PNR 106/PNR106 Final Exam V2 | Foundations of
Nursing Q&A with Rationale | Fortis College
1. A nurse is caring for a client who is scheduled for surgery. The client expresses concern
about the procedure. Which ethical principle is the nurse upholding by ensuring the client has
all necessary information to make an informed decision?
A. Beneficence
B. Autonomy
C. Justice
D. Fidelity
Correct Answer: B
Explanation: Autonomy refers to the right of the patient to make their own decisions
regarding healthcare. By ensuring the patient is fully informed before surgery, the nurse
respects the client’s self-determination. This is a core component of the informed consent
process in the Foundations of Nursing.
2. Which phase of the nursing process involves the nurse prioritizing patient problems and
setting measurable goals?
A. Assessment
B. Diagnosis
C. Implementation
,D. Planning
Correct Answer: D
Explanation: The planning phase is where the nurse establishes priorities and develops
measurable outcomes. It follows the diagnosis phase and precedes the actual intervention.
Successful planning requires collaboration with the client to ensure goals are realistic.
3. A nurse is preparing to perform hand hygiene. Which action is the most important step in
preventing the spread of microorganisms?
A. Using hot water to kill bacteria
B. Friction during the rubbing process
C. Applying plenty of moisturizing lotion after
D. Rinsing from the fingers toward the wrists
Correct Answer: B
Explanation: Friction is the most effective component of handwashing for removing
transient microbes. The CDC recommends rubbing hands together for at least 20 seconds.
Proper friction ensures that physical contaminants and pathogens are mechanically
loosened from the skin surface.
4. A nurse enters a room and finds a client lying on the floor. What is the priority nursing
action?
A. Call the physician immediately
, B. Assess the client for injuries
C. Complete an incident report
D. Move the client back to the bed
Correct Answer: B
Explanation: The first step in any emergency or change in status is to assess the client’s
condition. Moving the client without assessment could exacerbate potential spinal or bone
injuries. Once the client is stabilized, the nurse can then proceed with notification and
documentation.
5. A client has a localized area of intact skin that is non-blanchable and red over a bony
prominence. How should the nurse document this finding?
A. Stage 2 Pressure Injury
B. Stage 1 Pressure Injury
C. Deep Tissue Pressure Injury
D. Unstageable Pressure Injury
Correct Answer: B
Explanation: A Stage 1 pressure injury is characterized by intact skin with non-blanchable
redness. This indicates that the underlying tissue is under stress but the skin surface is not
broken. Early identification of Stage 1 injuries is crucial to prevent further tissue
breakdown.
Nursing Q&A with Rationale | Fortis College
1. A nurse is caring for a client who is scheduled for surgery. The client expresses concern
about the procedure. Which ethical principle is the nurse upholding by ensuring the client has
all necessary information to make an informed decision?
A. Beneficence
B. Autonomy
C. Justice
D. Fidelity
Correct Answer: B
Explanation: Autonomy refers to the right of the patient to make their own decisions
regarding healthcare. By ensuring the patient is fully informed before surgery, the nurse
respects the client’s self-determination. This is a core component of the informed consent
process in the Foundations of Nursing.
2. Which phase of the nursing process involves the nurse prioritizing patient problems and
setting measurable goals?
A. Assessment
B. Diagnosis
C. Implementation
,D. Planning
Correct Answer: D
Explanation: The planning phase is where the nurse establishes priorities and develops
measurable outcomes. It follows the diagnosis phase and precedes the actual intervention.
Successful planning requires collaboration with the client to ensure goals are realistic.
3. A nurse is preparing to perform hand hygiene. Which action is the most important step in
preventing the spread of microorganisms?
A. Using hot water to kill bacteria
B. Friction during the rubbing process
C. Applying plenty of moisturizing lotion after
D. Rinsing from the fingers toward the wrists
Correct Answer: B
Explanation: Friction is the most effective component of handwashing for removing
transient microbes. The CDC recommends rubbing hands together for at least 20 seconds.
Proper friction ensures that physical contaminants and pathogens are mechanically
loosened from the skin surface.
4. A nurse enters a room and finds a client lying on the floor. What is the priority nursing
action?
A. Call the physician immediately
, B. Assess the client for injuries
C. Complete an incident report
D. Move the client back to the bed
Correct Answer: B
Explanation: The first step in any emergency or change in status is to assess the client’s
condition. Moving the client without assessment could exacerbate potential spinal or bone
injuries. Once the client is stabilized, the nurse can then proceed with notification and
documentation.
5. A client has a localized area of intact skin that is non-blanchable and red over a bony
prominence. How should the nurse document this finding?
A. Stage 2 Pressure Injury
B. Stage 1 Pressure Injury
C. Deep Tissue Pressure Injury
D. Unstageable Pressure Injury
Correct Answer: B
Explanation: A Stage 1 pressure injury is characterized by intact skin with non-blanchable
redness. This indicates that the underlying tissue is under stress but the skin surface is not
broken. Early identification of Stage 1 injuries is crucial to prevent further tissue
breakdown.
