NRSG 100 Exam 2 V1 | NRSG 100 Fundamentals of
Nursing | Actual Q&A with Rationale (NRSG100
Exam 2) | Ivy Tech
1. Which action is the priority for a nurse to prevent the spread of healthcare-associated
infections?
A. Wearing a clean gown for every patient contact
B. Ensuring all patients are in private rooms
C. Using sterile gloves for all patient interactions
D. Performing hand hygiene before and after patient care
Correct Answer: D
Explanation: Hand hygiene is the single most effective method for preventing the
transmission of pathogens in the healthcare setting. It should be performed according to
WHO/CDC guidelines, including before and after patient contact. Failure to maintain hand
hygiene is the primary cause of healthcare-associated infections.
2. When measuring a patient’s blood pressure, which error would result in a falsely high
reading?
A. Using a cuff that is too wide
B. Releasing the valve too rapidly
C. Using a cuff that is too narrow
,D. Positioning the arm above the level of the heart
Correct Answer: C
Explanation: A blood pressure cuff that is too narrow or too small for the patient’s arm
circumference will yield a falsely high reading. The pressure required to occlude the artery
is overestimated by the small bladder size. Conversely, a cuff that is too wide will provide a
falsely low reading.
3. A nurse is caring for a patient on contact precautions. Which personal protective
equipment (PPE) is required?
A. Gown and gloves
B. N95 respirator and goggles
C. Surgical mask and shoe covers
D. No PPE is required if the nurse stays 3 feet away
Correct Answer: A
Explanation: Contact precautions require the use of a gown and gloves to prevent the
spread of organisms through direct or indirect contact with the patient or their
environment. These items should be donned before entering the room and removed before
leaving. This protocol is commonly used for infections like MRSA or VRE.
4. Which assessment finding is considered subjective data?
A. The patient states, ‘I feel dizzy’
, B. Blood pressure of 140/90 mmHg
C. Respiratory rate of 22 breaths per minute
D. A 2 cm stage II pressure injury
Correct Answer: A
Explanation: Subjective data consists of information provided by the patient that cannot
be independently measured or observed by the nurse. Symptoms such as pain, nausea, and
dizziness fall into this category. Objective data, in contrast, includes measurable signs like
vital signs or physical findings.
5. The nurse is implementing the RACE acronym during a fire. What does the ‘E’ stand for?
A. Extinguish
B. Evacuate everyone
C. Examine the area
D. Exit the building
Correct Answer: A
Explanation: The RACE acronym stands for Rescue, Alarm, Confine, and Extinguish. After
ensuring safety and sounding the alarm, the nurse may attempt to extinguish a small fire
using a portable fire extinguisher. If the fire is too large, evacuation becomes the priority.
6. What is the most appropriate position for a patient receiving an enema?
A. High Fowler’s
Nursing | Actual Q&A with Rationale (NRSG100
Exam 2) | Ivy Tech
1. Which action is the priority for a nurse to prevent the spread of healthcare-associated
infections?
A. Wearing a clean gown for every patient contact
B. Ensuring all patients are in private rooms
C. Using sterile gloves for all patient interactions
D. Performing hand hygiene before and after patient care
Correct Answer: D
Explanation: Hand hygiene is the single most effective method for preventing the
transmission of pathogens in the healthcare setting. It should be performed according to
WHO/CDC guidelines, including before and after patient contact. Failure to maintain hand
hygiene is the primary cause of healthcare-associated infections.
2. When measuring a patient’s blood pressure, which error would result in a falsely high
reading?
A. Using a cuff that is too wide
B. Releasing the valve too rapidly
C. Using a cuff that is too narrow
,D. Positioning the arm above the level of the heart
Correct Answer: C
Explanation: A blood pressure cuff that is too narrow or too small for the patient’s arm
circumference will yield a falsely high reading. The pressure required to occlude the artery
is overestimated by the small bladder size. Conversely, a cuff that is too wide will provide a
falsely low reading.
3. A nurse is caring for a patient on contact precautions. Which personal protective
equipment (PPE) is required?
A. Gown and gloves
B. N95 respirator and goggles
C. Surgical mask and shoe covers
D. No PPE is required if the nurse stays 3 feet away
Correct Answer: A
Explanation: Contact precautions require the use of a gown and gloves to prevent the
spread of organisms through direct or indirect contact with the patient or their
environment. These items should be donned before entering the room and removed before
leaving. This protocol is commonly used for infections like MRSA or VRE.
4. Which assessment finding is considered subjective data?
A. The patient states, ‘I feel dizzy’
, B. Blood pressure of 140/90 mmHg
C. Respiratory rate of 22 breaths per minute
D. A 2 cm stage II pressure injury
Correct Answer: A
Explanation: Subjective data consists of information provided by the patient that cannot
be independently measured or observed by the nurse. Symptoms such as pain, nausea, and
dizziness fall into this category. Objective data, in contrast, includes measurable signs like
vital signs or physical findings.
5. The nurse is implementing the RACE acronym during a fire. What does the ‘E’ stand for?
A. Extinguish
B. Evacuate everyone
C. Examine the area
D. Exit the building
Correct Answer: A
Explanation: The RACE acronym stands for Rescue, Alarm, Confine, and Extinguish. After
ensuring safety and sounding the alarm, the nurse may attempt to extinguish a small fire
using a portable fire extinguisher. If the fire is too large, evacuation becomes the priority.
6. What is the most appropriate position for a patient receiving an enema?
A. High Fowler’s
