NRSG 100 Exam 2 V2 NRSG 100 Exam 2
V2 NRSG 100 Exam 2 V2 NRSG 100 Exam
2 V2
1. A nurse is preparing to measure a patient’s blood pressure. Which action should the nurse
take to ensure an accurate reading?
A. Place the cuff over the patient’s clothing.
B. Position the arm above the level of the heart.
C. Ensure the cuff width is 40% of the arm circumference.
D. Deflate the cuff at a rate of 5 to 10 mmHg per second.
Correct Answer: C
Selecting the correct cuff size is critical for accurate blood pressure measurement. A cuff
that is too small can provide a false-high reading, while one that is too large can provide a
false-low reading. The bladder width should be approximately 40% of the circumference of
the midpoint of the limb being used.
2. When assessing a patient with a suspected localized infection, which clinical manifestation
should the nurse expect to find?
A. Redness and swelling at the site.
B. Increased white blood cell count.
C. Fever and chills.
,D. Generalized malaise.
Correct Answer: A
Localized infections are characterized by symptoms confined to a specific area, such as
erythema, edema, and warmth. Systemic infections, conversely, involve symptoms like
fever and elevated WBC counts that affect the entire body. Nurses must distinguish
between these to provide appropriate wound care and monitoring.
3. A nurse is caring for a patient who is at high risk for falls. Which intervention is the priority
for the nurse to implement?
A. Keep all four side rails in the up position.
B. Administer a sedative to keep the patient in bed.
C. Place the call light within the patient’s reach.
D. Apply a vest restraint while the patient is alone.
Correct Answer: C
Patient safety is maintained through the least restrictive measures possible to prevent
injury. Ensuring the call light is accessible allows the patient to request assistance before
attempting to ambulate alone. Using four side rails is often considered a form of restraint
and should be avoided unless medically indicated.
4. Which technique should the nurse use when performing hand hygiene with an alcohol-
based hand rub?
A. Rinse hands with water after applying the rub.
, B. Dry hands with a paper towel immediately after application.
C. Apply the rub only to the palms of the hands.
D. Rub hands together until the alcohol is completely dry.
Correct Answer: D
For alcohol-based hand rubs to be effective, the solution must come into contact with all
surfaces of the hands. Friction should be applied until the product has completely
evaporated to ensure microbial kill. This method is preferred when hands are not visibly
soiled but is not effective against spores like C. difficile.
5. A nurse is assisting a patient with oral hygiene who is unconscious. Which position should
the nurse place the patient in?
A. Supine.
B. Fowler’s.
C. Side-lying or Sims’ position.
D. Prone.
Correct Answer: C
Positioning an unconscious patient on their side prevents the aspiration of fluids into the
lungs. This allows gravity to help drainage exit the mouth rather than pooling in the
pharynx. Suction equipment should also be available at the bedside during the procedure.
V2 NRSG 100 Exam 2 V2 NRSG 100 Exam
2 V2
1. A nurse is preparing to measure a patient’s blood pressure. Which action should the nurse
take to ensure an accurate reading?
A. Place the cuff over the patient’s clothing.
B. Position the arm above the level of the heart.
C. Ensure the cuff width is 40% of the arm circumference.
D. Deflate the cuff at a rate of 5 to 10 mmHg per second.
Correct Answer: C
Selecting the correct cuff size is critical for accurate blood pressure measurement. A cuff
that is too small can provide a false-high reading, while one that is too large can provide a
false-low reading. The bladder width should be approximately 40% of the circumference of
the midpoint of the limb being used.
2. When assessing a patient with a suspected localized infection, which clinical manifestation
should the nurse expect to find?
A. Redness and swelling at the site.
B. Increased white blood cell count.
C. Fever and chills.
,D. Generalized malaise.
Correct Answer: A
Localized infections are characterized by symptoms confined to a specific area, such as
erythema, edema, and warmth. Systemic infections, conversely, involve symptoms like
fever and elevated WBC counts that affect the entire body. Nurses must distinguish
between these to provide appropriate wound care and monitoring.
3. A nurse is caring for a patient who is at high risk for falls. Which intervention is the priority
for the nurse to implement?
A. Keep all four side rails in the up position.
B. Administer a sedative to keep the patient in bed.
C. Place the call light within the patient’s reach.
D. Apply a vest restraint while the patient is alone.
Correct Answer: C
Patient safety is maintained through the least restrictive measures possible to prevent
injury. Ensuring the call light is accessible allows the patient to request assistance before
attempting to ambulate alone. Using four side rails is often considered a form of restraint
and should be avoided unless medically indicated.
4. Which technique should the nurse use when performing hand hygiene with an alcohol-
based hand rub?
A. Rinse hands with water after applying the rub.
, B. Dry hands with a paper towel immediately after application.
C. Apply the rub only to the palms of the hands.
D. Rub hands together until the alcohol is completely dry.
Correct Answer: D
For alcohol-based hand rubs to be effective, the solution must come into contact with all
surfaces of the hands. Friction should be applied until the product has completely
evaporated to ensure microbial kill. This method is preferred when hands are not visibly
soiled but is not effective against spores like C. difficile.
5. A nurse is assisting a patient with oral hygiene who is unconscious. Which position should
the nurse place the patient in?
A. Supine.
B. Fowler’s.
C. Side-lying or Sims’ position.
D. Prone.
Correct Answer: C
Positioning an unconscious patient on their side prevents the aspiration of fluids into the
lungs. This allows gravity to help drainage exit the mouth rather than pooling in the
pharynx. Suction equipment should also be available at the bedside during the procedure.
