems very agitated and angry today.
B) The patient's skin is warm, dry, and intact; radial pulse is 82 bpm.
C) The patient ate most of their breakfast and felt better.
D) The patient appears to be in a lot of pain.
Correct Answer: The patient's skin is warm, dry, and intact; radial pulse is 82
bpm.
Rationale: Objective data consists of observable and measurable facts, such as
skin condition and heart rate, rather than interpretations or feelings. The other
options contain subjective interpretations.
6. Which phase of the nursing process involves setting prioritized goals and
expected outcomes?
A) Assessment
B) Planning
C) Diagnosis
D) Implementation
Correct Answer: Planning
