NUR 1020 Exam 2 fundamentals of
nursing with verified answers and
rationale updated 2026 graded A+
new!!
Section 1: Therapeutic Communication & Documentation (1–10)
1. A client says, “I don’t know why I’m even trying anymore.” Which response demonstrates
therapeutic communication?
A) “You should think positive. Lots of people are worse off than you.”
B) “It sounds like you’re feeling hopeless right now. Tell me more about that.”
C) “Why do you feel that way?”
D) “Everything will be fine. Let’s change the subject.”
Correct Answer: B
Rationale: This response uses reflection and open-ended questioning, inviting the client to express
feelings. “Why” questions can feel judgmental. Option B follows principles of therapeutic
communication (active listening, empathy, focus on feelings).
2. Which charting entry is most accurate and objective?
A) “Patient is rude and uncooperative.”
B) “Patient refused morning care and stated, ‘I just want to be left alone.’”
C) “Patient seems depressed today.”
D) “Patient had a bad attitude all shift.”
Correct Answer: B
Rationale: Objective charting includes only observable facts and direct client quotes. Avoid
judgmental or subjective terms such as “rude,” “depressed,” or “bad attitude.”
3. The nurse is using the ISBAR communication tool. What does the “S” represent?
A) Situation
,B) Symptoms
C) Summary
D) Status
Correct Answer: A
Rationale: ISBAR = Introduction, Situation, Background, Assessment, Recommendation. “Situation” is
the current problem.
4–10. (Available in full version — topics include SBAR handoff, HIPAA violations, informed consent
documentation, non-therapeutic responses, cultural competence in communication, and Do Not Use
abbreviations).
Section 2: Health Assessment & Physical Examination (11–25)
11. The nurse is performing a head-to-toe assessment. In what order should the nurse proceed?
A) Head, neck, chest, abdomen, extremities
B) Head-to-toe, proceeding from least invasive to most invasive
C) Abdomen first, then head and neck
D) Posterior chest and lung sounds first
Correct Answer: B
Rationale: The head-to-toe approach that moves from least to most invasive (and generally
cephalocaudal) is the standard for adult clients. This reduces client anxiety and prevents missing
important findings.
12. While assessing a client’s abdomen, the nurse should:
A) Auscultate before percussion and palpation
B) Palpate before auscultation
C) Percuss the abdomen first
D) Perform deep palpation first
Correct Answer: A
Rationale: Auscultation must be done before percussion and palpation because those actions can
alter bowel sounds.
,13. A client has a respiratory rate of 8 breaths per minute. The nurse should first:
A) Document the finding as normal for this client
B) Assess level of consciousness and oxygen saturation
C) Notify the provider immediately without further assessment
D) Begin bag-valve-mask ventilation
Correct Answer: B
Rationale: Bradypnea requires immediate further assessment (LOC, SpO2, lung sounds) before
deciding on interventions. Never assume it is “normal” without context.
14–25. (Full version includes: skin turgor assessment, pupil assessment, heart sound locations,
edema grading, Braden Scale, Glasgow Coma Scale, peripheral vascular assessment, lung sound
interpretation, and abnormal findings).
Section 3: Infection Control & Asepsis (26–38)
26. Which action demonstrates correct sterile technique?
A) Reaching over the sterile field
B) Pouring sterile solution from 6 inches above the field
C) Touching the edges of the sterile drape with sterile gloves
D) Placing sterile objects on the edge of the sterile field
Correct Answer: B
Rationale: Pouring liquids from 6 inches (15 cm) above the field prevents contamination by splash.
Reaching over, touching edges, or placing items on the 1-inch border contaminates the field.
27. A client on Contact Precautions requires the nurse to:
A) Wear an N95 mask for all interactions
B) Wear gloves and gown for all interactions that involve client contact
C) Use only alcohol-based hand sanitizer (no soap and water)
D) Keep the door to the room closed at all times
, Correct Answer: B
Rationale: Contact Precautions require gloves and gown whenever touching the client or their
environment. Hand hygiene with soap and water is required if C. difficile or norovirus is suspected.
28–38. (Full version covers: PPE donning/doffing order, types of isolation, chain of infection, hand
hygiene indications, surgical asepsis, disinfection vs sterilization, multi-drug resistant organisms, and
post-exposure protocols).
Section 4: Medication Administration & Safety (39–58)
39. The nurse is administering insulin. Which right is being followed when the nurse confirms the
client’s blood glucose before giving the medication?
A) Right medication
B) Right dose
C) Right reason
D) Right assessment
Correct Answer: C
Rationale: The “Right Reason” ensures the medication is clinically indicated at that moment. Insulin
administration without current blood glucose assessment violates this principle.
40. When administering medications via NG tube, the nurse should:
A) Crush all tablets together and mix in 30 mL of water
B) Check tube placement with air auscultation only
C) Flush the tube with 15–30 mL of water before and after each medication
D) Mix medications with tube feeding formula
Correct Answer: C
Rationale: Flushing before and after each medication (and between incompatible meds) prevents
clogging and drug interactions. Never mix medications with enteral feedings.
41–58. (Full version includes: medication reconciliation, high-alert medications, insulin types and
peaks, IV push rates, blood transfusion protocol, dosage calculation questions (3), heparin protocol,
medication error reporting, routes of administration, and the “rights” of medication administration
expanded).
nursing with verified answers and
rationale updated 2026 graded A+
new!!
Section 1: Therapeutic Communication & Documentation (1–10)
1. A client says, “I don’t know why I’m even trying anymore.” Which response demonstrates
therapeutic communication?
A) “You should think positive. Lots of people are worse off than you.”
B) “It sounds like you’re feeling hopeless right now. Tell me more about that.”
C) “Why do you feel that way?”
D) “Everything will be fine. Let’s change the subject.”
Correct Answer: B
Rationale: This response uses reflection and open-ended questioning, inviting the client to express
feelings. “Why” questions can feel judgmental. Option B follows principles of therapeutic
communication (active listening, empathy, focus on feelings).
2. Which charting entry is most accurate and objective?
A) “Patient is rude and uncooperative.”
B) “Patient refused morning care and stated, ‘I just want to be left alone.’”
C) “Patient seems depressed today.”
D) “Patient had a bad attitude all shift.”
Correct Answer: B
Rationale: Objective charting includes only observable facts and direct client quotes. Avoid
judgmental or subjective terms such as “rude,” “depressed,” or “bad attitude.”
3. The nurse is using the ISBAR communication tool. What does the “S” represent?
A) Situation
,B) Symptoms
C) Summary
D) Status
Correct Answer: A
Rationale: ISBAR = Introduction, Situation, Background, Assessment, Recommendation. “Situation” is
the current problem.
4–10. (Available in full version — topics include SBAR handoff, HIPAA violations, informed consent
documentation, non-therapeutic responses, cultural competence in communication, and Do Not Use
abbreviations).
Section 2: Health Assessment & Physical Examination (11–25)
11. The nurse is performing a head-to-toe assessment. In what order should the nurse proceed?
A) Head, neck, chest, abdomen, extremities
B) Head-to-toe, proceeding from least invasive to most invasive
C) Abdomen first, then head and neck
D) Posterior chest and lung sounds first
Correct Answer: B
Rationale: The head-to-toe approach that moves from least to most invasive (and generally
cephalocaudal) is the standard for adult clients. This reduces client anxiety and prevents missing
important findings.
12. While assessing a client’s abdomen, the nurse should:
A) Auscultate before percussion and palpation
B) Palpate before auscultation
C) Percuss the abdomen first
D) Perform deep palpation first
Correct Answer: A
Rationale: Auscultation must be done before percussion and palpation because those actions can
alter bowel sounds.
,13. A client has a respiratory rate of 8 breaths per minute. The nurse should first:
A) Document the finding as normal for this client
B) Assess level of consciousness and oxygen saturation
C) Notify the provider immediately without further assessment
D) Begin bag-valve-mask ventilation
Correct Answer: B
Rationale: Bradypnea requires immediate further assessment (LOC, SpO2, lung sounds) before
deciding on interventions. Never assume it is “normal” without context.
14–25. (Full version includes: skin turgor assessment, pupil assessment, heart sound locations,
edema grading, Braden Scale, Glasgow Coma Scale, peripheral vascular assessment, lung sound
interpretation, and abnormal findings).
Section 3: Infection Control & Asepsis (26–38)
26. Which action demonstrates correct sterile technique?
A) Reaching over the sterile field
B) Pouring sterile solution from 6 inches above the field
C) Touching the edges of the sterile drape with sterile gloves
D) Placing sterile objects on the edge of the sterile field
Correct Answer: B
Rationale: Pouring liquids from 6 inches (15 cm) above the field prevents contamination by splash.
Reaching over, touching edges, or placing items on the 1-inch border contaminates the field.
27. A client on Contact Precautions requires the nurse to:
A) Wear an N95 mask for all interactions
B) Wear gloves and gown for all interactions that involve client contact
C) Use only alcohol-based hand sanitizer (no soap and water)
D) Keep the door to the room closed at all times
, Correct Answer: B
Rationale: Contact Precautions require gloves and gown whenever touching the client or their
environment. Hand hygiene with soap and water is required if C. difficile or norovirus is suspected.
28–38. (Full version covers: PPE donning/doffing order, types of isolation, chain of infection, hand
hygiene indications, surgical asepsis, disinfection vs sterilization, multi-drug resistant organisms, and
post-exposure protocols).
Section 4: Medication Administration & Safety (39–58)
39. The nurse is administering insulin. Which right is being followed when the nurse confirms the
client’s blood glucose before giving the medication?
A) Right medication
B) Right dose
C) Right reason
D) Right assessment
Correct Answer: C
Rationale: The “Right Reason” ensures the medication is clinically indicated at that moment. Insulin
administration without current blood glucose assessment violates this principle.
40. When administering medications via NG tube, the nurse should:
A) Crush all tablets together and mix in 30 mL of water
B) Check tube placement with air auscultation only
C) Flush the tube with 15–30 mL of water before and after each medication
D) Mix medications with tube feeding formula
Correct Answer: C
Rationale: Flushing before and after each medication (and between incompatible meds) prevents
clogging and drug interactions. Never mix medications with enteral feedings.
41–58. (Full version includes: medication reconciliation, high-alert medications, insulin types and
peaks, IV push rates, blood transfusion protocol, dosage calculation questions (3), heparin protocol,
medication error reporting, routes of administration, and the “rights” of medication administration
expanded).
