NUR 155 Foundations of Nursing
Exam 4 | Comprehensive Final Exam
2026/2027 (Newly Released)
Q1: Which of the following statements by a nurse demonstrates the concept of veracity?
A. "I will make sure you are not left alone during this difficult time."
B. "I will not share your diagnosis with your family without your permission." [CORRECT]
C. "I will ensure the medication I give you is the correct dosage."
D. "I will advocate for your right to refuse treatment."
Correct Answer: B
Rationale: Veracity is the ethical principle of truth-telling. Keeping the patient's diagnosis
confidential until the patient decides to disclose it respects the duty of honesty and privacy.
Option A describes fidelity, C describes non-maleficence/safety, and D describes
autonomy/advocacy.
Q2: A nurse is documenting patient care. Which entry best adheres to the legal guidelines for
documentation?
A. "Patient appears to be in a lot of pain and is anxious."
B. "Patient slept well overnight." [CORRECT]
C. "Dr. Smith notified of patient's condition."
D. "Patient seems aggressive toward staff."
Correct Answer: B
,Rationale: Documentation should be objective, factual, and concise. "Slept well overnight" is a
specific observation. Terms like "a lot," "anxious," "appears," and "aggressive" are subjective
and open to interpretation, unless the patient specifically stated those feelings.
Q3: When using the nursing process, which action is performed during the "Assessment" phase?
A. Setting patient-centered goals.
B. Collecting comprehensive data. [CORRECT]
C. Implementing nursing interventions.
D. Evaluating the effectiveness of care.
Correct Answer: B
Rationale: Assessment is the first step of the nursing process and involves gathering subjective
and objective data. Diagnosis, Planning (goals), Implementation (interventions), and Evaluation
follow.
Q4: A nurse is caring for a patient who speaks a different language. The nurse uses a family
member to translate. Which ethical principle is most at risk?
A. Beneficence
B. Fidelity
C. Confidentiality [CORRECT]
D. Justice
Correct Answer: C
Rationale: Using family members, especially children, as interpreters violates confidentiality
because the patient may not want the family member to know sensitive medical information. It
also risks inaccurate translation.
Q5: The nurse receives report on four patients. Which patient should the nurse assess first based
on Maslow's Hierarchy of Needs?
A. A patient reporting loneliness and social isolation.
B. A patient with a urinary catheter requesting assistance to the bathroom.
C. A patient with difficulty breathing and an oxygen saturation of 88%. [CORRECT]
D. A patient who is confused and trying to get out of bed.
Correct Answer: C
.
,Rationale: Physiological needs (oxygenation) are the base of Maslow's pyramid and take
priority over safety (D), love/belonging (A), or self-esteem/elimination needs (B).
Q6: Which communication technique uses silence to allow the patient time to gather thoughts?
A. Reflecting
B. Active listening
C. Therapeutic silence [CORRECT]
D. Clarifying
Correct Answer: C
Rationale: Therapeutic silence is a deliberate pause that encourages the patient to verbalize
feelings or thoughts without feeling rushed.
Q7: An example of an objective finding during a physical assessment is:
A. "Patient states, 'I have a headache.'"
B. "Patient reports pain level of 5 on a scale of 0-10."
C. "Skin is warm and dry with intact turgor." [CORRECT]
D. "Patient feels anxious about the surgery."
Correct Answer: C
Rationale: Objective data is what the nurse sees, hears, feels, or measures. Skin condition is
observable. Options A, B, and D are subjective data reported by the patient.
Q8: A nurse suspects an older adult patient is being abused by a caregiver. What is the nurse's
legal obligation?
A. Confront the caregiver immediately.
B. Document the suspicion and monitor the situation.
C. Report the suspicion to the appropriate authorities (Adult Protective Services). [CORRECT]
D. Ask the patient to move to a different facility.
Correct Answer: C
.
, Rationale: Nurses are mandatory reporters for abuse. Reporting to the proper authorities (e.g.,
APS) is a legal requirement; confronting the caregiver may endanger the patient.
Q9: In the context of the "Standard of Care," which action constitutes negligence?
A. The nurse forgets to cap a needle but disposes of it in the sharps container.
B. The nurse administers a medication 2 hours late without documenting a valid reason.
[CORRECT]
C. The delegatee forgets to empty a drainage bag, and the nurse corrects it.
D. The nurse performs a sterile field setup and touches the outer 1-inch edge.
Correct Answer: B
Rationale: Negligence involves a failure to act as a reasonable prudent nurse would act,
resulting in harm or risk of harm. Consistently late medication administration without valid
reason breaches the standard of care. Touching the outer 1 inch of a sterile field is usually
considered contaminated but not necessarily negligence in the legal sense unless it causes harm.
Q10: The nurse is using SBAR to communicate a change in patient status to the provider. What
does the "R" stand for?
A. Review
B. Report
C. Recommendation [CORRECT]
D. Response
Correct Answer: C
Rationale: SBAR stands for Situation, Background, Assessment, and Recommendation. The
Recommendation is what the nurse suggests should be done.
.
Exam 4 | Comprehensive Final Exam
2026/2027 (Newly Released)
Q1: Which of the following statements by a nurse demonstrates the concept of veracity?
A. "I will make sure you are not left alone during this difficult time."
B. "I will not share your diagnosis with your family without your permission." [CORRECT]
C. "I will ensure the medication I give you is the correct dosage."
D. "I will advocate for your right to refuse treatment."
Correct Answer: B
Rationale: Veracity is the ethical principle of truth-telling. Keeping the patient's diagnosis
confidential until the patient decides to disclose it respects the duty of honesty and privacy.
Option A describes fidelity, C describes non-maleficence/safety, and D describes
autonomy/advocacy.
Q2: A nurse is documenting patient care. Which entry best adheres to the legal guidelines for
documentation?
A. "Patient appears to be in a lot of pain and is anxious."
B. "Patient slept well overnight." [CORRECT]
C. "Dr. Smith notified of patient's condition."
D. "Patient seems aggressive toward staff."
Correct Answer: B
,Rationale: Documentation should be objective, factual, and concise. "Slept well overnight" is a
specific observation. Terms like "a lot," "anxious," "appears," and "aggressive" are subjective
and open to interpretation, unless the patient specifically stated those feelings.
Q3: When using the nursing process, which action is performed during the "Assessment" phase?
A. Setting patient-centered goals.
B. Collecting comprehensive data. [CORRECT]
C. Implementing nursing interventions.
D. Evaluating the effectiveness of care.
Correct Answer: B
Rationale: Assessment is the first step of the nursing process and involves gathering subjective
and objective data. Diagnosis, Planning (goals), Implementation (interventions), and Evaluation
follow.
Q4: A nurse is caring for a patient who speaks a different language. The nurse uses a family
member to translate. Which ethical principle is most at risk?
A. Beneficence
B. Fidelity
C. Confidentiality [CORRECT]
D. Justice
Correct Answer: C
Rationale: Using family members, especially children, as interpreters violates confidentiality
because the patient may not want the family member to know sensitive medical information. It
also risks inaccurate translation.
Q5: The nurse receives report on four patients. Which patient should the nurse assess first based
on Maslow's Hierarchy of Needs?
A. A patient reporting loneliness and social isolation.
B. A patient with a urinary catheter requesting assistance to the bathroom.
C. A patient with difficulty breathing and an oxygen saturation of 88%. [CORRECT]
D. A patient who is confused and trying to get out of bed.
Correct Answer: C
.
,Rationale: Physiological needs (oxygenation) are the base of Maslow's pyramid and take
priority over safety (D), love/belonging (A), or self-esteem/elimination needs (B).
Q6: Which communication technique uses silence to allow the patient time to gather thoughts?
A. Reflecting
B. Active listening
C. Therapeutic silence [CORRECT]
D. Clarifying
Correct Answer: C
Rationale: Therapeutic silence is a deliberate pause that encourages the patient to verbalize
feelings or thoughts without feeling rushed.
Q7: An example of an objective finding during a physical assessment is:
A. "Patient states, 'I have a headache.'"
B. "Patient reports pain level of 5 on a scale of 0-10."
C. "Skin is warm and dry with intact turgor." [CORRECT]
D. "Patient feels anxious about the surgery."
Correct Answer: C
Rationale: Objective data is what the nurse sees, hears, feels, or measures. Skin condition is
observable. Options A, B, and D are subjective data reported by the patient.
Q8: A nurse suspects an older adult patient is being abused by a caregiver. What is the nurse's
legal obligation?
A. Confront the caregiver immediately.
B. Document the suspicion and monitor the situation.
C. Report the suspicion to the appropriate authorities (Adult Protective Services). [CORRECT]
D. Ask the patient to move to a different facility.
Correct Answer: C
.
, Rationale: Nurses are mandatory reporters for abuse. Reporting to the proper authorities (e.g.,
APS) is a legal requirement; confronting the caregiver may endanger the patient.
Q9: In the context of the "Standard of Care," which action constitutes negligence?
A. The nurse forgets to cap a needle but disposes of it in the sharps container.
B. The nurse administers a medication 2 hours late without documenting a valid reason.
[CORRECT]
C. The delegatee forgets to empty a drainage bag, and the nurse corrects it.
D. The nurse performs a sterile field setup and touches the outer 1-inch edge.
Correct Answer: B
Rationale: Negligence involves a failure to act as a reasonable prudent nurse would act,
resulting in harm or risk of harm. Consistently late medication administration without valid
reason breaches the standard of care. Touching the outer 1 inch of a sterile field is usually
considered contaminated but not necessarily negligence in the legal sense unless it causes harm.
Q10: The nurse is using SBAR to communicate a change in patient status to the provider. What
does the "R" stand for?
A. Review
B. Report
C. Recommendation [CORRECT]
D. Response
Correct Answer: C
Rationale: SBAR stands for Situation, Background, Assessment, and Recommendation. The
Recommendation is what the nurse suggests should be done.
.
