Advanced Nursing Fundamentals - Exam 8 Practice Questions
|Answers |Rationales
1. A nurse is measuring a patient’s blood pressure using a cuff that is too small
for the patient’s arm circumference. What effect will this have on the reading?
A. The reading will be falsely low.
B. The reading will not be affected by cuff size.
C. The diastolic pressure will be accurate, but systolic will be high.
D. The reading will be falsely high.
Answer: D
Rationale: A blood pressure cuff that is too narrow or too small will result in a falsely high
reading because the cuff must be inflated more to occlude the artery.
2. Which type of transmission-based precaution should be implemented for a
patient diagnosed with Clostridioides difficile (C. diff)?
A. Airborne precautions
B. Droplet precautions
C. Protective environment
D. Contact precautions
Answer: D
Rationale: C. diff is transmitted through direct or indirect contact with feces or
contaminated surfaces, requiring contact precautions and handwashing with soap and
water.
,3. A patient refuses to take a prescribed medication. Which ethical principle is
the nurse upholding by respecting the patient’s decision?
A. Beneficence
B. Non-maleficence
C. Justice
D. Autonomy
Answer: D
Rationale: Autonomy refers to the right of patients to make their own decisions about
their medical care, including the right to refuse treatment.
4. When administering an intramuscular (IM) injection to an adult, which site is
considered the safest and most preferred?
A. Ventrogluteal
B. Dorsogluteal
C. Deltoid
D. Vastus lateralis
Answer: A
Rationale: The ventrogluteal site is preferred for IM injections in adults because it is away
from major nerves and blood vessels.
5. A nurse is caring for a patient with a nasal cannula delivering oxygen at 4
L/min. What is the approximate fraction of inspired oxygen (FiO2) being
delivered?
A. 24%
B. 28%
C. 32%
D. 36%
Answer: D
, Rationale: Oxygen concentration increases by approximately 4% for every 1 L/min of
flow. Starting from room air (21%), 4 L/min equals roughly 36-37% FiO2.
6. Which clinical manifestation is most characteristic of hypovolemia?
A. Hypertension
B. Bradycardia
C. Distended neck veins
D. Tachycardia
Answer: D
Rationale: Tachycardia is a compensatory mechanism to maintain cardiac output when
blood volume is low. Other signs include hypotension and decreased skin turgor.
7. In which position should the nurse place a patient for the administration of a
cleansing enema?
A. High-Fowler’s
B. Left side-lying (Sims’ position)
C. Prone
D. Supine
Answer: B
Rationale: The left side-lying (Sims’) position allows the enema solution to flow by gravity
into the sigmoid colon and rectum.
8. While preparing a sterile field, the nurse drops a sterile gauze pad onto the
one-inch border of the sterile drape. What is the nurse’s next action?
A. Consider the gauze pad contaminated.
B. Move the gauze to the center of the field with sterile forceps.
C. Continue with the procedure using that gauze.
D. Spray the border with antiseptic solution.
Answer: A
|Answers |Rationales
1. A nurse is measuring a patient’s blood pressure using a cuff that is too small
for the patient’s arm circumference. What effect will this have on the reading?
A. The reading will be falsely low.
B. The reading will not be affected by cuff size.
C. The diastolic pressure will be accurate, but systolic will be high.
D. The reading will be falsely high.
Answer: D
Rationale: A blood pressure cuff that is too narrow or too small will result in a falsely high
reading because the cuff must be inflated more to occlude the artery.
2. Which type of transmission-based precaution should be implemented for a
patient diagnosed with Clostridioides difficile (C. diff)?
A. Airborne precautions
B. Droplet precautions
C. Protective environment
D. Contact precautions
Answer: D
Rationale: C. diff is transmitted through direct or indirect contact with feces or
contaminated surfaces, requiring contact precautions and handwashing with soap and
water.
,3. A patient refuses to take a prescribed medication. Which ethical principle is
the nurse upholding by respecting the patient’s decision?
A. Beneficence
B. Non-maleficence
C. Justice
D. Autonomy
Answer: D
Rationale: Autonomy refers to the right of patients to make their own decisions about
their medical care, including the right to refuse treatment.
4. When administering an intramuscular (IM) injection to an adult, which site is
considered the safest and most preferred?
A. Ventrogluteal
B. Dorsogluteal
C. Deltoid
D. Vastus lateralis
Answer: A
Rationale: The ventrogluteal site is preferred for IM injections in adults because it is away
from major nerves and blood vessels.
5. A nurse is caring for a patient with a nasal cannula delivering oxygen at 4
L/min. What is the approximate fraction of inspired oxygen (FiO2) being
delivered?
A. 24%
B. 28%
C. 32%
D. 36%
Answer: D
, Rationale: Oxygen concentration increases by approximately 4% for every 1 L/min of
flow. Starting from room air (21%), 4 L/min equals roughly 36-37% FiO2.
6. Which clinical manifestation is most characteristic of hypovolemia?
A. Hypertension
B. Bradycardia
C. Distended neck veins
D. Tachycardia
Answer: D
Rationale: Tachycardia is a compensatory mechanism to maintain cardiac output when
blood volume is low. Other signs include hypotension and decreased skin turgor.
7. In which position should the nurse place a patient for the administration of a
cleansing enema?
A. High-Fowler’s
B. Left side-lying (Sims’ position)
C. Prone
D. Supine
Answer: B
Rationale: The left side-lying (Sims’) position allows the enema solution to flow by gravity
into the sigmoid colon and rectum.
8. While preparing a sterile field, the nurse drops a sterile gauze pad onto the
one-inch border of the sterile drape. What is the nurse’s next action?
A. Consider the gauze pad contaminated.
B. Move the gauze to the center of the field with sterile forceps.
C. Continue with the procedure using that gauze.
D. Spray the border with antiseptic solution.
Answer: A
