FOUNDATION OF NURSING QUESTIONS AND ANSWERS
Which action would the nurse perform first after discovering an electrical fire in a patient’s room?
a. Activate the fire alarm
b. Confine the fire by closing all doors and windows
c. Remove all patients in immediate danger
d. Extinguish the fire using the nearest fire extinguisher
Answer: c. Remove all patients in immediate danger
Rationale: The RACE acronym (Rescue, Alarm, Confine, Extinguish) guides fire safety. The first priority is
to rescue patients in immediate danger before sounding the alarm or attempting to contain the fire.
DIF: Apply
Q2.
A parent calls the pediatrician’s office frantic about the 2-year-old son who drank a bottle of cleaner.
Which instruction is most important for the nurse to give the parent?
a. Give the child milk
b. Give the child ipecac syrup
c. Call the poison control center
d. Take the child to the emergency department
Answer: c. Call the poison control center
Rationale: Poison control centers provide the most accurate and immediate instructions for ingestion
emergencies. Ipecac is no longer recommended and home remedies like milk can worsen injury.
DIF: Analyze
Q3.
Which intervention is no longer recommended for routine home treatment of poisoning cases?
a. Administration of ipecac syrup
b. Positioning the victim with the head turned to the side
c. Assessment for signs of ingestion of a harmful substance
d. Identification of the type and amount of substance ingested
,Answer: a. Administration of ipecac syrup
Rationale: Ipecac syrup is no longer recommended because it can cause aspiration, delays definitive
care, and has no proven benefit in poisoning cases. Assessment and identification of the ingested
substance remain critical.
DIF: Understand
Q4.
Arrange the steps in the proper order that the nurse would follow during a fire in a hospital:
1. Rescue and remove all patients who are in immediate danger
2. Confine the fire by closing doors, windows, and turning off oxygen/electrical equipment
3. Activate the alarm before attempting to extinguish even a minor fire
4. Extinguish the fire with an appropriate extinguisher
Correct Order:
• Rescue patients in immediate danger
• Activate the alarm
• Confine the fire
• Extinguish the fire
Answer: 1 → 3 → 2 → 4
Rationale: The RACE acronym ensures safety: Rescue, Alarm, Confine, Extinguish. Rescuing patients
always comes before activating alarms or fire suppression.
DIF: Apply
The nurse instructs the patient to color-code the hot water faucets and dials. To which age group would
this patient most likely belong?
a. Young adult
b. Older adult
c. Adolescent
d. Preschooler
Answer: b. Older adult
Rationale: Older adults may experience visual or cognitive changes that increase their risk of scalding or
injury. Color-coding is a safety intervention to enhance recognition and prevent accidents.
DIF: Apply
,Q2.
A nurse is performing a timed "get up and go" (TGUG) test for a patient. Place the steps in the correct
sequence:
1. Give verbal instructions to stand up and walk 10 feet as quickly and safely as possible.
2. Have the patient rise from a straight-backed chair without using arms for support.
3. Begin counting.
4. Look for unsteadiness in the patient’s gait.
5. Have the patient return to the chair and sit down without using arms for support.
6. Check time elapsed.
Correct Order: 2 → 1 → 3 → 4 → 5 → 6
Rationale: The TGUG test evaluates mobility, balance, and fall risk. The sequence ensures
standardization: start from sitting, ambulate safely, return to chair, and record time.
DIF: Apply
Q3.
In a hospital, the use of a restraint is ordered and renewed every 2 hours. Which is the likely age of the
patient?
a. 8 years
b. 15 years
c. 21 years
d. 35 years
Answer: b. 15 years
Rationale: According to The Joint Commission and CMS guidelines, restraint renewal frequency depends
on age:
• ≤ 9 years: every 1 hour
• 9–17 years: every 2 hours
• ≥ 18 years: every 4 hours
Thus, a 15-year-old patient requires restraint orders renewed every 2 hours.
DIF: Understand
Q4. Disaster Response
, The emergency department nurse learns that a tornado just hit the east side of town. Which action
would the nurse take first?
a. Prepare for an influx of patients
b. Contact the American Red Cross
c. Determine how to restore essential services
d. Evacuate patients per the disaster plan
Answer: a. Prepare for an influx of patients
Rationale: In a mass casualty or natural disaster, the priority in the hospital setting is to prepare for
triage and treatment of victims. Outside coordination (Red Cross, services, evacuation) follows
immediate readiness.
DIF: Apply
Q5.
Which complications would the nurse monitor for when using physical restraints? (Select all that apply.)
a. Constipation
b. Incontinence
c. Pressure injury
d. Increased appetite
e. Improved alertness
Answer: a, b, c
Rationale: Physical restraints can lead to immobility complications: constipation (↓ mobility),
incontinence (restricted toileting), and pressure injuries (impaired circulation & immobility). They do not
improve appetite or alertness.
DIF: Apply
QUESTION: Which action would the nurse perform during a fire? Select all that apply. One, some, or all
responses may be correct.
Use a fire extinguisher.
Open all doors and windows.
Turn off sources of oxygen.
Close all doors and windows.
Pour water everywhere. - ANSWER-Use a fire extinguisher.
Turn off sources of oxygen.
Close all doors and windows.
Which action would the nurse perform first after discovering an electrical fire in a patient’s room?
a. Activate the fire alarm
b. Confine the fire by closing all doors and windows
c. Remove all patients in immediate danger
d. Extinguish the fire using the nearest fire extinguisher
Answer: c. Remove all patients in immediate danger
Rationale: The RACE acronym (Rescue, Alarm, Confine, Extinguish) guides fire safety. The first priority is
to rescue patients in immediate danger before sounding the alarm or attempting to contain the fire.
DIF: Apply
Q2.
A parent calls the pediatrician’s office frantic about the 2-year-old son who drank a bottle of cleaner.
Which instruction is most important for the nurse to give the parent?
a. Give the child milk
b. Give the child ipecac syrup
c. Call the poison control center
d. Take the child to the emergency department
Answer: c. Call the poison control center
Rationale: Poison control centers provide the most accurate and immediate instructions for ingestion
emergencies. Ipecac is no longer recommended and home remedies like milk can worsen injury.
DIF: Analyze
Q3.
Which intervention is no longer recommended for routine home treatment of poisoning cases?
a. Administration of ipecac syrup
b. Positioning the victim with the head turned to the side
c. Assessment for signs of ingestion of a harmful substance
d. Identification of the type and amount of substance ingested
,Answer: a. Administration of ipecac syrup
Rationale: Ipecac syrup is no longer recommended because it can cause aspiration, delays definitive
care, and has no proven benefit in poisoning cases. Assessment and identification of the ingested
substance remain critical.
DIF: Understand
Q4.
Arrange the steps in the proper order that the nurse would follow during a fire in a hospital:
1. Rescue and remove all patients who are in immediate danger
2. Confine the fire by closing doors, windows, and turning off oxygen/electrical equipment
3. Activate the alarm before attempting to extinguish even a minor fire
4. Extinguish the fire with an appropriate extinguisher
Correct Order:
• Rescue patients in immediate danger
• Activate the alarm
• Confine the fire
• Extinguish the fire
Answer: 1 → 3 → 2 → 4
Rationale: The RACE acronym ensures safety: Rescue, Alarm, Confine, Extinguish. Rescuing patients
always comes before activating alarms or fire suppression.
DIF: Apply
The nurse instructs the patient to color-code the hot water faucets and dials. To which age group would
this patient most likely belong?
a. Young adult
b. Older adult
c. Adolescent
d. Preschooler
Answer: b. Older adult
Rationale: Older adults may experience visual or cognitive changes that increase their risk of scalding or
injury. Color-coding is a safety intervention to enhance recognition and prevent accidents.
DIF: Apply
,Q2.
A nurse is performing a timed "get up and go" (TGUG) test for a patient. Place the steps in the correct
sequence:
1. Give verbal instructions to stand up and walk 10 feet as quickly and safely as possible.
2. Have the patient rise from a straight-backed chair without using arms for support.
3. Begin counting.
4. Look for unsteadiness in the patient’s gait.
5. Have the patient return to the chair and sit down without using arms for support.
6. Check time elapsed.
Correct Order: 2 → 1 → 3 → 4 → 5 → 6
Rationale: The TGUG test evaluates mobility, balance, and fall risk. The sequence ensures
standardization: start from sitting, ambulate safely, return to chair, and record time.
DIF: Apply
Q3.
In a hospital, the use of a restraint is ordered and renewed every 2 hours. Which is the likely age of the
patient?
a. 8 years
b. 15 years
c. 21 years
d. 35 years
Answer: b. 15 years
Rationale: According to The Joint Commission and CMS guidelines, restraint renewal frequency depends
on age:
• ≤ 9 years: every 1 hour
• 9–17 years: every 2 hours
• ≥ 18 years: every 4 hours
Thus, a 15-year-old patient requires restraint orders renewed every 2 hours.
DIF: Understand
Q4. Disaster Response
, The emergency department nurse learns that a tornado just hit the east side of town. Which action
would the nurse take first?
a. Prepare for an influx of patients
b. Contact the American Red Cross
c. Determine how to restore essential services
d. Evacuate patients per the disaster plan
Answer: a. Prepare for an influx of patients
Rationale: In a mass casualty or natural disaster, the priority in the hospital setting is to prepare for
triage and treatment of victims. Outside coordination (Red Cross, services, evacuation) follows
immediate readiness.
DIF: Apply
Q5.
Which complications would the nurse monitor for when using physical restraints? (Select all that apply.)
a. Constipation
b. Incontinence
c. Pressure injury
d. Increased appetite
e. Improved alertness
Answer: a, b, c
Rationale: Physical restraints can lead to immobility complications: constipation (↓ mobility),
incontinence (restricted toileting), and pressure injuries (impaired circulation & immobility). They do not
improve appetite or alertness.
DIF: Apply
QUESTION: Which action would the nurse perform during a fire? Select all that apply. One, some, or all
responses may be correct.
Use a fire extinguisher.
Open all doors and windows.
Turn off sources of oxygen.
Close all doors and windows.
Pour water everywhere. - ANSWER-Use a fire extinguisher.
Turn off sources of oxygen.
Close all doors and windows.
