NUR 104 HESI – Foundations of Nursing Review V2 |
Fortis Actual Exam 2026/2027 | with Detailed Rationales |
Graded A+ Pass Guaranteed
Q1: A nurse is caring for a client who has been placed on contact precautions for
Clostridioides difficile infection. The nurse is preparing to administer oral medications.
Which action by the nurse demonstrates correct application of standard and
transmission-based precautions?
A. Donning a gown and gloves upon entering the room and removing them at the
doorway exit
B. Performing hand hygiene with an alcohol-based hand rub before leaving the client
room
C. Applying a gown and gloves before medication administration and performing hand
hygiene with soap and water after removing PPE at the doorway [CORRECT]
D. Wearing the same gloves for multiple client interactions to conserve supplies
Correct Answer: C
Rationale: Correct because C. difficile spores are not eliminated by alcohol-based hand
rubs; soap and water handwashing is required after removing PPE, and gown/gloves are
donned before client contact per contact precautions protocol.
Q2: Which intervention is the priority when a nurse discovers an elderly client attempting
to ambulate to the bathroom without assistance in a dimly lit hospital room?
A. Placing the call light within the client's reach and returning to the nursing station
B. Assisting the client back to bed and ensuring night lights are functional before
allowing further ambulation [CORRECT]
C. Documenting the incident in the medical record and notifying the physician in the
morning
D. Administering a sedative to prevent future episodes of unassisted ambulation
Correct Answer: B
Rationale: Correct because priority is immediate fall prevention through direct
assistance and environmental safety modification; night lights reduce fall risk in elderly
clients with altered depth perception.
,Q3: A nurse is preparing to insert a Foley catheter for a client. Which action by the nurse
maintains medical asepsis during the procedure?
A. Wearing sterile gloves to open the catheter kit outer packaging
B. Placing the sterile drape below the client's perineal area before donning sterile gloves
C. Cleaning the perineal area with the dominant hand while holding the sterile catheter
with the non-dominant hand
D. Performing hand hygiene before and after the procedure and using a sterile dominant
hand once sterile gloves are applied [CORRECT]
Correct Answer: D
Rationale: Correct because medical asepsis requires hand hygiene to reduce
microorganism transfer; sterile technique is maintained by using only sterile-gloved
hands for sterile items.
Q4: Which statement by a newly licensed nurse regarding standard precautions
indicates accurate recall of CDC guidelines?
A. "Standard precautions apply only to clients with known bloodborne infections."
B. "I should wear a mask when caring for any client who has a cough."
C. "Standard precautions apply to all clients and all body fluids except sweat."
[CORRECT]
D. "Gloves are optional when handling urine specimens from clients without infection."
Correct Answer: C
Rationale: Correct because standard precautions are used for all clients regardless of
infection status, and all body fluids except sweat are treated as potentially infectious
per CDC guidelines.
Q5: A nurse is reviewing the care plan for a client on droplet precautions for influenza.
The nurse recognizes that which PPE is required before entering the room?
A. N95 respirator, gown, and face shield
B. Surgical mask, gown, and gloves [CORRECT]
C. Gloves and goggles only
D. Gown and gloves only
Correct Answer: B
Rationale: Correct because droplet precautions require a surgical mask to protect
against respiratory droplets within 3 to 6 feet, plus gown and gloves for contact with
client or environment.
, Q6: The nurse manager is evaluating staff compliance with National Patient Safety
Goals. Which observation requires immediate intervention to prevent client harm?
A. A nurse verifying two client identifiers before medication administration
B. A nurse labeling a medication syringe at the client's bedside immediately after
withdrawal
C. A nurse administering a high-alert medication without an independent double check
[CORRECT]
D. A nurse raising the side rails before leaving a client on bedrest
Correct Answer: C
Rationale: Correct because high-alert medications require an independent double-check
to prevent medication errors; this is a critical National Patient Safety Goal requirement.
Q7: A nurse is caring for a client with a history of seizures. Which environmental
modification best reduces the risk of injury during a seizure episode?
A. Placing a padded tongue blade at the bedside for immediate use
B. Keeping the bed in the lowest position with side rails padded and up [CORRECT]
C. Restraining the client's extremities to prevent violent movements
D. Dimming all room lights to reduce neurological stimulation
Correct Answer: B
Rationale: Correct because lowering the bed reduces fall distance, and padded side rails
prevent injury; restraints and tongue blades are contraindicated during seizure activity.
Q8: A nurse is delegating the task of ambulating a client to an unlicensed assistive
personnel (UAP). Which instruction by the nurse demonstrates appropriate supervision
and safety prioritization?
A. "Walk the client to the end of the hall and back when you have time."
B. "Use a gait belt and keep the client on the weaker side during ambulation; report any
dizziness immediately." [CORRECT]
C. "Let the client hold onto the wall rails while you walk behind."
D. "If the client becomes tired, leave them sitting in the chair and return later."
Correct Answer: B
Rationale: Correct because a gait belt ensures safe transfer and ambulation; positioning
the client on the weaker side allows the nurse to support the unstable side and prevent
falls.
Q9: A nurse is caring for a client with a latex allergy. Which action by the nurse
demonstrates analysis of the implications for safe care delivery?
Fortis Actual Exam 2026/2027 | with Detailed Rationales |
Graded A+ Pass Guaranteed
Q1: A nurse is caring for a client who has been placed on contact precautions for
Clostridioides difficile infection. The nurse is preparing to administer oral medications.
Which action by the nurse demonstrates correct application of standard and
transmission-based precautions?
A. Donning a gown and gloves upon entering the room and removing them at the
doorway exit
B. Performing hand hygiene with an alcohol-based hand rub before leaving the client
room
C. Applying a gown and gloves before medication administration and performing hand
hygiene with soap and water after removing PPE at the doorway [CORRECT]
D. Wearing the same gloves for multiple client interactions to conserve supplies
Correct Answer: C
Rationale: Correct because C. difficile spores are not eliminated by alcohol-based hand
rubs; soap and water handwashing is required after removing PPE, and gown/gloves are
donned before client contact per contact precautions protocol.
Q2: Which intervention is the priority when a nurse discovers an elderly client attempting
to ambulate to the bathroom without assistance in a dimly lit hospital room?
A. Placing the call light within the client's reach and returning to the nursing station
B. Assisting the client back to bed and ensuring night lights are functional before
allowing further ambulation [CORRECT]
C. Documenting the incident in the medical record and notifying the physician in the
morning
D. Administering a sedative to prevent future episodes of unassisted ambulation
Correct Answer: B
Rationale: Correct because priority is immediate fall prevention through direct
assistance and environmental safety modification; night lights reduce fall risk in elderly
clients with altered depth perception.
,Q3: A nurse is preparing to insert a Foley catheter for a client. Which action by the nurse
maintains medical asepsis during the procedure?
A. Wearing sterile gloves to open the catheter kit outer packaging
B. Placing the sterile drape below the client's perineal area before donning sterile gloves
C. Cleaning the perineal area with the dominant hand while holding the sterile catheter
with the non-dominant hand
D. Performing hand hygiene before and after the procedure and using a sterile dominant
hand once sterile gloves are applied [CORRECT]
Correct Answer: D
Rationale: Correct because medical asepsis requires hand hygiene to reduce
microorganism transfer; sterile technique is maintained by using only sterile-gloved
hands for sterile items.
Q4: Which statement by a newly licensed nurse regarding standard precautions
indicates accurate recall of CDC guidelines?
A. "Standard precautions apply only to clients with known bloodborne infections."
B. "I should wear a mask when caring for any client who has a cough."
C. "Standard precautions apply to all clients and all body fluids except sweat."
[CORRECT]
D. "Gloves are optional when handling urine specimens from clients without infection."
Correct Answer: C
Rationale: Correct because standard precautions are used for all clients regardless of
infection status, and all body fluids except sweat are treated as potentially infectious
per CDC guidelines.
Q5: A nurse is reviewing the care plan for a client on droplet precautions for influenza.
The nurse recognizes that which PPE is required before entering the room?
A. N95 respirator, gown, and face shield
B. Surgical mask, gown, and gloves [CORRECT]
C. Gloves and goggles only
D. Gown and gloves only
Correct Answer: B
Rationale: Correct because droplet precautions require a surgical mask to protect
against respiratory droplets within 3 to 6 feet, plus gown and gloves for contact with
client or environment.
, Q6: The nurse manager is evaluating staff compliance with National Patient Safety
Goals. Which observation requires immediate intervention to prevent client harm?
A. A nurse verifying two client identifiers before medication administration
B. A nurse labeling a medication syringe at the client's bedside immediately after
withdrawal
C. A nurse administering a high-alert medication without an independent double check
[CORRECT]
D. A nurse raising the side rails before leaving a client on bedrest
Correct Answer: C
Rationale: Correct because high-alert medications require an independent double-check
to prevent medication errors; this is a critical National Patient Safety Goal requirement.
Q7: A nurse is caring for a client with a history of seizures. Which environmental
modification best reduces the risk of injury during a seizure episode?
A. Placing a padded tongue blade at the bedside for immediate use
B. Keeping the bed in the lowest position with side rails padded and up [CORRECT]
C. Restraining the client's extremities to prevent violent movements
D. Dimming all room lights to reduce neurological stimulation
Correct Answer: B
Rationale: Correct because lowering the bed reduces fall distance, and padded side rails
prevent injury; restraints and tongue blades are contraindicated during seizure activity.
Q8: A nurse is delegating the task of ambulating a client to an unlicensed assistive
personnel (UAP). Which instruction by the nurse demonstrates appropriate supervision
and safety prioritization?
A. "Walk the client to the end of the hall and back when you have time."
B. "Use a gait belt and keep the client on the weaker side during ambulation; report any
dizziness immediately." [CORRECT]
C. "Let the client hold onto the wall rails while you walk behind."
D. "If the client becomes tired, leave them sitting in the chair and return later."
Correct Answer: B
Rationale: Correct because a gait belt ensures safe transfer and ambulation; positioning
the client on the weaker side allows the nurse to support the unstable side and prevent
falls.
Q9: A nurse is caring for a client with a latex allergy. Which action by the nurse
demonstrates analysis of the implications for safe care delivery?
