NUR 104/NUR104 Exam 2 V2 | Foundations of
Nursing Q&A with Rationale | Fortis College
1. A nurse is preparing to measure a patient’s blood pressure. Which action by the nurse
would result in a falsely high blood pressure reading?
A. Positioning the arm at the level of the heart.
B. Deflating the cuff at a rate of 2 to 3 mmHg per second.
C. Using a cuff that is too narrow for the arm circumference.
D. Waiting 2 minutes before repeating the measurement.
Correct Answer: C
Explanation: If the blood pressure cuff is too narrow or too small, it will require more
pressure to occlude the artery, resulting in a falsely high reading. The bladder of the cuff
should encircle at least 80% of the adult arm. Proper cuff sizing is a fundamental skill in
nursing to ensure clinical data accuracy.
2. When performing hand hygiene, the nurse knows that which of the following is the most
effective way to prevent the spread of microorganisms?
A. Using hot water to kill bacteria on the skin surface.
B. Drying hands from the wrists down to the fingertips.
C. Rinsing hands with the fingers pointing upward toward the elbows.
D. Applying friction for at least 15 to 20 seconds during washing.
,Correct Answer: D
Explanation: Friction is the most important component of handwashing because it
physically removes transient microorganisms from the skin. The nurse should rub all
surfaces of the hands and fingers vigorously for at least 20 seconds. This mechanical action
is essential in breaking the chain of infection in the clinical setting.
3. A patient is placed on Contact Precautions for a wound infection with Methicillin-resistant
Staphylococcus aureus (MRSA). Which personal protective equipment (PPE) must the nurse
don before entering the room?
A. Gloves only.
B. N95 respirator and gloves.
C. Mask and eye protection.
D. Gown and gloves.
Correct Answer: D
Explanation: Contact precautions require the use of gloves and a gown to prevent the
transmission of pathogens through direct or indirect contact. These barriers protect the
nurse’s clothing and skin from contamination by the patient’s environment or drainage.
Adhering to these precautions is critical for preventing healthcare-associated infections.
4. The nurse is assessing a patient with a high risk for falls. Which nursing intervention is the
priority to ensure patient safety?
A. Keeping all four side rails in the upright position.
, B. Placing the bed in the lowest position with the wheels locked.
C. Requesting a prescription for soft wrist restraints.
D. Encouraging the patient to walk to the bathroom independently.
Correct Answer: B
Explanation: Keeping the bed in the lowest position reduces the distance to the floor in the
event of a fall, thereby minimizing potential injury. Locking the wheels prevents the bed
from moving when the patient attempts to transfer. These are standard safety measures
implemented for all hospitalized patients, especially those at high risk.
5. Which stage of the nursing process involves the nurse collecting objective and subjective
data about the patient’s health status?
A. Diagnosis
B. Planning
C. Assessment
D. Implementation
Correct Answer: C
Explanation: Assessment is the first step of the nursing process and involves the
systematic collection of data. This includes performing a physical examination and
interviewing the patient for their history. Accurate assessment is the foundation upon
which the rest of the nursing care plan is built.
Nursing Q&A with Rationale | Fortis College
1. A nurse is preparing to measure a patient’s blood pressure. Which action by the nurse
would result in a falsely high blood pressure reading?
A. Positioning the arm at the level of the heart.
B. Deflating the cuff at a rate of 2 to 3 mmHg per second.
C. Using a cuff that is too narrow for the arm circumference.
D. Waiting 2 minutes before repeating the measurement.
Correct Answer: C
Explanation: If the blood pressure cuff is too narrow or too small, it will require more
pressure to occlude the artery, resulting in a falsely high reading. The bladder of the cuff
should encircle at least 80% of the adult arm. Proper cuff sizing is a fundamental skill in
nursing to ensure clinical data accuracy.
2. When performing hand hygiene, the nurse knows that which of the following is the most
effective way to prevent the spread of microorganisms?
A. Using hot water to kill bacteria on the skin surface.
B. Drying hands from the wrists down to the fingertips.
C. Rinsing hands with the fingers pointing upward toward the elbows.
D. Applying friction for at least 15 to 20 seconds during washing.
,Correct Answer: D
Explanation: Friction is the most important component of handwashing because it
physically removes transient microorganisms from the skin. The nurse should rub all
surfaces of the hands and fingers vigorously for at least 20 seconds. This mechanical action
is essential in breaking the chain of infection in the clinical setting.
3. A patient is placed on Contact Precautions for a wound infection with Methicillin-resistant
Staphylococcus aureus (MRSA). Which personal protective equipment (PPE) must the nurse
don before entering the room?
A. Gloves only.
B. N95 respirator and gloves.
C. Mask and eye protection.
D. Gown and gloves.
Correct Answer: D
Explanation: Contact precautions require the use of gloves and a gown to prevent the
transmission of pathogens through direct or indirect contact. These barriers protect the
nurse’s clothing and skin from contamination by the patient’s environment or drainage.
Adhering to these precautions is critical for preventing healthcare-associated infections.
4. The nurse is assessing a patient with a high risk for falls. Which nursing intervention is the
priority to ensure patient safety?
A. Keeping all four side rails in the upright position.
, B. Placing the bed in the lowest position with the wheels locked.
C. Requesting a prescription for soft wrist restraints.
D. Encouraging the patient to walk to the bathroom independently.
Correct Answer: B
Explanation: Keeping the bed in the lowest position reduces the distance to the floor in the
event of a fall, thereby minimizing potential injury. Locking the wheels prevents the bed
from moving when the patient attempts to transfer. These are standard safety measures
implemented for all hospitalized patients, especially those at high risk.
5. Which stage of the nursing process involves the nurse collecting objective and subjective
data about the patient’s health status?
A. Diagnosis
B. Planning
C. Assessment
D. Implementation
Correct Answer: C
Explanation: Assessment is the first step of the nursing process and involves the
systematic collection of data. This includes performing a physical examination and
interviewing the patient for their history. Accurate assessment is the foundation upon
which the rest of the nursing care plan is built.
