NRSG 100 Exam 2 V2 | NRSG 100 Fundamentals of
Nursing | Actual Q&A with Rationale (NRSG100
Exam 2) | Ivy Tech
1. A nurse is performing hand hygiene before providing care. Which action by the nurse
represents the most effective technique for destroying microorganisms?
A. Rinsing hands with hot water to kill bacteria
B. Applying friction for at least 20 seconds while washing
C. Using a communal bar of soap for mechanical cleaning
D. Drying hands from the elbows down to the fingertips
Correct Answer: B
Explanation: Friction is the most important component of handwashing because it
mechanically removes microorganisms from the skin. The CDC recommends scrubbing all
surfaces of the hands for at least 20 seconds to ensure adequate decontamination. This
practice is essential in preventing healthcare-associated infections within the clinical
setting.
2. When removing personal protective equipment (PPE) after caring for a patient on contact
precautions, which item should the nurse remove first?
A. Gloves
B. Gown
,C. Mask
D. Goggles
Correct Answer: A
Explanation: The gloves are considered the most contaminated piece of PPE and should be
removed first to prevent cross-contamination. Following glove removal, the nurse typically
removes eye protection and the gown, then the mask last. Proper doffing sequence is
critical for maintaining the safety of the healthcare worker and preventing the spread of
pathogens.
3. A nurse is assessing a patient’s radial and apical pulses simultaneously and notes a
difference between the two rates. What is this clinical finding called?
A. Pulse pressure
B. Pulse deficit
C. Pulse rhythm
D. Pulse amplitude
Correct Answer: B
Explanation: A pulse deficit occurs when the radial pulse rate is lower than the apical
pulse rate, indicating that some heart contractions are not strong enough to perfuse the
peripheral arteries. This condition is often associated with dysrhythmias such as atrial
fibrillation. The nurse should report this finding as it suggests a decrease in cardiac output
efficiency.
, 4. The nurse is preparing to measure a patient’s blood pressure. Which action should the
nurse take to ensure an accurate reading?
A. Use a cuff with a bladder that covers 20% of the arm circumference
B. Use a cuff with a bladder width that is 40% of the arm circumference
C. Position the patient’s arm above the level of the heart
D. Deflate the cuff at a rate of 10 mmHg per second
Correct Answer: B
Explanation: Selecting the correct cuff size is vital; the bladder width should be
approximately 40% of the arm circumference to avoid false readings. A cuff that is too
small will yield a falsely high reading, while one that is too large will yield a falsely low
reading. Proper technique ensures that clinical decisions are based on accurate
physiological data.
5. A patient is diagnosed with orthostatic hypotension. Which finding would the nurse expect
when assessing this patient’s blood pressure?
A. A rise in systolic blood pressure when standing
B. A decrease in heart rate when moving from lying to sitting
C. A decrease in systolic pressure of at least 20 mmHg when standing
D. An increase in diastolic pressure of 15 mmHg when sitting
Correct Answer: C
Nursing | Actual Q&A with Rationale (NRSG100
Exam 2) | Ivy Tech
1. A nurse is performing hand hygiene before providing care. Which action by the nurse
represents the most effective technique for destroying microorganisms?
A. Rinsing hands with hot water to kill bacteria
B. Applying friction for at least 20 seconds while washing
C. Using a communal bar of soap for mechanical cleaning
D. Drying hands from the elbows down to the fingertips
Correct Answer: B
Explanation: Friction is the most important component of handwashing because it
mechanically removes microorganisms from the skin. The CDC recommends scrubbing all
surfaces of the hands for at least 20 seconds to ensure adequate decontamination. This
practice is essential in preventing healthcare-associated infections within the clinical
setting.
2. When removing personal protective equipment (PPE) after caring for a patient on contact
precautions, which item should the nurse remove first?
A. Gloves
B. Gown
,C. Mask
D. Goggles
Correct Answer: A
Explanation: The gloves are considered the most contaminated piece of PPE and should be
removed first to prevent cross-contamination. Following glove removal, the nurse typically
removes eye protection and the gown, then the mask last. Proper doffing sequence is
critical for maintaining the safety of the healthcare worker and preventing the spread of
pathogens.
3. A nurse is assessing a patient’s radial and apical pulses simultaneously and notes a
difference between the two rates. What is this clinical finding called?
A. Pulse pressure
B. Pulse deficit
C. Pulse rhythm
D. Pulse amplitude
Correct Answer: B
Explanation: A pulse deficit occurs when the radial pulse rate is lower than the apical
pulse rate, indicating that some heart contractions are not strong enough to perfuse the
peripheral arteries. This condition is often associated with dysrhythmias such as atrial
fibrillation. The nurse should report this finding as it suggests a decrease in cardiac output
efficiency.
, 4. The nurse is preparing to measure a patient’s blood pressure. Which action should the
nurse take to ensure an accurate reading?
A. Use a cuff with a bladder that covers 20% of the arm circumference
B. Use a cuff with a bladder width that is 40% of the arm circumference
C. Position the patient’s arm above the level of the heart
D. Deflate the cuff at a rate of 10 mmHg per second
Correct Answer: B
Explanation: Selecting the correct cuff size is vital; the bladder width should be
approximately 40% of the arm circumference to avoid false readings. A cuff that is too
small will yield a falsely high reading, while one that is too large will yield a falsely low
reading. Proper technique ensures that clinical decisions are based on accurate
physiological data.
5. A patient is diagnosed with orthostatic hypotension. Which finding would the nurse expect
when assessing this patient’s blood pressure?
A. A rise in systolic blood pressure when standing
B. A decrease in heart rate when moving from lying to sitting
C. A decrease in systolic pressure of at least 20 mmHg when standing
D. An increase in diastolic pressure of 15 mmHg when sitting
Correct Answer: C
