NSG 104 — Nursing Skills Questions and
Correct Answers (Verified Answers) Plus
Rationale 2027 Q&A| Instant Download Pdf
1. Which action is most important before performing any nursing
procedure that involves direct patient contact?
A. Document the procedure
B. Gather all supplies
C. Perform hand hygiene
D. Apply clean gloves
Answer: C. Perform hand hygiene
Rationale: Hand hygiene is the most important measure for
preventing the transmission of microorganisms. It should be
performed before and after patient contact and before clean or
aseptic procedures.
2. Which position is generally most appropriate for administering
oral medications to an alert patient?
A. Prone
B. Supine
,C. Fowler's
D. Trendelenburg
Answer: C. Fowler's
Rationale: Fowler's position promotes swallowing and reduces the risk
of aspiration. An upright or semi-upright position is preferred when
administering oral medications.
3. A nurse is preparing to administer medication through a feeding
tube. What should the nurse do first?
A. Crush all medications together
B. Verify tube placement according to facility policy
C. Add medication directly to the feeding formula
D. Flush the tube after administering all medications
Answer: B. Verify tube placement according to facility policy
Rationale: Correct tube placement must be established before
medication administration to reduce the risk of administering
medication into an inappropriate location. Medications should also
generally be administered separately and with appropriate flushing.
4. Which device is commonly used to measure a patient's oxygen
saturation?
,A. Sphygmomanometer
B. Stethoscope
C. Pulse oximeter
D. Peak-flow meter
Answer: C. Pulse oximeter
Rationale: A pulse oximeter uses a sensor to estimate peripheral
oxygen saturation and also provides a pulse rate. It is commonly
placed on a finger, toe, or other appropriate site.
5. Which finding should the nurse recognize as a possible indication
of impaired oxygenation?
A. Pink skin
B. Respiratory rate of 16 breaths/minute
C. Cyanosis
D. Warm extremities
Answer: C. Cyanosis
Rationale: Cyanosis is a bluish discoloration of the skin or mucous
membranes that may occur with inadequate oxygenation. It requires
prompt assessment and consideration of the patient's overall clinical
condition.
, 6. When measuring blood pressure manually, where should the
nurse place the blood pressure cuff?
A. Over the elbow joint
B. Around the forearm only
C. With the bladder centered over the brachial artery
D. Directly over the patient's wrist
Answer: C. With the bladder centered over the brachial artery
Rationale: Correct cuff placement is necessary for an accurate blood
pressure measurement. The inflatable bladder should be
appropriately positioned over the brachial artery.
7. A blood pressure cuff that is too small for the patient's arm may
produce which result?
A. Falsely low blood pressure
B. Falsely high blood pressure
C. No effect on the reading
D. An inaccurate pulse rate only
Answer: B. Falsely high blood pressure
Rationale: A cuff that is too small can cause the blood pressure
reading to be falsely elevated. The cuff should be appropriately sized
for the patient's arm circumference.
Correct Answers (Verified Answers) Plus
Rationale 2027 Q&A| Instant Download Pdf
1. Which action is most important before performing any nursing
procedure that involves direct patient contact?
A. Document the procedure
B. Gather all supplies
C. Perform hand hygiene
D. Apply clean gloves
Answer: C. Perform hand hygiene
Rationale: Hand hygiene is the most important measure for
preventing the transmission of microorganisms. It should be
performed before and after patient contact and before clean or
aseptic procedures.
2. Which position is generally most appropriate for administering
oral medications to an alert patient?
A. Prone
B. Supine
,C. Fowler's
D. Trendelenburg
Answer: C. Fowler's
Rationale: Fowler's position promotes swallowing and reduces the risk
of aspiration. An upright or semi-upright position is preferred when
administering oral medications.
3. A nurse is preparing to administer medication through a feeding
tube. What should the nurse do first?
A. Crush all medications together
B. Verify tube placement according to facility policy
C. Add medication directly to the feeding formula
D. Flush the tube after administering all medications
Answer: B. Verify tube placement according to facility policy
Rationale: Correct tube placement must be established before
medication administration to reduce the risk of administering
medication into an inappropriate location. Medications should also
generally be administered separately and with appropriate flushing.
4. Which device is commonly used to measure a patient's oxygen
saturation?
,A. Sphygmomanometer
B. Stethoscope
C. Pulse oximeter
D. Peak-flow meter
Answer: C. Pulse oximeter
Rationale: A pulse oximeter uses a sensor to estimate peripheral
oxygen saturation and also provides a pulse rate. It is commonly
placed on a finger, toe, or other appropriate site.
5. Which finding should the nurse recognize as a possible indication
of impaired oxygenation?
A. Pink skin
B. Respiratory rate of 16 breaths/minute
C. Cyanosis
D. Warm extremities
Answer: C. Cyanosis
Rationale: Cyanosis is a bluish discoloration of the skin or mucous
membranes that may occur with inadequate oxygenation. It requires
prompt assessment and consideration of the patient's overall clinical
condition.
, 6. When measuring blood pressure manually, where should the
nurse place the blood pressure cuff?
A. Over the elbow joint
B. Around the forearm only
C. With the bladder centered over the brachial artery
D. Directly over the patient's wrist
Answer: C. With the bladder centered over the brachial artery
Rationale: Correct cuff placement is necessary for an accurate blood
pressure measurement. The inflatable bladder should be
appropriately positioned over the brachial artery.
7. A blood pressure cuff that is too small for the patient's arm may
produce which result?
A. Falsely low blood pressure
B. Falsely high blood pressure
C. No effect on the reading
D. An inaccurate pulse rate only
Answer: B. Falsely high blood pressure
Rationale: A cuff that is too small can cause the blood pressure
reading to be falsely elevated. The cuff should be appropriately sized
for the patient's arm circumference.
