NRSG 100 Exam 2 V1 | NRSG 100
Fundamentals of Nursing | Actual Q&A
with Rationale (NRSG100 Exam 2) | Ivy
Tech
1. When assessing a patient’s radial pulse, the nurse notes an irregular rhythm. What is the
most appropriate next action for the nurse to take?
A. Assess the apical pulse for one full minute.
B. Assess the pulse for 15 seconds and multiply by four.
C. Notify the healthcare provider immediately of the findings.
D. Document the pulse as ‘irregular’ and recheck in 4 hours.
Correct Answer: A
When a peripheral pulse is irregular, an apical pulse measurement is required to
determine the actual heart rate and assess for a pulse deficit. Assessing for a full minute
ensures accuracy by capturing any fluctuations in the rhythm. This is a critical step before
reporting findings to the provider or documenting the final assessment.
2. Which link in the chain of infection is broken when a nurse performs thorough hand
hygiene before a sterile procedure?
A. Mode of transmission
B. Portal of entry
,C. Reservoir
D. Susceptible host
Correct Answer: A
Hand hygiene is the most effective way to interrupt the mode of transmission by removing
pathogens from the hands. By cleaning the hands, the nurse prevents the movement of
microorganisms from one location to another. This action is essential in both medical and
surgical asepsis to protect the patient from healthcare-associated infections.
3. A nurse is preparing to transfer a patient with left-sided weakness from the bed to a chair.
Where should the nurse place the chair?
A. Directly in front of the patient.
B. On the patient’s left side.
C. On the patient’s right side.
D. At the foot of the bed.
Correct Answer: C
The chair should be placed on the patient’s stronger side, which in this case is the right
side, to facilitate a safer and more stable transfer. This allows the patient to bear weight on
the unaffected leg and use their stronger arm for support when sitting down. Positioning
the chair correctly reduces the risk of falls and increases the patient’s confidence during
mobility.
, 4. According to the Braden Scale, which patient would be considered at the highest risk for
developing a pressure injury?
A. A patient with a total score of 20.
B. A patient with a total score of 16.
C. A patient with a total score of 23.
D. A patient with a total score of 9.
Correct Answer: D
On the Braden Scale, lower scores indicate a higher risk for pressure injury development.
A score of 9 represents a very high risk, requiring intensive preventative nursing
interventions. The scale evaluates six categories: sensory perception, moisture, activity,
mobility, nutrition, and friction/shear.
5. While measuring a patient’s blood pressure, the nurse finds the cuff is too small for the
patient’s arm. What impact will this have on the reading?
A. The systolic reading will be accurate, but diastolic will be high.
B. The blood pressure reading will be falsely low.
C. The blood pressure reading will be falsely high.
D. The cuff size does not affect the blood pressure reading.
Correct Answer: C
Fundamentals of Nursing | Actual Q&A
with Rationale (NRSG100 Exam 2) | Ivy
Tech
1. When assessing a patient’s radial pulse, the nurse notes an irregular rhythm. What is the
most appropriate next action for the nurse to take?
A. Assess the apical pulse for one full minute.
B. Assess the pulse for 15 seconds and multiply by four.
C. Notify the healthcare provider immediately of the findings.
D. Document the pulse as ‘irregular’ and recheck in 4 hours.
Correct Answer: A
When a peripheral pulse is irregular, an apical pulse measurement is required to
determine the actual heart rate and assess for a pulse deficit. Assessing for a full minute
ensures accuracy by capturing any fluctuations in the rhythm. This is a critical step before
reporting findings to the provider or documenting the final assessment.
2. Which link in the chain of infection is broken when a nurse performs thorough hand
hygiene before a sterile procedure?
A. Mode of transmission
B. Portal of entry
,C. Reservoir
D. Susceptible host
Correct Answer: A
Hand hygiene is the most effective way to interrupt the mode of transmission by removing
pathogens from the hands. By cleaning the hands, the nurse prevents the movement of
microorganisms from one location to another. This action is essential in both medical and
surgical asepsis to protect the patient from healthcare-associated infections.
3. A nurse is preparing to transfer a patient with left-sided weakness from the bed to a chair.
Where should the nurse place the chair?
A. Directly in front of the patient.
B. On the patient’s left side.
C. On the patient’s right side.
D. At the foot of the bed.
Correct Answer: C
The chair should be placed on the patient’s stronger side, which in this case is the right
side, to facilitate a safer and more stable transfer. This allows the patient to bear weight on
the unaffected leg and use their stronger arm for support when sitting down. Positioning
the chair correctly reduces the risk of falls and increases the patient’s confidence during
mobility.
, 4. According to the Braden Scale, which patient would be considered at the highest risk for
developing a pressure injury?
A. A patient with a total score of 20.
B. A patient with a total score of 16.
C. A patient with a total score of 23.
D. A patient with a total score of 9.
Correct Answer: D
On the Braden Scale, lower scores indicate a higher risk for pressure injury development.
A score of 9 represents a very high risk, requiring intensive preventative nursing
interventions. The scale evaluates six categories: sensory perception, moisture, activity,
mobility, nutrition, and friction/shear.
5. While measuring a patient’s blood pressure, the nurse finds the cuff is too small for the
patient’s arm. What impact will this have on the reading?
A. The systolic reading will be accurate, but diastolic will be high.
B. The blood pressure reading will be falsely low.
C. The blood pressure reading will be falsely high.
D. The cuff size does not affect the blood pressure reading.
Correct Answer: C
