NRSG 100 Final Exam V2 | NRSG 100
Fundamentals of Nursing | Actual Q&A
with Rationale (NRSG100 Final Exam) | Ivy
Tech
1. A nurse is performing hand hygiene after caring for a client with Clostridium difficile. Which
of the following actions is the most appropriate?
A. Wash hands with non-antimicrobial soap and water for at least 15 to 20 seconds.
B. Use an alcohol-based hand rub for at least 15 seconds.
C. Rinse hands with hot water to kill the bacterial spores.
D. Apply sterile gloves before touching the client’s bed rails.
Correct Answer: A
Handwashing with soap and water is mandatory when dealing with C. difficile because
alcohol-based rubs are ineffective against its spores. The mechanical action of rubbing
hands under running water helps physically remove the spores from the skin surface. Using
hot water is discouraged as it can increase the risk of dermatitis and skin breakdown.
2. When assessing a client’s blood pressure, the nurse notes that the cuff is too small for the
client’s arm circumference. Which of the following results should the nurse expect?
A. A false low reading.
B. A reading that is accurate only if the arm is at heart level.
,C. A false high reading.
D. A reading that is only affected by the diastolic pressure.
Correct Answer: C
A blood pressure cuff that is too narrow or too small will result in a false high reading
because it requires more pressure to occlude the artery. Conversely, a cuff that is too wide
or too large will provide a false low reading. It is critical for the nurse to select the
appropriate cuff size, which should have a bladder width of approximately 40% of the arm
circumference.
3. A nurse is preparing to administer an oral medication to a client. Which of the following
actions should the nurse take first to ensure patient safety?
A. Verify the client’s identity using two unique identifiers.
B. Document the administration in the electronic health record.
C. Check the expiration date of the medication.
D. Explain the purpose of the medication to the client.
Correct Answer: A
Identifying the client using two unique identifiers, such as name and date of birth, is the
first and most critical step in preventing medication errors. This practice aligns with
National Patient Safety Goals and Ivy Tech’s standards for safe nursing care. While checking
expiration dates and explaining medications are important steps, they occur after or
alongside the primary identification process.
,4. A nurse is caring for a client who is at high risk for falls. Which of the following
interventions should be included in the plan of care?
A. Keep all four side rails in the upright position at all times.
B. Provide the client with non-skid footwear.
C. Place the bed in the highest position to facilitate easy exit.
D. Encourage the client to walk to the bathroom independently at night.
Correct Answer: B
Non-skid footwear provides traction and reduces the risk of slipping, which is a key
component of a comprehensive fall prevention plan. Keeping all four side rails up is often
considered a physical restraint and can actually increase the risk of injury if the client tries
to climb over them. The bed should always be kept in the lowest position to minimize the
distance to the floor in the event of a fall.
5. A nurse is caring for a client who is 24 hours post-operative. Which of the following nursing
statements exemplifies the ‘Evaluation’ phase of the nursing process?
A. ‘The client reports pain as a 3 on a scale of 0 to 10.’
B. ‘The client is unable to walk 50 feet as previously planned due to shortness of breath.’
C. ‘The client will walk 50 feet in the hallway by the end of the shift.’
D. ‘Administer morphine 2 mg IV bolus for pain reported over 7.’
Correct Answer: B
, Evaluation involves comparing the client’s current status with the goals and outcomes
that were established during the planning phase. In this scenario, the nurse identifies that
the goal was not met and provides the reason why, which is the hallmark of evaluation. The
other options represent assessment (pain report), planning (the goal), and implementation
(administering medication).
6. A nurse is educating a client about a clear liquid diet. Which of the following food items
should the nurse include as an acceptable choice?
A. Apple juice
B. Orange juice with pulp
C. Vanilla pudding
D. Cream of mushroom soup
Correct Answer: A
A clear liquid diet consists of foods that are liquid at room temperature and are
transparent to light. Apple juice meets these criteria, whereas pudding, orange juice with
pulp, and cream-based soups are considered part of a full liquid diet. This diet is often
prescribed to minimize residue in the GI tract before procedures or during recovery from
illness.
7. Which of the following legal concepts describes a nurse who performs a procedure on a
client without their informed consent?
A. Slander
Fundamentals of Nursing | Actual Q&A
with Rationale (NRSG100 Final Exam) | Ivy
Tech
1. A nurse is performing hand hygiene after caring for a client with Clostridium difficile. Which
of the following actions is the most appropriate?
A. Wash hands with non-antimicrobial soap and water for at least 15 to 20 seconds.
B. Use an alcohol-based hand rub for at least 15 seconds.
C. Rinse hands with hot water to kill the bacterial spores.
D. Apply sterile gloves before touching the client’s bed rails.
Correct Answer: A
Handwashing with soap and water is mandatory when dealing with C. difficile because
alcohol-based rubs are ineffective against its spores. The mechanical action of rubbing
hands under running water helps physically remove the spores from the skin surface. Using
hot water is discouraged as it can increase the risk of dermatitis and skin breakdown.
2. When assessing a client’s blood pressure, the nurse notes that the cuff is too small for the
client’s arm circumference. Which of the following results should the nurse expect?
A. A false low reading.
B. A reading that is accurate only if the arm is at heart level.
,C. A false high reading.
D. A reading that is only affected by the diastolic pressure.
Correct Answer: C
A blood pressure cuff that is too narrow or too small will result in a false high reading
because it requires more pressure to occlude the artery. Conversely, a cuff that is too wide
or too large will provide a false low reading. It is critical for the nurse to select the
appropriate cuff size, which should have a bladder width of approximately 40% of the arm
circumference.
3. A nurse is preparing to administer an oral medication to a client. Which of the following
actions should the nurse take first to ensure patient safety?
A. Verify the client’s identity using two unique identifiers.
B. Document the administration in the electronic health record.
C. Check the expiration date of the medication.
D. Explain the purpose of the medication to the client.
Correct Answer: A
Identifying the client using two unique identifiers, such as name and date of birth, is the
first and most critical step in preventing medication errors. This practice aligns with
National Patient Safety Goals and Ivy Tech’s standards for safe nursing care. While checking
expiration dates and explaining medications are important steps, they occur after or
alongside the primary identification process.
,4. A nurse is caring for a client who is at high risk for falls. Which of the following
interventions should be included in the plan of care?
A. Keep all four side rails in the upright position at all times.
B. Provide the client with non-skid footwear.
C. Place the bed in the highest position to facilitate easy exit.
D. Encourage the client to walk to the bathroom independently at night.
Correct Answer: B
Non-skid footwear provides traction and reduces the risk of slipping, which is a key
component of a comprehensive fall prevention plan. Keeping all four side rails up is often
considered a physical restraint and can actually increase the risk of injury if the client tries
to climb over them. The bed should always be kept in the lowest position to minimize the
distance to the floor in the event of a fall.
5. A nurse is caring for a client who is 24 hours post-operative. Which of the following nursing
statements exemplifies the ‘Evaluation’ phase of the nursing process?
A. ‘The client reports pain as a 3 on a scale of 0 to 10.’
B. ‘The client is unable to walk 50 feet as previously planned due to shortness of breath.’
C. ‘The client will walk 50 feet in the hallway by the end of the shift.’
D. ‘Administer morphine 2 mg IV bolus for pain reported over 7.’
Correct Answer: B
, Evaluation involves comparing the client’s current status with the goals and outcomes
that were established during the planning phase. In this scenario, the nurse identifies that
the goal was not met and provides the reason why, which is the hallmark of evaluation. The
other options represent assessment (pain report), planning (the goal), and implementation
(administering medication).
6. A nurse is educating a client about a clear liquid diet. Which of the following food items
should the nurse include as an acceptable choice?
A. Apple juice
B. Orange juice with pulp
C. Vanilla pudding
D. Cream of mushroom soup
Correct Answer: A
A clear liquid diet consists of foods that are liquid at room temperature and are
transparent to light. Apple juice meets these criteria, whereas pudding, orange juice with
pulp, and cream-based soups are considered part of a full liquid diet. This diet is often
prescribed to minimize residue in the GI tract before procedures or during recovery from
illness.
7. Which of the following legal concepts describes a nurse who performs a procedure on a
client without their informed consent?
A. Slander
