JOYCE UNIVERSITY OF NURSING
NUR 125: NURSING FUNDAMENTALS
FINAL EXAMINATION
SECTION I: SAFETY, INFECTION CONTROL, & ETHICAL/LEGAL
ISSUES (Questions 1-20)
1. A nurse is caring for a client on contact precautions for Clostridioides
difficile. Which of the following actions by the nurse demonstrates proper
understanding of infection control?
• A. Using an alcohol-based hand rub before entering the room.
• B. Wearing a surgical mask during all client interactions.
• C. Performing hand hygiene with soap and water after removing gloves.
• D. Removing the gown and mask before leaving the client’s room.
• Rationale: C. difficile spores are not killed by alcohol-based hand rubs.
Soap and water are required for mechanical removal of the spores. Gloves
are always worn, but a mask is not required for contact precautions unless
there is a risk of splash.
2. A client is placed in restraints after becoming violent. Which of the
following actions is most important for the nurse to document?
• A. The type of restraint used.
• B. The family’s opinion on the restraint use.
• C. The specific behaviors that necessitated the restraint.
• D. The cost of the restraint device.
• Rationale: Restraints are a last resort. The nurse must document the
specific, objective, and imminent risk of harm to self or others that justified
the use of restraints to meet legal and ethical standards.
,3. A nurse is preparing to administer a medication to a client. The client states,
“I’ve never seen that pill before.” What is the nurse’s priority action?
• A. Stop the administration and re-verify the medication order and the
client’s identity.
• B. Explain the medication’s purpose to the client and administer it.
• C. Tell the client it is the same medication as always.
• D. Ask the client if they are refusing the medication.
• Rationale: The client’s statement is a challenge to the “Right Medication”
and “Right Client” of the Six Rights of Medication Administration. The
nurse must stop and verify the order, the client’s identity using two
identifiers, and the medication label.
4. A nurse is applying a wrist restraint for a client. How many fingers should
the nurse be able to fit between the restraint and the client’s wrist?
• A. One
• B. Two
• C. Three
• D. Four
• Rationale: The standard of care is to allow one to two fingers to fit between
the restraint and the skin to ensure it is secure enough to prevent removal but
not tight enough to impede circulation or cause injury.
5. A nurse is teaching a client about advance directives. Which statement by
the client indicates a correct understanding?
• A. “My advance directives will tell the doctor exactly how to treat me.”
• B. “I can change my mind about my advance directives at any time.”
• C. “Once I sign this, my family cannot make any decisions for me.”
• D. “My living will goes into effect as soon as I sign it.”
• Rationale: Advance directives are legal documents that express a client’s
wishes regarding healthcare decisions. They can be revoked or changed by
the client at any time as long as the client is competent.
, 6. A nurse is caring for a client post-operative day one. Which finding is
the best indicator that the client has adequate pain management?
• A. The client’s heart rate is 88 bpm.
• B. The client’s blood pressure is 118/76 mmHg.
• C. The client reports being able to deep breathe and cough without
difficulty.
• D. The client’s pain score is 0 on a 0-10 scale.
• Rationale: The goal of pain management in the post-op period is to
facilitate healing and prevent complications like atelectasis and pneumonia.
Functional goals (e.g., ability to cough, ambulate) are more meaningful than
just a low pain score, as some clients may have a tolerable level of pain.
7. A healthcare provider writes an order that a nurse feels is unsafe. According
to the ethical principle of accountability, what is the nurse’s first action?
• A. Administer the medication and document concerns later.
• B. Clarify the order with the healthcare provider.
• C. Refuse to administer the medication and leave the unit.
• D. Ask the charge nurse to administer the medication.
• Rationale: The nurse’s first responsibility is to question and clarify an
unclear or unsafe order. This demonstrates accountability and advocacy for
the client’s safety.
8. A nurse is preparing to insert a urinary catheter. Which technique is
appropriate for maintaining surgical asepsis (sterile technique)?
• A. Wearing clean gloves to handle the sterile catheter.
• B. Placing the sterile field on a wet surface after cleaning it.
• C. Opening the sterile kit towards the body to avoid contamination.
• D. Holding sterile objects at or above waist level.
• Rationale: In sterile technique, any object held below the waist or above the
chest is considered contaminated. The sterile field must be kept dry and
within the line of sight.
NUR 125: NURSING FUNDAMENTALS
FINAL EXAMINATION
SECTION I: SAFETY, INFECTION CONTROL, & ETHICAL/LEGAL
ISSUES (Questions 1-20)
1. A nurse is caring for a client on contact precautions for Clostridioides
difficile. Which of the following actions by the nurse demonstrates proper
understanding of infection control?
• A. Using an alcohol-based hand rub before entering the room.
• B. Wearing a surgical mask during all client interactions.
• C. Performing hand hygiene with soap and water after removing gloves.
• D. Removing the gown and mask before leaving the client’s room.
• Rationale: C. difficile spores are not killed by alcohol-based hand rubs.
Soap and water are required for mechanical removal of the spores. Gloves
are always worn, but a mask is not required for contact precautions unless
there is a risk of splash.
2. A client is placed in restraints after becoming violent. Which of the
following actions is most important for the nurse to document?
• A. The type of restraint used.
• B. The family’s opinion on the restraint use.
• C. The specific behaviors that necessitated the restraint.
• D. The cost of the restraint device.
• Rationale: Restraints are a last resort. The nurse must document the
specific, objective, and imminent risk of harm to self or others that justified
the use of restraints to meet legal and ethical standards.
,3. A nurse is preparing to administer a medication to a client. The client states,
“I’ve never seen that pill before.” What is the nurse’s priority action?
• A. Stop the administration and re-verify the medication order and the
client’s identity.
• B. Explain the medication’s purpose to the client and administer it.
• C. Tell the client it is the same medication as always.
• D. Ask the client if they are refusing the medication.
• Rationale: The client’s statement is a challenge to the “Right Medication”
and “Right Client” of the Six Rights of Medication Administration. The
nurse must stop and verify the order, the client’s identity using two
identifiers, and the medication label.
4. A nurse is applying a wrist restraint for a client. How many fingers should
the nurse be able to fit between the restraint and the client’s wrist?
• A. One
• B. Two
• C. Three
• D. Four
• Rationale: The standard of care is to allow one to two fingers to fit between
the restraint and the skin to ensure it is secure enough to prevent removal but
not tight enough to impede circulation or cause injury.
5. A nurse is teaching a client about advance directives. Which statement by
the client indicates a correct understanding?
• A. “My advance directives will tell the doctor exactly how to treat me.”
• B. “I can change my mind about my advance directives at any time.”
• C. “Once I sign this, my family cannot make any decisions for me.”
• D. “My living will goes into effect as soon as I sign it.”
• Rationale: Advance directives are legal documents that express a client’s
wishes regarding healthcare decisions. They can be revoked or changed by
the client at any time as long as the client is competent.
, 6. A nurse is caring for a client post-operative day one. Which finding is
the best indicator that the client has adequate pain management?
• A. The client’s heart rate is 88 bpm.
• B. The client’s blood pressure is 118/76 mmHg.
• C. The client reports being able to deep breathe and cough without
difficulty.
• D. The client’s pain score is 0 on a 0-10 scale.
• Rationale: The goal of pain management in the post-op period is to
facilitate healing and prevent complications like atelectasis and pneumonia.
Functional goals (e.g., ability to cough, ambulate) are more meaningful than
just a low pain score, as some clients may have a tolerable level of pain.
7. A healthcare provider writes an order that a nurse feels is unsafe. According
to the ethical principle of accountability, what is the nurse’s first action?
• A. Administer the medication and document concerns later.
• B. Clarify the order with the healthcare provider.
• C. Refuse to administer the medication and leave the unit.
• D. Ask the charge nurse to administer the medication.
• Rationale: The nurse’s first responsibility is to question and clarify an
unclear or unsafe order. This demonstrates accountability and advocacy for
the client’s safety.
8. A nurse is preparing to insert a urinary catheter. Which technique is
appropriate for maintaining surgical asepsis (sterile technique)?
• A. Wearing clean gloves to handle the sterile catheter.
• B. Placing the sterile field on a wet surface after cleaning it.
• C. Opening the sterile kit towards the body to avoid contamination.
• D. Holding sterile objects at or above waist level.
• Rationale: In sterile technique, any object held below the waist or above the
chest is considered contaminated. The sterile field must be kept dry and
within the line of sight.
