NUR 155 Exam 1 V1 | NUR 155
Foundations of Nursing | Q&A with
Rationale (NUR155 Exam 1) | Galen
College of Nursing
1. A nurse is performing a physical assessment on a patient. Which phase of the nursing
process is the nurse currently executing?
A. Assessment
B. Diagnosis
C. Implementation
D. Planning
Answer: A
Rationale: Assessment is the first step of the nursing process and involves systematic data
collection. This phase includes gathering both subjective and objective data to identify the
patient’s health status. Proper assessment provides the necessary evidence for the
subsequent development of nursing diagnoses.
2. When assessing the radial pulse of a patient with a regular rhythm, how long should the
nurse count?
A. 15 seconds and multiply by 4
B. 30 seconds and multiply by 2
,C. Full 60 seconds
D. 1 minute and 30 seconds
Answer: B
Rationale: The standard procedure for a regular radial pulse is to count for 30 seconds and
multiply by two. If the rhythm is irregular, the nurse must count for a full minute to ensure
accuracy. This method balances efficiency with clinical reliability for stable patients.
3. Which of the following is an example of objective data?
A. Patient reporting a headache
B. Patient stating they feel nauseous
C. Patient describing their pain as a 7 out of 10
D. Blood pressure reading of 140/90 mmHg
Answer: D
Rationale: Objective data are measurable and observable signs gathered through physical
examination and diagnostic testing. A blood pressure reading is a quantitative
measurement that can be verified by another healthcare professional. Subjective data,
conversely, consist of information perceived only by the patient, such as pain or feelings.
4. The nurse is preparing to wash their hands. According to standard guidelines, what is the
minimum duration for rubbing hands with soap?
A. 15 to 20 seconds
, B. 10 seconds
C. 30 to 45 seconds
D. 60 seconds
Answer: A
Rationale: Friction is the most important factor in handwashing for removing
microorganisms from the skin. The CDC recommends scrubbing all surfaces of the hands
for at least 15 to 20 seconds. This duration ensures that transient flora are effectively
dislodged and rinsed away.
5. A patient is on contact precautions. Which personal protective equipment (PPE) is
mandatory when entering the room?
A. Mask and goggles
B. Gown and gloves
C. N95 respirator
D. Gloves only
Answer: B
Rationale: Contact precautions are designed to prevent the transmission of infectious
agents through direct or indirect contact. The nurse must wear a gown and gloves to
prevent contaminating their clothing and skin. These barriers are essential when handling
the patient or their immediate environment.
Foundations of Nursing | Q&A with
Rationale (NUR155 Exam 1) | Galen
College of Nursing
1. A nurse is performing a physical assessment on a patient. Which phase of the nursing
process is the nurse currently executing?
A. Assessment
B. Diagnosis
C. Implementation
D. Planning
Answer: A
Rationale: Assessment is the first step of the nursing process and involves systematic data
collection. This phase includes gathering both subjective and objective data to identify the
patient’s health status. Proper assessment provides the necessary evidence for the
subsequent development of nursing diagnoses.
2. When assessing the radial pulse of a patient with a regular rhythm, how long should the
nurse count?
A. 15 seconds and multiply by 4
B. 30 seconds and multiply by 2
,C. Full 60 seconds
D. 1 minute and 30 seconds
Answer: B
Rationale: The standard procedure for a regular radial pulse is to count for 30 seconds and
multiply by two. If the rhythm is irregular, the nurse must count for a full minute to ensure
accuracy. This method balances efficiency with clinical reliability for stable patients.
3. Which of the following is an example of objective data?
A. Patient reporting a headache
B. Patient stating they feel nauseous
C. Patient describing their pain as a 7 out of 10
D. Blood pressure reading of 140/90 mmHg
Answer: D
Rationale: Objective data are measurable and observable signs gathered through physical
examination and diagnostic testing. A blood pressure reading is a quantitative
measurement that can be verified by another healthcare professional. Subjective data,
conversely, consist of information perceived only by the patient, such as pain or feelings.
4. The nurse is preparing to wash their hands. According to standard guidelines, what is the
minimum duration for rubbing hands with soap?
A. 15 to 20 seconds
, B. 10 seconds
C. 30 to 45 seconds
D. 60 seconds
Answer: A
Rationale: Friction is the most important factor in handwashing for removing
microorganisms from the skin. The CDC recommends scrubbing all surfaces of the hands
for at least 15 to 20 seconds. This duration ensures that transient flora are effectively
dislodged and rinsed away.
5. A patient is on contact precautions. Which personal protective equipment (PPE) is
mandatory when entering the room?
A. Mask and goggles
B. Gown and gloves
C. N95 respirator
D. Gloves only
Answer: B
Rationale: Contact precautions are designed to prevent the transmission of infectious
agents through direct or indirect contact. The nurse must wear a gown and gloves to
prevent contaminating their clothing and skin. These barriers are essential when handling
the patient or their immediate environment.
