NUR 101 FUNDAMENTALS OF NURSING
UPDATED EXAM GUIDE 2026 EDITION Q&A
1. A 72-year-old patient is admitted with confusion and a
suspected urinary tract infection. Which nursing action best
follows the nursing process during the initial care phase?
A. Administer prescribed antibiotics immediately.
B. Ask the patient’s family about home remedies used.
C. Perform a focused assessment of mental status and vital
signs.
D. Document the patient’s history from the transfer sheet
only.
Correct Answer: C
Explanation: Performing a focused assessment collects
current data to guide immediate nursing decisions; giving
antibiotics (A) should follow assessment and orders, family
history (B) is useful but secondary, and relying only on
transfer documents (D) risks missing current findings.
2. Which step of the nursing process involves setting
measurable goals with expected outcomes?
A. Assessment
B. Planning
C. Implementation
D. Evaluation
Correct Answer: B
Explanation: Planning establishes measurable, time-
framed goals and expected outcomes; assessment collects
data, implementation carries out interventions, and
evaluation compares outcomes to goals.
,3. When prioritizing care using the Maslow-based approach,
which problem should the nurse address first for a
postoperative patient with dyspnea, mild anxiety, and low
self-esteem?
A. Mild anxiety
B. Low self-esteem
C. Dyspnea
D. Pain at the incision site
Correct Answer: C
Explanation: Airway/breathing (dyspnea) is a
physiological priority and must be addressed first; anxiety
and self-esteem are lower priorities, and pain is important
but secondary to compromised breathing.
4. A patient has a new prescription for a medication that the
nurse does not recognize. What is the safest initial nursing
action?
A. Administer the medication and monitor the patient
closely.
B. Verify the medication name, dose, and indication with the
prescriber or pharmacist.
C. Ask the patient whether they have taken the medication
before.
D. Replace the medication with one that treats the same
condition.
Correct Answer: B
Explanation: Verification with prescriber/pharmacist
ensures correct medication and prevents errors;
administering without verification (A) is unsafe, patient
recall (C) is helpful but insufficient, and substituting
, medications (D) is outside nursing scope without prescriber
order.
5. Which is the best rationale for using hand hygiene before
and after patient contact?
A. It reduces the nurse’s skin flora permanently.
B. It eliminates the need for sterile technique during
procedures.
C. It prevents health-care associated infections by removing
transient microbes.
D. It is required for legal documentation.
Correct Answer: C
Explanation: Hand hygiene removes/transient microbes
and reduces healthcare-associated infections; it does not
permanently alter resident flora (A), replace sterile
technique (B), nor is it performed solely for documentation
(D).
6. A nurse prepares to provide a sterile dressing change. Which
action maintains a sterile field?
A. Reaching over the sterile field with bare hands.
B. Turning the back to the sterile field while removing gloves.
C. Opening sterile packages so the inner surface faces
upward and not touching it.
D. Allowing sterile forceps to rest on a moist surface.
Correct Answer: C
Explanation: Opening packages so the inner surface faces
upward preserves sterility; reaching over (A) and turning
, away (B) compromise sterility, and moisture (D) allows
microbial movement and contaminates instruments.
7. A patient with chronic heart failure has 2+ pitting edema in
both lower extremities. Which nursing intervention is most
appropriate to include in the plan of care?
A. Encourage bed rest and avoid leg elevation.
B. Monitor intake and output and daily weights.
C. Apply heat packs to lower legs to reduce swelling.
D. Restrict protein intake to decrease fluid accumulation.
Correct Answer: B
Explanation: Monitoring I&O and daily weights helps
detect fluid retention and guide treatment; leg elevation
(not avoidance) can help, heat is contraindicated (C), and
protein restriction (D) is not an appropriate edema
intervention.
8. When documenting a patient’s shift assessment, which entry
demonstrates best practice?
A. “Patient is better today.”
B. “BP 128/76 mmHg, apical HR 78 bpm, RR 16/min, temp
36.8°C; skin warm, intact; denies pain.”
C. “No changes since last note.”
D. “Administered meds as needed.”
Correct Answer: B
Explanation: Option B provides specific, objective,
measurable data; vague statements (A, C, D) fail to
communicate necessary clinical detail.
UPDATED EXAM GUIDE 2026 EDITION Q&A
1. A 72-year-old patient is admitted with confusion and a
suspected urinary tract infection. Which nursing action best
follows the nursing process during the initial care phase?
A. Administer prescribed antibiotics immediately.
B. Ask the patient’s family about home remedies used.
C. Perform a focused assessment of mental status and vital
signs.
D. Document the patient’s history from the transfer sheet
only.
Correct Answer: C
Explanation: Performing a focused assessment collects
current data to guide immediate nursing decisions; giving
antibiotics (A) should follow assessment and orders, family
history (B) is useful but secondary, and relying only on
transfer documents (D) risks missing current findings.
2. Which step of the nursing process involves setting
measurable goals with expected outcomes?
A. Assessment
B. Planning
C. Implementation
D. Evaluation
Correct Answer: B
Explanation: Planning establishes measurable, time-
framed goals and expected outcomes; assessment collects
data, implementation carries out interventions, and
evaluation compares outcomes to goals.
,3. When prioritizing care using the Maslow-based approach,
which problem should the nurse address first for a
postoperative patient with dyspnea, mild anxiety, and low
self-esteem?
A. Mild anxiety
B. Low self-esteem
C. Dyspnea
D. Pain at the incision site
Correct Answer: C
Explanation: Airway/breathing (dyspnea) is a
physiological priority and must be addressed first; anxiety
and self-esteem are lower priorities, and pain is important
but secondary to compromised breathing.
4. A patient has a new prescription for a medication that the
nurse does not recognize. What is the safest initial nursing
action?
A. Administer the medication and monitor the patient
closely.
B. Verify the medication name, dose, and indication with the
prescriber or pharmacist.
C. Ask the patient whether they have taken the medication
before.
D. Replace the medication with one that treats the same
condition.
Correct Answer: B
Explanation: Verification with prescriber/pharmacist
ensures correct medication and prevents errors;
administering without verification (A) is unsafe, patient
recall (C) is helpful but insufficient, and substituting
, medications (D) is outside nursing scope without prescriber
order.
5. Which is the best rationale for using hand hygiene before
and after patient contact?
A. It reduces the nurse’s skin flora permanently.
B. It eliminates the need for sterile technique during
procedures.
C. It prevents health-care associated infections by removing
transient microbes.
D. It is required for legal documentation.
Correct Answer: C
Explanation: Hand hygiene removes/transient microbes
and reduces healthcare-associated infections; it does not
permanently alter resident flora (A), replace sterile
technique (B), nor is it performed solely for documentation
(D).
6. A nurse prepares to provide a sterile dressing change. Which
action maintains a sterile field?
A. Reaching over the sterile field with bare hands.
B. Turning the back to the sterile field while removing gloves.
C. Opening sterile packages so the inner surface faces
upward and not touching it.
D. Allowing sterile forceps to rest on a moist surface.
Correct Answer: C
Explanation: Opening packages so the inner surface faces
upward preserves sterility; reaching over (A) and turning
, away (B) compromise sterility, and moisture (D) allows
microbial movement and contaminates instruments.
7. A patient with chronic heart failure has 2+ pitting edema in
both lower extremities. Which nursing intervention is most
appropriate to include in the plan of care?
A. Encourage bed rest and avoid leg elevation.
B. Monitor intake and output and daily weights.
C. Apply heat packs to lower legs to reduce swelling.
D. Restrict protein intake to decrease fluid accumulation.
Correct Answer: B
Explanation: Monitoring I&O and daily weights helps
detect fluid retention and guide treatment; leg elevation
(not avoidance) can help, heat is contraindicated (C), and
protein restriction (D) is not an appropriate edema
intervention.
8. When documenting a patient’s shift assessment, which entry
demonstrates best practice?
A. “Patient is better today.”
B. “BP 128/76 mmHg, apical HR 78 bpm, RR 16/min, temp
36.8°C; skin warm, intact; denies pain.”
C. “No changes since last note.”
D. “Administered meds as needed.”
Correct Answer: B
Explanation: Option B provides specific, objective,
measurable data; vague statements (A, C, D) fail to
communicate necessary clinical detail.
