West Coast University NURS 100 Final Exam Practice
Questions and Answers (2026–2027): Fundamentals of
Nursing, Patient Safety & Clinical Judgment
1. A nurse is using the nursing process to care for a newly admitted
patient. Which sequence is correct?
A) Assessment, diagnosis, planning, implementation, evaluation
B) Diagnosis, assessment, planning, evaluation, implementation
C) Planning, assessment, diagnosis, implementation, evaluation
D) Assessment, planning, diagnosis, implementation, evaluation
Answer: A
Rationale: The nursing process follows the sequential steps of assessment,
diagnosis, planning, implementation, and evaluation.
2. A patient states, "My stomach hurts." The nurse documents this as
which type of data?
A) Objective
B) Subjective
C) Laboratory
D) Diagnostic
Answer: B
Rationale: Subjective data are reported by the patient and cannot be
directly observed or measured by the nurse.
,3. A nurse obtains a blood pressure of 88/54 mm Hg in an adult.
Which action is most appropriate first?
A) Document the finding only
B) Recheck the blood pressure and assess for signs of hypoperfusion
C) Administer a prescribed antihypertensive
D) Wait 1 hour and recheck
Answer: B
Rationale: A low blood pressure should be verified and correlated with
clinical signs such as dizziness, confusion, or poor capillary refill before
interventions.
4. Which action is the most important way to prevent healthcare-
associated infections?
A) Wearing gloves for all patient contact
B) Performing hand hygiene before and after patient contact
C) Changing linens daily
D) Administering prophylactic antibiotics
Answer: B
Rationale: Hand hygiene is the single most effective measure for
preventing healthcare-associated infections.
2
,5. A nurse is preparing to enter a patient’s room under contact
precautions. Which PPE should be applied first?
A) Gloves
B) Mask
C) Gown
D) Goggles
Answer: C
Rationale: When donning PPE, the gown is applied first, followed by mask
or respirator, goggles or face shield, and gloves last.
6. Which patient is at highest risk for falls?
A) A 30-year-old postoperative patient who is alert and oriented
B) An 82-year-old patient taking a sedative and a diuretic
C) A 45-year-old patient with a casted arm
D) A 19-year-old patient with gastroenteritis
Answer: B
Rationale: Advanced age, sedation, and diuretic use increase fall risk
through impaired cognition, dizziness, and urinary urgency.
7. A nurse applies restraints to a patient. Which action is required?
A) Check the patient every 4 hours
3
, B) Obtain a new order every 24 hours for violent behavior
C) Assess circulation, skin integrity, and need for continued restraint at
regular intervals
D) Tie the restraints to the side rails
Answer: C
Rationale: Restrained patients require frequent assessment of circulation,
skin, safety, and continued need, according to facility policy and law.
8. A stage 2 pressure injury is best described as:
A) Intact skin with nonblanchable redness
B) Partial-thickness loss of skin with exposed dermis
C) Full-thickness loss with visible bone, tendon, or muscle
D) Purple or maroon localized area of intact skin
Answer: B
Rationale: A stage 2 pressure injury involves partial-thickness skin loss
with exposed dermis and may present as a shallow open ulcer or blister.
9. Which is one of the “rights” of medication administration?
A) Right to refuse all medications
B) Right patient, right medication, right dose, right route, right time
C) Right to self-administer all medications
D) Right to choose the medication dose
4
Questions and Answers (2026–2027): Fundamentals of
Nursing, Patient Safety & Clinical Judgment
1. A nurse is using the nursing process to care for a newly admitted
patient. Which sequence is correct?
A) Assessment, diagnosis, planning, implementation, evaluation
B) Diagnosis, assessment, planning, evaluation, implementation
C) Planning, assessment, diagnosis, implementation, evaluation
D) Assessment, planning, diagnosis, implementation, evaluation
Answer: A
Rationale: The nursing process follows the sequential steps of assessment,
diagnosis, planning, implementation, and evaluation.
2. A patient states, "My stomach hurts." The nurse documents this as
which type of data?
A) Objective
B) Subjective
C) Laboratory
D) Diagnostic
Answer: B
Rationale: Subjective data are reported by the patient and cannot be
directly observed or measured by the nurse.
,3. A nurse obtains a blood pressure of 88/54 mm Hg in an adult.
Which action is most appropriate first?
A) Document the finding only
B) Recheck the blood pressure and assess for signs of hypoperfusion
C) Administer a prescribed antihypertensive
D) Wait 1 hour and recheck
Answer: B
Rationale: A low blood pressure should be verified and correlated with
clinical signs such as dizziness, confusion, or poor capillary refill before
interventions.
4. Which action is the most important way to prevent healthcare-
associated infections?
A) Wearing gloves for all patient contact
B) Performing hand hygiene before and after patient contact
C) Changing linens daily
D) Administering prophylactic antibiotics
Answer: B
Rationale: Hand hygiene is the single most effective measure for
preventing healthcare-associated infections.
2
,5. A nurse is preparing to enter a patient’s room under contact
precautions. Which PPE should be applied first?
A) Gloves
B) Mask
C) Gown
D) Goggles
Answer: C
Rationale: When donning PPE, the gown is applied first, followed by mask
or respirator, goggles or face shield, and gloves last.
6. Which patient is at highest risk for falls?
A) A 30-year-old postoperative patient who is alert and oriented
B) An 82-year-old patient taking a sedative and a diuretic
C) A 45-year-old patient with a casted arm
D) A 19-year-old patient with gastroenteritis
Answer: B
Rationale: Advanced age, sedation, and diuretic use increase fall risk
through impaired cognition, dizziness, and urinary urgency.
7. A nurse applies restraints to a patient. Which action is required?
A) Check the patient every 4 hours
3
, B) Obtain a new order every 24 hours for violent behavior
C) Assess circulation, skin integrity, and need for continued restraint at
regular intervals
D) Tie the restraints to the side rails
Answer: C
Rationale: Restrained patients require frequent assessment of circulation,
skin, safety, and continued need, according to facility policy and law.
8. A stage 2 pressure injury is best described as:
A) Intact skin with nonblanchable redness
B) Partial-thickness loss of skin with exposed dermis
C) Full-thickness loss with visible bone, tendon, or muscle
D) Purple or maroon localized area of intact skin
Answer: B
Rationale: A stage 2 pressure injury involves partial-thickness skin loss
with exposed dermis and may present as a shallow open ulcer or blister.
9. Which is one of the “rights” of medication administration?
A) Right to refuse all medications
B) Right patient, right medication, right dose, right route, right time
C) Right to self-administer all medications
D) Right to choose the medication dose
4
