NUR 111 FUNDAMENTALS OF NURSING I EXAM
GUIDE 2026 VERSION Q&A
1. A nurse is caring for a client who reports pain as 7 on a 0–10 scale. The nurse
administers the prescribed analgesic. Which action demonstrates the evaluation
phase of the nursing process?
A. Asking the client to rate the pain 30 minutes after administration
B. Explaining the side effects of the analgesic before giving it
C. Identifying that the client has acute pain related to surgical incision
D. Elevating the client’s legs to improve circulation
Correct Answer: A
Explanation: Evaluation involves reassessing the client after an intervention to
determine effectiveness. Asking to rate the pain again measures outcome. B is
implementation, C is diagnosis, D is unrelated intervention.
2. A nursing student asks why the nursing process is considered cyclical rather than
linear. Which response by the instructor is most accurate?
A. “Each phase must be completed exactly once per client encounter.”
B. “The process ends after evaluation unless the client deteriorates.”
C. “Information from evaluation often leads back to reassessment or new
diagnoses.”
D. “Physicians must approve each cycle before nurses can proceed.”
Correct Answer: C
Explanation: The nursing process is cyclical because evaluation results may modify
the plan, requiring reassessment or new diagnoses. A and B are false; D is incorrect
because nursing process is independent.
3. A nurse is performing a physical assessment on an older adult client. Which
finding would the nurse document as an expected age-related change rather
than an abnormal finding?
, A. Diminished radial pulse and cool extremities
B. Loss of subcutaneous fat and skin turgor decrease
C. Crackles in bilateral lung bases and pedal edema
D. Confusion to time and place with agitation
Correct Answer: B
Explanation: Loss of subcutaneous fat and decreased skin turgor are common age-
related changes due to collagen alterations. A suggests vascular insufficiency, C
suggests fluid overload, D suggests delirium or dementia—all abnormal.
4. A client with urinary incontinence is learning bladder retraining. Which statement
by the client indicates correct understanding?
A. “I will drink less than 1 liter of fluid daily to reduce urine output.”
B. “I will urinate every 2 hours even if I don’t feel the urge.”
C. “I will wait until my bladder feels completely full before voiding.”
D. “I will avoid pelvic floor exercises because they worsen leakage.”
Correct Answer: B
Explanation: Scheduled voiding every 2–3 hours is key to bladder retraining. A leads
to dehydration and concentrated urine; C reinforces incontinence; D is false—Kegel
exercises improve control.
5. A nurse is preparing to insert an indwelling urinary catheter for a female client.
After positioning the client and setting up a sterile field, which action should the
nurse perform next?
A. Clean the meatus with antiseptic swabs using a circular motion
B. Lubricate the catheter tip and insert it 2–3 inches
C. Inflate the balloon with 10 mL of sterile water
D. Identify the urethral meatus between the labia minora
Correct Answer: D
Explanation: Locate the urethral meatus before any cleaning or insertion to avoid
contamination and ensure correct placement. Cleaning (A) comes after locating
meatus; B and C come after identification.
,6. A nurse receives a handoff report that a client has a stage 3 pressure injury on the
sacrum. Which characteristic would the nurse expect to observe?
A. Nonblanchable erythema with intact skin
B. Full-thickness skin loss with visible subcutaneous fat but no bone exposure
C. Full-thickness tissue loss with exposed muscle and tendon
D. Intact skin with a serum-filled blister
Correct Answer: B
*Explanation: Stage 3 pressure injury shows full-thickness loss with visible
subcutaneous fat, possibly undermining, but no bone/muscle/tendon. A is stage
1; C is stage 4; D is stage 2.*
7. Which client is at highest risk for developing a deep vein thrombosis (DVT)?
A. A 25-year-old athlete recovering from a hamstring strain
B. A 45-year-old postoperative hip replacement client on bed rest
C. A 60-year-old with well-controlled hypertension walking daily
D. A 30-year-old with migraine taking oral contraceptives but active
Correct Answer: B
Explanation: Postoperative hip surgery, immobility, and bed rest are high-risk triad
for DVT (Virchow’s stasis, hypercoagulability, vessel damage). C is low risk; D has
one risk factor but is active.
8. A nurse is educating a client about a low-sodium diet for heart failure. Which
food choice by the client indicates effective teaching?
A. Canned vegetable soup with saltine crackers
B. Fresh grilled chicken breast with steamed broccoli
C. Deli ham sandwich with pickles and mustard
D. Frozen lasagna with added table salt
Correct Answer: B
Explanation: Fresh, unprocessed foods are naturally low in sodium. A, C, and D all
contain high sodium from processing, preservatives, or added salt.
, 9. A nursing instructor asks students to identify the correct order of steps for sterile
gloving using the closed method. Which sequence is correct?
A. Open inner wrapper, don sterile gown, pick up first glove by folded cuff, insert
hand, repeat for second glove
B. Pick up both gloves at once, insert left hand, then right hand, then adjust
fingers
C. Open outer wrapper, don sterile gown, open inner wrapper, glove dominant
hand first using cuff-to-cuff technique
D. Wash hands, open outer wrapper, pick up glove by palm, slide hand in, then
repeat
Correct Answer: A
Explanation: Closed gloving requires sterile gown first, then opening inner wrapper,
picking up first glove by the folded cuff (never touching outside), inserting hand,
then repeating. C is close but omits cuff-to-cuff specificity; B and D are open-
gloving methods or wrong order.
10. A client with an nasogastric (NG) tube attached to low intermittent suction has a
prescription for gastric residual checks every 4 hours. The nurse aspirates 350 mL
of greenish fluid. What is the priority action?
A. Return all aspirate and continue feeding as scheduled
B. Discard aspirate and document output
C. Return aspirate and notify the provider for >250 mL residual
D. Hold feeding and replace aspirate unless contraindicated
Correct Answer: D
Explanation: Standard practice is to replace aspirate to prevent electrolyte loss.
Hold feeding if residual exceeds 250–500 mL (varies by policy). Notify provider if
high residual persists. A ignores high residual; B discarding is incorrect; C notifying
is correct but not before holding.
11. A nurse is assessing a postoperative client for signs of hypovolemic shock. Which
finding requires immediate intervention?
A. Blood pressure 100/68 mm Hg, heart rate 88 bpm
B. Urine output 25 mL over 2 hours
C. Respiratory rate 18 breaths per minute
GUIDE 2026 VERSION Q&A
1. A nurse is caring for a client who reports pain as 7 on a 0–10 scale. The nurse
administers the prescribed analgesic. Which action demonstrates the evaluation
phase of the nursing process?
A. Asking the client to rate the pain 30 minutes after administration
B. Explaining the side effects of the analgesic before giving it
C. Identifying that the client has acute pain related to surgical incision
D. Elevating the client’s legs to improve circulation
Correct Answer: A
Explanation: Evaluation involves reassessing the client after an intervention to
determine effectiveness. Asking to rate the pain again measures outcome. B is
implementation, C is diagnosis, D is unrelated intervention.
2. A nursing student asks why the nursing process is considered cyclical rather than
linear. Which response by the instructor is most accurate?
A. “Each phase must be completed exactly once per client encounter.”
B. “The process ends after evaluation unless the client deteriorates.”
C. “Information from evaluation often leads back to reassessment or new
diagnoses.”
D. “Physicians must approve each cycle before nurses can proceed.”
Correct Answer: C
Explanation: The nursing process is cyclical because evaluation results may modify
the plan, requiring reassessment or new diagnoses. A and B are false; D is incorrect
because nursing process is independent.
3. A nurse is performing a physical assessment on an older adult client. Which
finding would the nurse document as an expected age-related change rather
than an abnormal finding?
, A. Diminished radial pulse and cool extremities
B. Loss of subcutaneous fat and skin turgor decrease
C. Crackles in bilateral lung bases and pedal edema
D. Confusion to time and place with agitation
Correct Answer: B
Explanation: Loss of subcutaneous fat and decreased skin turgor are common age-
related changes due to collagen alterations. A suggests vascular insufficiency, C
suggests fluid overload, D suggests delirium or dementia—all abnormal.
4. A client with urinary incontinence is learning bladder retraining. Which statement
by the client indicates correct understanding?
A. “I will drink less than 1 liter of fluid daily to reduce urine output.”
B. “I will urinate every 2 hours even if I don’t feel the urge.”
C. “I will wait until my bladder feels completely full before voiding.”
D. “I will avoid pelvic floor exercises because they worsen leakage.”
Correct Answer: B
Explanation: Scheduled voiding every 2–3 hours is key to bladder retraining. A leads
to dehydration and concentrated urine; C reinforces incontinence; D is false—Kegel
exercises improve control.
5. A nurse is preparing to insert an indwelling urinary catheter for a female client.
After positioning the client and setting up a sterile field, which action should the
nurse perform next?
A. Clean the meatus with antiseptic swabs using a circular motion
B. Lubricate the catheter tip and insert it 2–3 inches
C. Inflate the balloon with 10 mL of sterile water
D. Identify the urethral meatus between the labia minora
Correct Answer: D
Explanation: Locate the urethral meatus before any cleaning or insertion to avoid
contamination and ensure correct placement. Cleaning (A) comes after locating
meatus; B and C come after identification.
,6. A nurse receives a handoff report that a client has a stage 3 pressure injury on the
sacrum. Which characteristic would the nurse expect to observe?
A. Nonblanchable erythema with intact skin
B. Full-thickness skin loss with visible subcutaneous fat but no bone exposure
C. Full-thickness tissue loss with exposed muscle and tendon
D. Intact skin with a serum-filled blister
Correct Answer: B
*Explanation: Stage 3 pressure injury shows full-thickness loss with visible
subcutaneous fat, possibly undermining, but no bone/muscle/tendon. A is stage
1; C is stage 4; D is stage 2.*
7. Which client is at highest risk for developing a deep vein thrombosis (DVT)?
A. A 25-year-old athlete recovering from a hamstring strain
B. A 45-year-old postoperative hip replacement client on bed rest
C. A 60-year-old with well-controlled hypertension walking daily
D. A 30-year-old with migraine taking oral contraceptives but active
Correct Answer: B
Explanation: Postoperative hip surgery, immobility, and bed rest are high-risk triad
for DVT (Virchow’s stasis, hypercoagulability, vessel damage). C is low risk; D has
one risk factor but is active.
8. A nurse is educating a client about a low-sodium diet for heart failure. Which
food choice by the client indicates effective teaching?
A. Canned vegetable soup with saltine crackers
B. Fresh grilled chicken breast with steamed broccoli
C. Deli ham sandwich with pickles and mustard
D. Frozen lasagna with added table salt
Correct Answer: B
Explanation: Fresh, unprocessed foods are naturally low in sodium. A, C, and D all
contain high sodium from processing, preservatives, or added salt.
, 9. A nursing instructor asks students to identify the correct order of steps for sterile
gloving using the closed method. Which sequence is correct?
A. Open inner wrapper, don sterile gown, pick up first glove by folded cuff, insert
hand, repeat for second glove
B. Pick up both gloves at once, insert left hand, then right hand, then adjust
fingers
C. Open outer wrapper, don sterile gown, open inner wrapper, glove dominant
hand first using cuff-to-cuff technique
D. Wash hands, open outer wrapper, pick up glove by palm, slide hand in, then
repeat
Correct Answer: A
Explanation: Closed gloving requires sterile gown first, then opening inner wrapper,
picking up first glove by the folded cuff (never touching outside), inserting hand,
then repeating. C is close but omits cuff-to-cuff specificity; B and D are open-
gloving methods or wrong order.
10. A client with an nasogastric (NG) tube attached to low intermittent suction has a
prescription for gastric residual checks every 4 hours. The nurse aspirates 350 mL
of greenish fluid. What is the priority action?
A. Return all aspirate and continue feeding as scheduled
B. Discard aspirate and document output
C. Return aspirate and notify the provider for >250 mL residual
D. Hold feeding and replace aspirate unless contraindicated
Correct Answer: D
Explanation: Standard practice is to replace aspirate to prevent electrolyte loss.
Hold feeding if residual exceeds 250–500 mL (varies by policy). Notify provider if
high residual persists. A ignores high residual; B discarding is incorrect; C notifying
is correct but not before holding.
11. A nurse is assessing a postoperative client for signs of hypovolemic shock. Which
finding requires immediate intervention?
A. Blood pressure 100/68 mm Hg, heart rate 88 bpm
B. Urine output 25 mL over 2 hours
C. Respiratory rate 18 breaths per minute
