NUR104 Exam 3 and Hesi - Foundations of Nursing
Questions and Answers
1. Infection Control
A nurse is caring for a patient with tuberculosis. Which type of precautions should the
nurse implement?
A. Contact precautions
B. Droplet precautions
C. Airborne precautions
D. Standard precautions
Answer: C. Airborne precautions
Rationale: TB is transmitted via airborne particles; N95 respirator and negative pressure
room are required.
2. Vital Signs
A patient’s blood pressure is 88/56 mmHg. The nurse should recognize this as:
A. Hypertension
B. Hypotension
C. Normal
D. Prehypertension
Answer: B. Hypotension
Rationale: Normal BP is ~120/80; values below 90/60 indicate hypotension.
3. Nursing Process
During the assessment phase of the nursing process, the nurse should:
A. Identify patient goals
B. Collect subjective and objective data
C. Implement nursing interventions
D. Evaluate patient outcomes
Answer: B. Collect subjective and objective data
Rationale: Assessment is the first step, focusing on gathering data to guide care.
4. Patient Safety
Which action best prevents patient falls in a hospital setting?
A. Keeping the bed in the highest position
B. Ensuring call light is within reach
C. Encouraging patients to walk without assistance
D. Removing non-slip socks
Answer: B. Ensuring call light is within reach
Rationale: Accessibility to help reduces risk of unassisted ambulation and falls.
,5. Pharmacology Basics
A nurse is administering digoxin. Which assessment is most important before giving the
medication?
A. Respiratory rate
B. Apical pulse
C. Blood glucose
D. Temperature
Answer: B. Apical pulse
Rationale: Digoxin can cause bradycardia; apical pulse must be >60 bpm before
administration.
6. Hand Hygiene
Which situation requires handwashing with soap and water instead of alcohol-based
sanitizer?
A. Before donning gloves
B. After removing gloves
C. After caring for a patient with C. difficile
D. Before entering a patient’s room
Answer: C. After caring for a patient with C. difficile
Rationale: Alcohol-based sanitizers are ineffective against C. difficile spores.
7. Oxygen Therapy
A patient with COPD is receiving oxygen. Which oxygen delivery device is most
appropriate?
A. Non-rebreather mask
B. Nasal cannula at 2 L/min
C. Venturi mask at 40% FiO₂
D. Simple mask at 10 L/min
Answer: B. Nasal cannula at 2 L/min
Rationale: COPD patients require low-flow oxygen to prevent CO₂ retention.
8. Legal/Ethical Issues
A nurse witnesses another nurse documenting care that was not provided. What is the
best action?
A. Ignore the situation
B. Report to the charge nurse
C. Confront the nurse privately
D. Document the incident in the patient’s chart
Answer: B. Report to the charge nurse
Rationale: Falsifying records is unethical and must be reported through proper
channels.
, 9. Nutrition
Which food is best for a patient with iron-deficiency anemia?
A. Milk
B. Spinach
C. Apples
D. Rice
Answer: B. Spinach
Rationale: Dark leafy greens are rich in iron.
10. Communication
A patient says, “I feel so hopeless.” The nurse’s best response is:
A. “Don’t worry, everything will be fine.”
B. “Why do you feel that way?”
C. “Tell me more about what makes you feel hopeless.”
D. “You shouldn’t feel that way.”
Answer: C. “Tell me more about what makes you feel hopeless.”
Rationale: Open-ended therapeutic communication encourages expression.
11. Vital Signs
Which finding requires immediate intervention?
A. Respiratory rate 18/min
B. Temperature 37.2°C
C. Blood pressure 180/110 mmHg
D. Pulse 72 bpm
Answer: C. Blood pressure 180/110 mmHg
Rationale: Hypertensive crisis requires urgent attention.
12. Safety
Which intervention prevents aspiration in a patient with dysphagia?
A. Offering thin liquids
B. Positioning in high Fowler’s during meals
C. Encouraging rapid eating
D. Providing a straw
Answer: B. Positioning in high Fowler’s during meals
Rationale: Upright positioning reduces aspiration risk.
13. Medication Administration
The nurse is giving an IM injection. Which site is safest for adults?
A. Deltoid
B. Ventrogluteal
C. Dorsogluteal
Questions and Answers
1. Infection Control
A nurse is caring for a patient with tuberculosis. Which type of precautions should the
nurse implement?
A. Contact precautions
B. Droplet precautions
C. Airborne precautions
D. Standard precautions
Answer: C. Airborne precautions
Rationale: TB is transmitted via airborne particles; N95 respirator and negative pressure
room are required.
2. Vital Signs
A patient’s blood pressure is 88/56 mmHg. The nurse should recognize this as:
A. Hypertension
B. Hypotension
C. Normal
D. Prehypertension
Answer: B. Hypotension
Rationale: Normal BP is ~120/80; values below 90/60 indicate hypotension.
3. Nursing Process
During the assessment phase of the nursing process, the nurse should:
A. Identify patient goals
B. Collect subjective and objective data
C. Implement nursing interventions
D. Evaluate patient outcomes
Answer: B. Collect subjective and objective data
Rationale: Assessment is the first step, focusing on gathering data to guide care.
4. Patient Safety
Which action best prevents patient falls in a hospital setting?
A. Keeping the bed in the highest position
B. Ensuring call light is within reach
C. Encouraging patients to walk without assistance
D. Removing non-slip socks
Answer: B. Ensuring call light is within reach
Rationale: Accessibility to help reduces risk of unassisted ambulation and falls.
,5. Pharmacology Basics
A nurse is administering digoxin. Which assessment is most important before giving the
medication?
A. Respiratory rate
B. Apical pulse
C. Blood glucose
D. Temperature
Answer: B. Apical pulse
Rationale: Digoxin can cause bradycardia; apical pulse must be >60 bpm before
administration.
6. Hand Hygiene
Which situation requires handwashing with soap and water instead of alcohol-based
sanitizer?
A. Before donning gloves
B. After removing gloves
C. After caring for a patient with C. difficile
D. Before entering a patient’s room
Answer: C. After caring for a patient with C. difficile
Rationale: Alcohol-based sanitizers are ineffective against C. difficile spores.
7. Oxygen Therapy
A patient with COPD is receiving oxygen. Which oxygen delivery device is most
appropriate?
A. Non-rebreather mask
B. Nasal cannula at 2 L/min
C. Venturi mask at 40% FiO₂
D. Simple mask at 10 L/min
Answer: B. Nasal cannula at 2 L/min
Rationale: COPD patients require low-flow oxygen to prevent CO₂ retention.
8. Legal/Ethical Issues
A nurse witnesses another nurse documenting care that was not provided. What is the
best action?
A. Ignore the situation
B. Report to the charge nurse
C. Confront the nurse privately
D. Document the incident in the patient’s chart
Answer: B. Report to the charge nurse
Rationale: Falsifying records is unethical and must be reported through proper
channels.
, 9. Nutrition
Which food is best for a patient with iron-deficiency anemia?
A. Milk
B. Spinach
C. Apples
D. Rice
Answer: B. Spinach
Rationale: Dark leafy greens are rich in iron.
10. Communication
A patient says, “I feel so hopeless.” The nurse’s best response is:
A. “Don’t worry, everything will be fine.”
B. “Why do you feel that way?”
C. “Tell me more about what makes you feel hopeless.”
D. “You shouldn’t feel that way.”
Answer: C. “Tell me more about what makes you feel hopeless.”
Rationale: Open-ended therapeutic communication encourages expression.
11. Vital Signs
Which finding requires immediate intervention?
A. Respiratory rate 18/min
B. Temperature 37.2°C
C. Blood pressure 180/110 mmHg
D. Pulse 72 bpm
Answer: C. Blood pressure 180/110 mmHg
Rationale: Hypertensive crisis requires urgent attention.
12. Safety
Which intervention prevents aspiration in a patient with dysphagia?
A. Offering thin liquids
B. Positioning in high Fowler’s during meals
C. Encouraging rapid eating
D. Providing a straw
Answer: B. Positioning in high Fowler’s during meals
Rationale: Upright positioning reduces aspiration risk.
13. Medication Administration
The nurse is giving an IM injection. Which site is safest for adults?
A. Deltoid
B. Ventrogluteal
C. Dorsogluteal
