NUR 104 / NUR104 HESI – Foundations of Nursing
Review V2 Actual Exam 2026/2027 with Detailed
Rationales | 100% Verified | Pass Guaranteed – A+
Graded
SECTION 1: SAFETY & INFECTION CONTROL (Questions 1–15)
Q1: A nurse is preparing to administer a medication to a patient. Which action is the
priority to ensure patient safety before medication administration?
A. Verify the medication expiration date only
B. Check the patient's allergy band after preparing the medication
C. Perform the "five rights" of medication administration including right patient, right
drug, right dose, right route, and right time [CORRECT]
D. Ask the patient to state their room number for identification
Correct Answer: C
Rationale: Correct because the five rights of medication administration are the
foundational safety checks that prevent medication errors and ensure the correct
therapy is delivered to the correct patient at the correct time.
Q2: A patient with tuberculosis is admitted to the hospital. Which type of isolation
precautions should the nurse implement?
A. Contact precautions
B. Droplet precautions
C. Airborne precautions [CORRECT]
D. Standard precautions only
Correct Answer: C
Rationale: Correct because tuberculosis is transmitted via airborne droplet nuclei
that remain suspended in the air; airborne precautions require a negative-pressure
room and N95 respirator use to prevent transmission.
Q3: A nurse witnesses a needlestick injury after recapping a used syringe. Which is
the priority action?
A. Complete an incident report before leaving the unit
B. Wash the area with soap and water and report to employee health immediately
[CORRECT]
,C. Apply povidone-iodine and return to patient care
D. Wait for the end of the shift to assess for symptoms
Correct Answer: B
Rationale: Correct because immediate washing with soap and water reduces viral
load at the exposure site, and prompt reporting to employee health enables timely
assessment, source patient testing, and potential post-exposure prophylaxis.
Q4: A patient on a medical-surgical unit is at high risk for falls. Which intervention is
most effective for fall prevention?
A. Keep the bed in the lowest position with side rails up and call light within reach
[CORRECT]
B. Restrain the patient to the bed to prevent ambulation
C. Turn off the room lights to promote sleep
D. Remove the bedside commode to discourage independent toileting
Correct Answer: A
Rationale: Correct because maintaining the bed in the lowest position reduces injury
severity if a fall occurs, while keeping the call light accessible and side rails up
provides safety without restricting autonomy.
Q5: During a fire emergency on the nursing unit, which action should the nurse take
first according to the RACE protocol?
A. Activate the alarm and rescue patients in immediate danger [CORRECT]
B. Extinguish the fire with the nearest fire extinguisher
C. Close all doors and windows on the unit
D. Evacuate the entire unit immediately
Correct Answer: A
Rationale: Correct because the RACE protocol prioritizes Rescue of patients in
immediate danger, Activation of the fire alarm, Containment of the fire, and
Evacuation/Extinguishment; rescue and alarm activation are the first priorities.
Q6: A nurse is caring for a patient with Clostridioides difficile infection. Which hand
hygiene method is required when leaving the patient's room?
A. Alcohol-based hand rub
B. Soap and water handwashing [CORRECT]
C. Antiseptic towelettes
D. No hand hygiene needed if gloves were worn
Correct Answer: B
, Rationale: Correct because C. difficile spores are resistant to alcohol-based hand
sanitizers; soap and water with mechanical friction is required to physically remove
spores from the hands.
Q7: A nurse is applying a sequential compression device to a postoperative patient.
Which safety check is essential before application?
A. Ensure the patient has a DVT diagnosed first
B. Assess bilateral pedal pulses and skin integrity [CORRECT]
C. Apply the device over the patient's clothing without inspection
D. Inflate the device to maximum pressure for effectiveness
Correct Answer: B
Rationale: Correct because assessing pedal pulses and skin integrity before
application establishes a baseline for circulation and tissue integrity, ensuring the
device can be safely applied without exacerbating existing vascular compromise.
Q8: A patient receiving oxygen via nasal cannula reports dry nasal passages. Which
nursing intervention is appropriate?
A. Increase the oxygen flow rate to humidify the oxygen
B. Apply water-soluble lubricant to the nares [CORRECT]
C. Switch to a simple face mask without humidification
D. Discontinue oxygen therapy until moisture returns
Correct Answer: B
Rationale: Correct because water-soluble lubricant reduces nasal mucosal irritation
and dryness without posing an aspiration risk or altering the prescribed oxygen
delivery system.
Q9: A nurse is preparing to transfer a patient from bed to chair using a gait belt.
Which technique is correct?
A. Place the gait belt around the patient's chest
B. Position the gait belt securely around the patient's waist over clothing [CORRECT]
C. Fasten the gait belt loosely to allow the patient to breathe
D. Grasp the gait belt from the front to pull the patient upward
Correct Answer: B
Rationale: Correct because placing the gait belt securely around the waist over
clothing provides the nurse with a stable handhold for safe transfer while
maintaining patient comfort and preventing skin injury.
Review V2 Actual Exam 2026/2027 with Detailed
Rationales | 100% Verified | Pass Guaranteed – A+
Graded
SECTION 1: SAFETY & INFECTION CONTROL (Questions 1–15)
Q1: A nurse is preparing to administer a medication to a patient. Which action is the
priority to ensure patient safety before medication administration?
A. Verify the medication expiration date only
B. Check the patient's allergy band after preparing the medication
C. Perform the "five rights" of medication administration including right patient, right
drug, right dose, right route, and right time [CORRECT]
D. Ask the patient to state their room number for identification
Correct Answer: C
Rationale: Correct because the five rights of medication administration are the
foundational safety checks that prevent medication errors and ensure the correct
therapy is delivered to the correct patient at the correct time.
Q2: A patient with tuberculosis is admitted to the hospital. Which type of isolation
precautions should the nurse implement?
A. Contact precautions
B. Droplet precautions
C. Airborne precautions [CORRECT]
D. Standard precautions only
Correct Answer: C
Rationale: Correct because tuberculosis is transmitted via airborne droplet nuclei
that remain suspended in the air; airborne precautions require a negative-pressure
room and N95 respirator use to prevent transmission.
Q3: A nurse witnesses a needlestick injury after recapping a used syringe. Which is
the priority action?
A. Complete an incident report before leaving the unit
B. Wash the area with soap and water and report to employee health immediately
[CORRECT]
,C. Apply povidone-iodine and return to patient care
D. Wait for the end of the shift to assess for symptoms
Correct Answer: B
Rationale: Correct because immediate washing with soap and water reduces viral
load at the exposure site, and prompt reporting to employee health enables timely
assessment, source patient testing, and potential post-exposure prophylaxis.
Q4: A patient on a medical-surgical unit is at high risk for falls. Which intervention is
most effective for fall prevention?
A. Keep the bed in the lowest position with side rails up and call light within reach
[CORRECT]
B. Restrain the patient to the bed to prevent ambulation
C. Turn off the room lights to promote sleep
D. Remove the bedside commode to discourage independent toileting
Correct Answer: A
Rationale: Correct because maintaining the bed in the lowest position reduces injury
severity if a fall occurs, while keeping the call light accessible and side rails up
provides safety without restricting autonomy.
Q5: During a fire emergency on the nursing unit, which action should the nurse take
first according to the RACE protocol?
A. Activate the alarm and rescue patients in immediate danger [CORRECT]
B. Extinguish the fire with the nearest fire extinguisher
C. Close all doors and windows on the unit
D. Evacuate the entire unit immediately
Correct Answer: A
Rationale: Correct because the RACE protocol prioritizes Rescue of patients in
immediate danger, Activation of the fire alarm, Containment of the fire, and
Evacuation/Extinguishment; rescue and alarm activation are the first priorities.
Q6: A nurse is caring for a patient with Clostridioides difficile infection. Which hand
hygiene method is required when leaving the patient's room?
A. Alcohol-based hand rub
B. Soap and water handwashing [CORRECT]
C. Antiseptic towelettes
D. No hand hygiene needed if gloves were worn
Correct Answer: B
, Rationale: Correct because C. difficile spores are resistant to alcohol-based hand
sanitizers; soap and water with mechanical friction is required to physically remove
spores from the hands.
Q7: A nurse is applying a sequential compression device to a postoperative patient.
Which safety check is essential before application?
A. Ensure the patient has a DVT diagnosed first
B. Assess bilateral pedal pulses and skin integrity [CORRECT]
C. Apply the device over the patient's clothing without inspection
D. Inflate the device to maximum pressure for effectiveness
Correct Answer: B
Rationale: Correct because assessing pedal pulses and skin integrity before
application establishes a baseline for circulation and tissue integrity, ensuring the
device can be safely applied without exacerbating existing vascular compromise.
Q8: A patient receiving oxygen via nasal cannula reports dry nasal passages. Which
nursing intervention is appropriate?
A. Increase the oxygen flow rate to humidify the oxygen
B. Apply water-soluble lubricant to the nares [CORRECT]
C. Switch to a simple face mask without humidification
D. Discontinue oxygen therapy until moisture returns
Correct Answer: B
Rationale: Correct because water-soluble lubricant reduces nasal mucosal irritation
and dryness without posing an aspiration risk or altering the prescribed oxygen
delivery system.
Q9: A nurse is preparing to transfer a patient from bed to chair using a gait belt.
Which technique is correct?
A. Place the gait belt around the patient's chest
B. Position the gait belt securely around the patient's waist over clothing [CORRECT]
C. Fasten the gait belt loosely to allow the patient to breathe
D. Grasp the gait belt from the front to pull the patient upward
Correct Answer: B
Rationale: Correct because placing the gait belt securely around the waist over
clothing provides the nurse with a stable handhold for safe transfer while
maintaining patient comfort and preventing skin injury.
