NUR 155 Exam 1 V3 | NUR 155
Foundations of Nursing | Q&A with
Rationale (NUR155 Exam 1) | Galen
College of Nursing
1. A nurse is washing their hands before entering a patient’s room. Which action is the most
important component of handwashing for removing microorganisms?
A. Using extremely hot water to kill bacteria
B. Drying hands starting from the elbows down
C. Using antibacterial soap rather than plain soap
D. Applying friction for at least 20 seconds
Answer: D
Rationale: Friction is the most important component of handwashing because it physically
loosens and removes dirt and microorganisms from the skin. The Centers for Disease
Control and Prevention (CDC) recommends scrubbing all surfaces of the hands for a
minimum of 20 seconds. This mechanical action is more critical than the temperature of the
water or the specific type of soap used.
2. Which step of the nursing process involves the systematic collection and verification of
data?
A. Planning
,B. Assessment
C. Implementation
D. Diagnosis
Answer: B
Rationale: Assessment is the first step of the nursing process and involves the deliberate
and systematic collection of information about a patient. During this phase, the nurse
gathers both subjective and objective data to determine the patient’s current and past
health status. Accurate assessment is essential because it forms the foundation for all
subsequent nursing decisions and actions.
3. A patient refuses a scheduled dose of medication. Which ethical principle is the nurse
upholding by respecting this decision?
A. Autonomy
B. Justice
C. Nonmaleficence
D. Beneficence
Answer: A
Rationale: Autonomy refers to the right of patients to make their own decisions about
their medical care without being influenced by healthcare providers. By respecting a
patient’s refusal of medication, the nurse acknowledges the patient’s independence and
, self-determination. The nurse’s role is to ensure the patient is informed of the risks of
refusal while ultimately honoring the patient’s choice.
4. When measuring a patient’s blood pressure, the nurse notes that the cuff is too small for
the patient’s arm. What effect will this have on the reading?
A. The cuff size does not affect the blood pressure reading
B. The blood pressure reading will be falsely low
C. The systolic reading will be low and diastolic high
D. The blood pressure reading will be falsely high
Answer: D
Rationale: Using a blood pressure cuff that is too small for the patient’s limb circumference
will result in a falsely elevated blood pressure reading. This occurs because the small
bladder cannot distribute pressure evenly, requiring more pressure to occlude the artery.
Conversely, a cuff that is too large will result in a falsely low reading.
5. A nurse is preparing to provide oral care to an unconscious patient. In which position
should the nurse place the patient?
A. Supine
B. Side-lying (Lateral)
C. High-Fowler’s
D. Prone
Foundations of Nursing | Q&A with
Rationale (NUR155 Exam 1) | Galen
College of Nursing
1. A nurse is washing their hands before entering a patient’s room. Which action is the most
important component of handwashing for removing microorganisms?
A. Using extremely hot water to kill bacteria
B. Drying hands starting from the elbows down
C. Using antibacterial soap rather than plain soap
D. Applying friction for at least 20 seconds
Answer: D
Rationale: Friction is the most important component of handwashing because it physically
loosens and removes dirt and microorganisms from the skin. The Centers for Disease
Control and Prevention (CDC) recommends scrubbing all surfaces of the hands for a
minimum of 20 seconds. This mechanical action is more critical than the temperature of the
water or the specific type of soap used.
2. Which step of the nursing process involves the systematic collection and verification of
data?
A. Planning
,B. Assessment
C. Implementation
D. Diagnosis
Answer: B
Rationale: Assessment is the first step of the nursing process and involves the deliberate
and systematic collection of information about a patient. During this phase, the nurse
gathers both subjective and objective data to determine the patient’s current and past
health status. Accurate assessment is essential because it forms the foundation for all
subsequent nursing decisions and actions.
3. A patient refuses a scheduled dose of medication. Which ethical principle is the nurse
upholding by respecting this decision?
A. Autonomy
B. Justice
C. Nonmaleficence
D. Beneficence
Answer: A
Rationale: Autonomy refers to the right of patients to make their own decisions about
their medical care without being influenced by healthcare providers. By respecting a
patient’s refusal of medication, the nurse acknowledges the patient’s independence and
, self-determination. The nurse’s role is to ensure the patient is informed of the risks of
refusal while ultimately honoring the patient’s choice.
4. When measuring a patient’s blood pressure, the nurse notes that the cuff is too small for
the patient’s arm. What effect will this have on the reading?
A. The cuff size does not affect the blood pressure reading
B. The blood pressure reading will be falsely low
C. The systolic reading will be low and diastolic high
D. The blood pressure reading will be falsely high
Answer: D
Rationale: Using a blood pressure cuff that is too small for the patient’s limb circumference
will result in a falsely elevated blood pressure reading. This occurs because the small
bladder cannot distribute pressure evenly, requiring more pressure to occlude the artery.
Conversely, a cuff that is too large will result in a falsely low reading.
5. A nurse is preparing to provide oral care to an unconscious patient. In which position
should the nurse place the patient?
A. Supine
B. Side-lying (Lateral)
C. High-Fowler’s
D. Prone
