NURS 100 ASSESSMENT 2 WCU
2026/2027 WITH 120 QUESTIONS
AND DETAILED CORRECT
ANSWERS | ALREADY GRADED
A+ | GUARANTEED SUCCESS |
NURS 100 PRACTICE EXAM116
Which restraint-free alternative is best for the nurse to use for an 84-year-old
patient after hip replacement who has confusion and incontinence?
a. A room near the nurses' station and decreased sensory stimuli
b. A pressure sensor alarm and a room near the nurses' station
c. Side rails up and decreased sensory stimuli
d. A 24-hour sitter and the patient's favorite TV program
b. A pressure sensor alarm and a room near the nurses' station
,Patients with confusion may not remember to call for assistance before getting up,
especially if they have had an episode of incontinence. A pressure sensor alarm
that can be used in a bed or chair should be implemented as a priority intervention
along with moving the patient to a room near the nurses station, where the patient
be more closely monitored. Although decreasing sensory stimuli may help patient
with confusion, it is not a priority intervention. A 24-hour sitter is costly and used
only after all other restraint-free alternative are exhausted.
Which activity would be most appropriate for the registered nurse (RN) to delegate
to unlicensed assistive personnel (UAP)?
a. Assessing the patient for fall risk and complications of restraint use
b. Evaluating the patient's ability to perform activities of daily living (ADLs)
c. Assisting with or performing the patient's ADLs
d. Teaching the patient use of assistive devices
c. Assisting with or performing the patient's ADLs
UAP such as patient care technicians and nursing assistants, provide hands-on care
for patients who may require complete care or total assistance with their activities
of daily living (ADL's). However, RN's are responsible for supervising and guiding
the UAP so direct care is provided in a safe manner. RNs are responsible for
performing patient assessments, and the OT evaluates the patients ability to
perform ADL's. A physical therapist evaluates mobility and initially teaches the
patient to use an assistive device. If use assistive device needs reinforcement, the
RN does the teaching.
Which patient appears to be at greatest risk for falls?
a. 66 year old post-op, oriented x 3, taking opioid pain meds
,b. 71 year old with pneumonia, oriented x 2, on oxygen and IV
c. 76 year old with acute confusion, knows name, incontinent, has an IV
d. 80 year old post-op, oriented x 3, has a cast, opioid pain medications
c. 76 year old with acute confusion, knows name, incontinent, has an IV
The 76 year old with acute confusion and incontinence with a continuous IV
appears to be at greatest risk for falls. While the other patients also have sources of
tethering (e.g., oxygen and IV tubing) and opioid pain medications, the acute
confusion and incontinence along with the IV tethering produce the most
significant risk.
An ambulatory diabetic patient states that she is unable to reach her feet to clip her
toenails. The patient's toenails are long and thick. What is the next step the nurse
should take?
a. Soak the patient's feet, and trim her toenails using clippers.
b. Delegate foot care of this patient to the unlicensed assistive personnel (UAP).
c. Assess the patient's self-care abilities.
d. Ask the primary care provider (PCP) for a referral to a podiatrist.
d. Ask the primary care provider (PCP) for a referral to a podiatrist.
Referral to Podiatrist is appropriate when the diabetic patient is unable to care for
her feet. Soaking is contraindicated for patients with diabetes due to the risk for
skin breakdown. Clippers are not appropriate if nails are thick. Delegating of nail
care to the UAP is inappropriate for patients with peripheral neuropathy. The nurse
already knows the patient's self-care status abilities in regard to her feet.
, Which action by a female patient lets the nurse know the patient has understood
perineal care teaching?
a. The patient washes her perineum with a circular motion beginning at the urinary
meatus.
b. The patient washes her perineum from front to back using a clean washcloth.
c. The patient washes her perineum from back to front with long, firm strokes.
d. The patient washes her perineum lightly to prevent tissue damage.
b. The patient washes her perineum from front to back using a clean
washcloth.
The female perineum is always washed from front to back, washing the area near
the urinary meatus and working back to the anus to avoid introducing organisms
into the urinary tract. Circular motion is used for male patient, washing around the
urinary meatus first then washing down the shaft of the penis.
Objective data can be gathered from the patient during which aspects of the
physical assessment process? (Select all that apply.)
a. Patient interview
b. Health history
c. General survey
d. Physical examination
e. Laboratory testing
2026/2027 WITH 120 QUESTIONS
AND DETAILED CORRECT
ANSWERS | ALREADY GRADED
A+ | GUARANTEED SUCCESS |
NURS 100 PRACTICE EXAM116
Which restraint-free alternative is best for the nurse to use for an 84-year-old
patient after hip replacement who has confusion and incontinence?
a. A room near the nurses' station and decreased sensory stimuli
b. A pressure sensor alarm and a room near the nurses' station
c. Side rails up and decreased sensory stimuli
d. A 24-hour sitter and the patient's favorite TV program
b. A pressure sensor alarm and a room near the nurses' station
,Patients with confusion may not remember to call for assistance before getting up,
especially if they have had an episode of incontinence. A pressure sensor alarm
that can be used in a bed or chair should be implemented as a priority intervention
along with moving the patient to a room near the nurses station, where the patient
be more closely monitored. Although decreasing sensory stimuli may help patient
with confusion, it is not a priority intervention. A 24-hour sitter is costly and used
only after all other restraint-free alternative are exhausted.
Which activity would be most appropriate for the registered nurse (RN) to delegate
to unlicensed assistive personnel (UAP)?
a. Assessing the patient for fall risk and complications of restraint use
b. Evaluating the patient's ability to perform activities of daily living (ADLs)
c. Assisting with or performing the patient's ADLs
d. Teaching the patient use of assistive devices
c. Assisting with or performing the patient's ADLs
UAP such as patient care technicians and nursing assistants, provide hands-on care
for patients who may require complete care or total assistance with their activities
of daily living (ADL's). However, RN's are responsible for supervising and guiding
the UAP so direct care is provided in a safe manner. RNs are responsible for
performing patient assessments, and the OT evaluates the patients ability to
perform ADL's. A physical therapist evaluates mobility and initially teaches the
patient to use an assistive device. If use assistive device needs reinforcement, the
RN does the teaching.
Which patient appears to be at greatest risk for falls?
a. 66 year old post-op, oriented x 3, taking opioid pain meds
,b. 71 year old with pneumonia, oriented x 2, on oxygen and IV
c. 76 year old with acute confusion, knows name, incontinent, has an IV
d. 80 year old post-op, oriented x 3, has a cast, opioid pain medications
c. 76 year old with acute confusion, knows name, incontinent, has an IV
The 76 year old with acute confusion and incontinence with a continuous IV
appears to be at greatest risk for falls. While the other patients also have sources of
tethering (e.g., oxygen and IV tubing) and opioid pain medications, the acute
confusion and incontinence along with the IV tethering produce the most
significant risk.
An ambulatory diabetic patient states that she is unable to reach her feet to clip her
toenails. The patient's toenails are long and thick. What is the next step the nurse
should take?
a. Soak the patient's feet, and trim her toenails using clippers.
b. Delegate foot care of this patient to the unlicensed assistive personnel (UAP).
c. Assess the patient's self-care abilities.
d. Ask the primary care provider (PCP) for a referral to a podiatrist.
d. Ask the primary care provider (PCP) for a referral to a podiatrist.
Referral to Podiatrist is appropriate when the diabetic patient is unable to care for
her feet. Soaking is contraindicated for patients with diabetes due to the risk for
skin breakdown. Clippers are not appropriate if nails are thick. Delegating of nail
care to the UAP is inappropriate for patients with peripheral neuropathy. The nurse
already knows the patient's self-care status abilities in regard to her feet.
, Which action by a female patient lets the nurse know the patient has understood
perineal care teaching?
a. The patient washes her perineum with a circular motion beginning at the urinary
meatus.
b. The patient washes her perineum from front to back using a clean washcloth.
c. The patient washes her perineum from back to front with long, firm strokes.
d. The patient washes her perineum lightly to prevent tissue damage.
b. The patient washes her perineum from front to back using a clean
washcloth.
The female perineum is always washed from front to back, washing the area near
the urinary meatus and working back to the anus to avoid introducing organisms
into the urinary tract. Circular motion is used for male patient, washing around the
urinary meatus first then washing down the shaft of the penis.
Objective data can be gathered from the patient during which aspects of the
physical assessment process? (Select all that apply.)
a. Patient interview
b. Health history
c. General survey
d. Physical examination
e. Laboratory testing
