,Hondros College NUR 150 Fundamental
Concepts of Practical Nursing I Exam 2 Practice
Pack 2026–2027 | Questions, Answers &
Rationales
Q1. A nurse is caring for an older adult client who is immobile after a hip fracture. Which
finding should the nurse report to the provider immediately?
A. Redness over the sacrum that does not blanch
B. Dry, flaky skin on both heels
C. Mild muscle weakness in the legs
D. Complaint of constipation for 1 day
Correct Answer: A. Redness over the sacrum that does not blanch
Rationale: Nonblanchable redness over the sacrum is a stage 1 pressure injury and indicates
tissue damage from unrelieved pressure. This requires immediate intervention, including
repositioning, pressure-relieving support, and provider notification to prevent progression to
a deeper wound. Dry skin, mild weakness, and 1 day of constipation are important but not
immediately life-threatening. The nurse must prioritize skin integrity because immobility
greatly increases pressure injury risk.
Key Takeaway: Nonblanchable redness means a stage 1 pressure injury; act now.
Q2. A nurse is preparing to perform a sterile dressing change. Which action demonstrates
correct sterile technique?
A. Reaching over the sterile field to obtain supplies
B. Keeping the sterile field below waist level
C. Opening the sterile package away from the body and adding items without touching the
field
D. Using a clean glove to touch the sterile dressing
,Correct Answer: C. Opening the sterile package away from the body and adding items without
touching the field
Rationale: Sterile technique requires that the nurse avoid reaching over the sterile field, keep
the field above waist level, and add items without contaminating them. Using clean gloves to
touch a sterile dressing contaminates the field. Reaching over the field allows microorganisms
from the nurse's clothing or skin to fall into the field. Keeping the field below waist level
contaminates it because the waist and below are considered unsterile areas.
Key Takeaway: Sterile field stays above the waist and is never reached over.
Q3. A nurse is caring for a client who is on contact precautions for a wound infection. Which
action should the nurse take first when leaving the room?
A. Remove gloves, then gown, then perform hand hygiene
B. Perform hand hygiene, then remove gloves and gown
C. Remove gown first, then gloves, then mask
D. Remove mask, then gloves, then gown
Correct Answer: A. Remove gloves, then gown, then perform hand hygiene
Rationale: The correct sequence for removing personal protective equipment is to remove the
gloves first, then the gown, and then perform hand hygiene. If a mask or eye protection was
worn, it is removed after the gown and before hand hygiene, with hand hygiene performed
after removal of all PPE. Removing the gown before the gloves can contaminate the hands.
Performing hand hygiene before removing PPE defeats the purpose. Contact precautions
require gloves and gown for all room entry.
Key Takeaway: Gloves off first, then gown, then hand hygiene.
Q4. A nurse is assessing a client for pain. The client reports pain at a level of 8 on a 0 to 10
scale. Which action should the nurse take first?
A. Administer the prescribed analgesic immediately
B. Reposition the client and reassess in 30 minutes
C. Assess the pain using the client's own report and characteristics of the pain
D. Document the pain score and continue with the shift assessment
, Correct Answer: C. Assess the pain using the client's own report and characteristics of the
pain
Rationale: The nurse must first assess the pain using the client's self-report, which is the most
reliable indicator of pain, and gather details about location, quality, duration, and aggravating
or relieving factors. This assessment guides the choice of intervention. Administering an
analgesic without assessment may be unsafe or inappropriate. Repositioning alone may not
address the cause of pain. Documenting and continuing without intervention delays relief.
Pain is a priority concern and requires prompt assessment and intervention.
Key Takeaway: Pain is what the client says it is; assess before acting.
Q5. A nurse is caring for a client who is at risk for falls. Which action should the nurse take
first?
A. Apply a bed alarm and keep the bed in the lowest position
B. Administer a prescribed sedative to prevent night wandering
C. Place the client in a restraint vest
D. Ask the family to stay at the bedside at all times
Correct Answer: A. Apply a bed alarm and keep the bed in the lowest position
Rationale: The first line of fall prevention includes environmental safety measures such as
keeping the bed in the lowest position, activating a bed alarm, and ensuring call light access.
Restraints require a provider order and are a last resort. Sedatives increase fall risk and should
not be used to prevent wandering. Family presence is helpful but cannot replace nursing
safety interventions. The nurse must use the least restrictive measures first.
Key Takeaway: Lowest bed and bed alarm first; restraints are last resort.
Q6. A nurse is teaching a client about hand hygiene. Which statement by the client indicates
correct understanding?
A. "I should wash my hands for at least 10 seconds."
B. "I should use alcohol-based hand rub when my hands are visibly soiled."
C. "I should wash my hands for at least 20 seconds with soap and water."
D. "I should wear gloves instead of washing my hands."
Concepts of Practical Nursing I Exam 2 Practice
Pack 2026–2027 | Questions, Answers &
Rationales
Q1. A nurse is caring for an older adult client who is immobile after a hip fracture. Which
finding should the nurse report to the provider immediately?
A. Redness over the sacrum that does not blanch
B. Dry, flaky skin on both heels
C. Mild muscle weakness in the legs
D. Complaint of constipation for 1 day
Correct Answer: A. Redness over the sacrum that does not blanch
Rationale: Nonblanchable redness over the sacrum is a stage 1 pressure injury and indicates
tissue damage from unrelieved pressure. This requires immediate intervention, including
repositioning, pressure-relieving support, and provider notification to prevent progression to
a deeper wound. Dry skin, mild weakness, and 1 day of constipation are important but not
immediately life-threatening. The nurse must prioritize skin integrity because immobility
greatly increases pressure injury risk.
Key Takeaway: Nonblanchable redness means a stage 1 pressure injury; act now.
Q2. A nurse is preparing to perform a sterile dressing change. Which action demonstrates
correct sterile technique?
A. Reaching over the sterile field to obtain supplies
B. Keeping the sterile field below waist level
C. Opening the sterile package away from the body and adding items without touching the
field
D. Using a clean glove to touch the sterile dressing
,Correct Answer: C. Opening the sterile package away from the body and adding items without
touching the field
Rationale: Sterile technique requires that the nurse avoid reaching over the sterile field, keep
the field above waist level, and add items without contaminating them. Using clean gloves to
touch a sterile dressing contaminates the field. Reaching over the field allows microorganisms
from the nurse's clothing or skin to fall into the field. Keeping the field below waist level
contaminates it because the waist and below are considered unsterile areas.
Key Takeaway: Sterile field stays above the waist and is never reached over.
Q3. A nurse is caring for a client who is on contact precautions for a wound infection. Which
action should the nurse take first when leaving the room?
A. Remove gloves, then gown, then perform hand hygiene
B. Perform hand hygiene, then remove gloves and gown
C. Remove gown first, then gloves, then mask
D. Remove mask, then gloves, then gown
Correct Answer: A. Remove gloves, then gown, then perform hand hygiene
Rationale: The correct sequence for removing personal protective equipment is to remove the
gloves first, then the gown, and then perform hand hygiene. If a mask or eye protection was
worn, it is removed after the gown and before hand hygiene, with hand hygiene performed
after removal of all PPE. Removing the gown before the gloves can contaminate the hands.
Performing hand hygiene before removing PPE defeats the purpose. Contact precautions
require gloves and gown for all room entry.
Key Takeaway: Gloves off first, then gown, then hand hygiene.
Q4. A nurse is assessing a client for pain. The client reports pain at a level of 8 on a 0 to 10
scale. Which action should the nurse take first?
A. Administer the prescribed analgesic immediately
B. Reposition the client and reassess in 30 minutes
C. Assess the pain using the client's own report and characteristics of the pain
D. Document the pain score and continue with the shift assessment
, Correct Answer: C. Assess the pain using the client's own report and characteristics of the
pain
Rationale: The nurse must first assess the pain using the client's self-report, which is the most
reliable indicator of pain, and gather details about location, quality, duration, and aggravating
or relieving factors. This assessment guides the choice of intervention. Administering an
analgesic without assessment may be unsafe or inappropriate. Repositioning alone may not
address the cause of pain. Documenting and continuing without intervention delays relief.
Pain is a priority concern and requires prompt assessment and intervention.
Key Takeaway: Pain is what the client says it is; assess before acting.
Q5. A nurse is caring for a client who is at risk for falls. Which action should the nurse take
first?
A. Apply a bed alarm and keep the bed in the lowest position
B. Administer a prescribed sedative to prevent night wandering
C. Place the client in a restraint vest
D. Ask the family to stay at the bedside at all times
Correct Answer: A. Apply a bed alarm and keep the bed in the lowest position
Rationale: The first line of fall prevention includes environmental safety measures such as
keeping the bed in the lowest position, activating a bed alarm, and ensuring call light access.
Restraints require a provider order and are a last resort. Sedatives increase fall risk and should
not be used to prevent wandering. Family presence is helpful but cannot replace nursing
safety interventions. The nurse must use the least restrictive measures first.
Key Takeaway: Lowest bed and bed alarm first; restraints are last resort.
Q6. A nurse is teaching a client about hand hygiene. Which statement by the client indicates
correct understanding?
A. "I should wash my hands for at least 10 seconds."
B. "I should use alcohol-based hand rub when my hands are visibly soiled."
C. "I should wash my hands for at least 20 seconds with soap and water."
D. "I should wear gloves instead of washing my hands."
