NSG 3100 Fundamental Concepts & Skills I Exam 1 | 75 Multiple
Questions And Answers With Rationale | 2026/2027 Updates
Question 1.
A nurse is performing an initial assessment on a newly admitted patient. Which action best demonstrates the assessment
phase of the nursing process?
A. Documenting the patient's vital signs and health history in the electronic record.
B. Formulating nursing diagnoses based on the patient's reported symptoms.
C. Collecting subjective and objective data through interview, observation, and physical examination.
D. Establishing measurable goals with the patient for the hospital stay.
Correct Answer: C
Rationale:
The assessment phase of the nursing process involves systematically collecting comprehensive data about the patient,
including subjective data (what the patient says) and objective data (what the nurse observes and measures).
Documentation (A) is part of implementation, formulating diagnoses (B) is the diagnosis phase, and establishing goals (D)
is the planning phase.
Question 2.
A nurse is caring for a patient with a suspected infection. Which action is most effective in breaking the chain of infection
at the portal of entry?
A. Wearing gloves when handling the patient's linens.
B. Administering prophylactic antibiotics as ordered.
C. Ensuring invasive devices are inserted using aseptic technique and removed as soon as possible.
D. Placing the patient in a private room with the door closed.
Correct Answer: C
Rationale:
The portal of entry is the route by which pathogens enter the body. Invasive devices (IV catheters, urinary catheters,
endotracheal tubes) create artificial portals of entry. Using aseptic technique during insertion and removing devices
promptly when no longer needed directly protects the portal of entry. Gloves (A) protect the nurse, antibiotics (B) act at
the susceptible host level, and a private room (D) addresses transmission.
Question 3.
A nurse enters a patient's room and finds the patient on the floor beside the bed. The patient is conscious and states, 'I
tried to get to the bathroom by myself.' The nurse's first priority action is to:
A. Call for assistance and assess the patient for injuries.
B. Immediately return the patient to bed to prevent further injury.
C. Document the incident in the electronic health record.
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,D. Notify the patient's family of the fall.
Correct Answer: A
Rationale:
The nurse's first priority after a fall is to call for help and conduct a thorough assessment for injuries before moving the
patient. Moving the patient prematurely could exacerbate fractures, spinal injuries, or internal bleeding. Assessment must
precede documentation, notification, or repositioning. This follows the nursing process and patient safety protocols.
Question 4.
During morning assessment, a nurse notes a patient's oral temperature is 38.9 C (102 F), pulse 110 bpm, respirations
24/min, and blood pressure 118/72 mmHg. The nurse recognizes these findings are consistent with:
A. The body's compensatory response to infection.
B. Hypovolemic shock.
C. Orthostatic hypotension.
D. Bradycardia secondary to increased intracranial pressure.
Correct Answer: A
Rationale:
Fever (pyrexia) triggers physiological responses including tachycardia (increased heart rate) and tachypnea (increased
respiratory rate) as the body attempts to meet increased metabolic demands and dissipate heat. This pattern is
characteristic of the body's compensatory response to infection or inflammation. Hypovolemic shock would typically
present with hypotension, orthostatic hypotension requires positional vital sign changes, and increased ICP causes
bradycardia with hypertension (Cushing's triad).
Question 5.
A nurse is delegating tasks to unlicensed assistive personnel (UAP). Which task is most appropriate to delegate?
A. Assessing a postoperative patient's surgical incision for signs of infection.
B. Measuring and recording intake and output for a stable patient.
C. Administering oral medications to a newly admitted patient.
D. Teaching a patient how to use an incentive spirometer.
Correct Answer: B
Rationale:
Delegation to UAP is appropriate for tasks that are routine, do not require nursing judgment, and fall within the UAP's
training scope. Measuring and recording I&O is a standard, repetitive task. Assessment, medication administration, and
patient teaching require professional nursing licensure, clinical judgment, and critical thinking-functions that cannot be
delegated to unlicensed personnel under the Nurse Practice Act.
Question 6.
Page 2
, A nurse is preparing to transfer a patient from the bed to a wheelchair using a gait belt. The nurse should position the
wheelchair:
A. At the foot of the bed facing the hallway.
B. Parallel to the bed on the patient's stronger side.
C. At a 45-degree angle to the bed on the patient's stronger side.
D. Directly behind the patient.
Correct Answer: C
Rationale:
The wheelchair should be placed at a 45-degree angle to the bed on the patient's stronger side to facilitate safe pivoting
and reduce strain on both the patient and nurse. This positioning allows the patient to use their stronger extremities for
support during the transfer. The brakes must be locked, footrests swung away, and the bed lowered to the lowest position
before initiating the transfer.
Question 7.
A nurse is assessing a patient's radial pulse and notes an irregular rhythm. To confirm the finding, the nurse should:
A. Count the pulse for 15 seconds and multiply by 4.
B. Count the pulse for 30 seconds and multiply by 2.
C. Count the pulse for a full 60 seconds.
D. Auscultate the apical pulse for 15 seconds.
Correct Answer: C
Rationale:
When an irregular pulse is detected, the nurse must count for a full 60 seconds to obtain an accurate rate because irregular
rhythms may have varying intervals between beats. Counting for shorter periods and multiplying can produce inaccurate
results with irregular rhythms. Additionally, the nurse should auscultate the apical pulse for a full 60 seconds and compare
it to the radial pulse to assess for a pulse deficit, which indicates some cardiac contractions are too weak to produce a
peripheral pulse.
Question 8.
A nurse is caring for a patient who has been on bed rest for 5 days. The nurse notes bilateral pedal edema. The nurse
understands that this finding is most likely caused by:
A. Increased capillary permeability from inflammation.
B. Decreased venous return due to immobility.
C. Excessive sodium intake from hospital meals.
D. Right-sided heart failure.
Correct Answer: B
Rationale:
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Questions And Answers With Rationale | 2026/2027 Updates
Question 1.
A nurse is performing an initial assessment on a newly admitted patient. Which action best demonstrates the assessment
phase of the nursing process?
A. Documenting the patient's vital signs and health history in the electronic record.
B. Formulating nursing diagnoses based on the patient's reported symptoms.
C. Collecting subjective and objective data through interview, observation, and physical examination.
D. Establishing measurable goals with the patient for the hospital stay.
Correct Answer: C
Rationale:
The assessment phase of the nursing process involves systematically collecting comprehensive data about the patient,
including subjective data (what the patient says) and objective data (what the nurse observes and measures).
Documentation (A) is part of implementation, formulating diagnoses (B) is the diagnosis phase, and establishing goals (D)
is the planning phase.
Question 2.
A nurse is caring for a patient with a suspected infection. Which action is most effective in breaking the chain of infection
at the portal of entry?
A. Wearing gloves when handling the patient's linens.
B. Administering prophylactic antibiotics as ordered.
C. Ensuring invasive devices are inserted using aseptic technique and removed as soon as possible.
D. Placing the patient in a private room with the door closed.
Correct Answer: C
Rationale:
The portal of entry is the route by which pathogens enter the body. Invasive devices (IV catheters, urinary catheters,
endotracheal tubes) create artificial portals of entry. Using aseptic technique during insertion and removing devices
promptly when no longer needed directly protects the portal of entry. Gloves (A) protect the nurse, antibiotics (B) act at
the susceptible host level, and a private room (D) addresses transmission.
Question 3.
A nurse enters a patient's room and finds the patient on the floor beside the bed. The patient is conscious and states, 'I
tried to get to the bathroom by myself.' The nurse's first priority action is to:
A. Call for assistance and assess the patient for injuries.
B. Immediately return the patient to bed to prevent further injury.
C. Document the incident in the electronic health record.
Page 1
,D. Notify the patient's family of the fall.
Correct Answer: A
Rationale:
The nurse's first priority after a fall is to call for help and conduct a thorough assessment for injuries before moving the
patient. Moving the patient prematurely could exacerbate fractures, spinal injuries, or internal bleeding. Assessment must
precede documentation, notification, or repositioning. This follows the nursing process and patient safety protocols.
Question 4.
During morning assessment, a nurse notes a patient's oral temperature is 38.9 C (102 F), pulse 110 bpm, respirations
24/min, and blood pressure 118/72 mmHg. The nurse recognizes these findings are consistent with:
A. The body's compensatory response to infection.
B. Hypovolemic shock.
C. Orthostatic hypotension.
D. Bradycardia secondary to increased intracranial pressure.
Correct Answer: A
Rationale:
Fever (pyrexia) triggers physiological responses including tachycardia (increased heart rate) and tachypnea (increased
respiratory rate) as the body attempts to meet increased metabolic demands and dissipate heat. This pattern is
characteristic of the body's compensatory response to infection or inflammation. Hypovolemic shock would typically
present with hypotension, orthostatic hypotension requires positional vital sign changes, and increased ICP causes
bradycardia with hypertension (Cushing's triad).
Question 5.
A nurse is delegating tasks to unlicensed assistive personnel (UAP). Which task is most appropriate to delegate?
A. Assessing a postoperative patient's surgical incision for signs of infection.
B. Measuring and recording intake and output for a stable patient.
C. Administering oral medications to a newly admitted patient.
D. Teaching a patient how to use an incentive spirometer.
Correct Answer: B
Rationale:
Delegation to UAP is appropriate for tasks that are routine, do not require nursing judgment, and fall within the UAP's
training scope. Measuring and recording I&O is a standard, repetitive task. Assessment, medication administration, and
patient teaching require professional nursing licensure, clinical judgment, and critical thinking-functions that cannot be
delegated to unlicensed personnel under the Nurse Practice Act.
Question 6.
Page 2
, A nurse is preparing to transfer a patient from the bed to a wheelchair using a gait belt. The nurse should position the
wheelchair:
A. At the foot of the bed facing the hallway.
B. Parallel to the bed on the patient's stronger side.
C. At a 45-degree angle to the bed on the patient's stronger side.
D. Directly behind the patient.
Correct Answer: C
Rationale:
The wheelchair should be placed at a 45-degree angle to the bed on the patient's stronger side to facilitate safe pivoting
and reduce strain on both the patient and nurse. This positioning allows the patient to use their stronger extremities for
support during the transfer. The brakes must be locked, footrests swung away, and the bed lowered to the lowest position
before initiating the transfer.
Question 7.
A nurse is assessing a patient's radial pulse and notes an irregular rhythm. To confirm the finding, the nurse should:
A. Count the pulse for 15 seconds and multiply by 4.
B. Count the pulse for 30 seconds and multiply by 2.
C. Count the pulse for a full 60 seconds.
D. Auscultate the apical pulse for 15 seconds.
Correct Answer: C
Rationale:
When an irregular pulse is detected, the nurse must count for a full 60 seconds to obtain an accurate rate because irregular
rhythms may have varying intervals between beats. Counting for shorter periods and multiplying can produce inaccurate
results with irregular rhythms. Additionally, the nurse should auscultate the apical pulse for a full 60 seconds and compare
it to the radial pulse to assess for a pulse deficit, which indicates some cardiac contractions are too weak to produce a
peripheral pulse.
Question 8.
A nurse is caring for a patient who has been on bed rest for 5 days. The nurse notes bilateral pedal edema. The nurse
understands that this finding is most likely caused by:
A. Increased capillary permeability from inflammation.
B. Decreased venous return due to immobility.
C. Excessive sodium intake from hospital meals.
D. Right-sided heart failure.
Correct Answer: B
Rationale:
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