NRSG 100 Exam 2 V3 | NRSG 100
Fundamentals of Nursing | Actual Q&A
with Rationale (NRSG100 Exam 2) | Ivy
Tech
1. A nurse is preparing to perform hand hygiene after providing care to a client who has
Clostridium difficile. Which of the following actions should the nurse take?
A. Use an alcohol-based hand rub
B. Apply a small amount of antiseptic foam
C. Wash hands with soap and water
D. Rinse hands with hot water before applying soap
Correct Answer: C
C. difficile is a spore-forming bacterium that is resistant to alcohol-based hand sanitizers.
Physical scrubbing with soap and water is necessary to mechanically remove the spores
from the hands. Hot water should be avoided as it can cause skin irritation and increase the
risk of dermatitis.
2. Which of the following is the correct order for removing personal protective equipment
(PPE) after caring for a client in isolation?
A. Gloves, Goggles, Gown, Mask
B. Mask, Gown, Gloves, Goggles
,C. Gown, Gloves, Mask, Goggles
D. Goggles, Mask, Gloves, Gown
Correct Answer: A
The gloves are considered the most contaminated piece of PPE and should be removed
first. Goggles or a face shield are removed next by the headband or earpieces to avoid
touching the front. The mask is removed last after exiting the room to ensure respiratory
protection remains until the nurse is in a clean area.
3. A nurse is assessing a client’s blood pressure and notes the sound becomes muffled. This
corresponds to which Korotkoff phase?
A. Phase I
B. Phase II
C. Phase IV
D. Phase V
Correct Answer: C
Phase IV is characterized by a distinct muffling of sounds as the cuff pressure falls below
the vessel pressure. Phase I represents the systolic pressure when the first clear tapping
sound is heard. Phase V is the point where the sound disappears completely, representing
the diastolic pressure in most adults.
, 4. A nurse is caring for a client who is at high risk for falls. Which of the following is the
priority nursing action?
A. Apply physical restraints
B. Administer a sedative
C. Keep all four side rails up
D. Place the call light within reach
Correct Answer: D
Ensuring the call light is within reach is a fundamental safety intervention that allows the
client to request assistance. Applying restraints or raising four side rails is considered a
restrictive practice and can increase the risk of injury if the client tries to climb over them.
Safety interventions should always start with the least restrictive measures first.
5. When performing a bed bath, in which direction should the nurse wash the client’s
extremities?
A. Proximal to distal
B. Distal to proximal
C. Side to side
D. Circular motions
Correct Answer: B
Fundamentals of Nursing | Actual Q&A
with Rationale (NRSG100 Exam 2) | Ivy
Tech
1. A nurse is preparing to perform hand hygiene after providing care to a client who has
Clostridium difficile. Which of the following actions should the nurse take?
A. Use an alcohol-based hand rub
B. Apply a small amount of antiseptic foam
C. Wash hands with soap and water
D. Rinse hands with hot water before applying soap
Correct Answer: C
C. difficile is a spore-forming bacterium that is resistant to alcohol-based hand sanitizers.
Physical scrubbing with soap and water is necessary to mechanically remove the spores
from the hands. Hot water should be avoided as it can cause skin irritation and increase the
risk of dermatitis.
2. Which of the following is the correct order for removing personal protective equipment
(PPE) after caring for a client in isolation?
A. Gloves, Goggles, Gown, Mask
B. Mask, Gown, Gloves, Goggles
,C. Gown, Gloves, Mask, Goggles
D. Goggles, Mask, Gloves, Gown
Correct Answer: A
The gloves are considered the most contaminated piece of PPE and should be removed
first. Goggles or a face shield are removed next by the headband or earpieces to avoid
touching the front. The mask is removed last after exiting the room to ensure respiratory
protection remains until the nurse is in a clean area.
3. A nurse is assessing a client’s blood pressure and notes the sound becomes muffled. This
corresponds to which Korotkoff phase?
A. Phase I
B. Phase II
C. Phase IV
D. Phase V
Correct Answer: C
Phase IV is characterized by a distinct muffling of sounds as the cuff pressure falls below
the vessel pressure. Phase I represents the systolic pressure when the first clear tapping
sound is heard. Phase V is the point where the sound disappears completely, representing
the diastolic pressure in most adults.
, 4. A nurse is caring for a client who is at high risk for falls. Which of the following is the
priority nursing action?
A. Apply physical restraints
B. Administer a sedative
C. Keep all four side rails up
D. Place the call light within reach
Correct Answer: D
Ensuring the call light is within reach is a fundamental safety intervention that allows the
client to request assistance. Applying restraints or raising four side rails is considered a
restrictive practice and can increase the risk of injury if the client tries to climb over them.
Safety interventions should always start with the least restrictive measures first.
5. When performing a bed bath, in which direction should the nurse wash the client’s
extremities?
A. Proximal to distal
B. Distal to proximal
C. Side to side
D. Circular motions
Correct Answer: B
