PNR 106/PNR106 Exam 2 V2 | Foundations
of Nursing Q&A with Rationale | Fortis
College
1. When measuring a patient’s blood pressure, which action by the nurse ensures an accurate
reading?
A. Placing the cuff over the patient’s thick sweater sleeve.
B. Deflating the cuff quickly at a rate of 10 mmHg per second.
C. Positioning the patient’s arm above the level of the heart.
D. Using a cuff with a bladder width that is 40% of the arm circumference.
Correct Answer: D
Expert Explanation: The nurse must use a blood pressure cuff of the correct size to ensure
diagnostic accuracy. A bladder width of approximately 40% of the arm circumference is the
clinical standard for adult patients. Using a cuff that is too small or too large will result in
false high or false low readings respectively.
2. A nurse is caring for a client who is under contact precautions. Which of the following
items of personal protective equipment (PPE) should the nurse put on first?
A. Gloves
B. Goggles
C. Mask
,D. Gown
Correct Answer: D
Expert Explanation: When donning PPE for contact precautions, the nurse should follow
the standard sequence starting with the gown. The gown provides the largest area of
protection for the nurse’s clothing from contaminated surfaces. Following this, the mask,
goggles, and finally gloves are applied to ensure full coverage.
3. A nurse is documenting patient care in a medical record. Which of the following entries is
an example of objective data?
A. ‘The patient states that their leg feels like it is burning.’
B. ‘The patient reports feeling nauseated after eating breakfast.’
C. ‘The patient says they are worried about the upcoming surgery.’
D. ‘The patient’s skin is warm and dry to the touch.’
Correct Answer: D
Expert Explanation: Objective data consists of observable and measurable signs that the
nurse can see, hear, feel, or smell. In this case, skin temperature and moisture are physical
findings gathered through palpation. Subjective data, by contrast, includes the patient’s
personal perceptions and feelings that cannot be verified by the nurse.
4. A nurse discovers a small fire in a trash can in a patient’s room. According to the RACE
acronym, which action should the nurse perform first?
A. Activate the fire alarm system.
, B. Extinguish the fire with a portable extinguisher.
C. Confine the fire by closing the door.
D. Rescue the patient from immediate danger.
Correct Answer: D
Expert Explanation: The RACE acronym stands for Rescue, Alarm, Confine, and
Extinguish. The nurse’s immediate priority in any fire situation is the safety of the patients
in the immediate area. Once the patient is moved to safety, the nurse can proceed to
activate the alarm and contain the fire.
5. According to Maslow’s Hierarchy of Needs, which of the following patient needs should the
nurse prioritize?
A. A patient’s need for social interaction with family.
B. A patient’s need for oxygenation and airway patency.
C. A patient’s need for self-esteem and recognition.
D. A patient’s need for a safe and secure environment.
Correct Answer: B
Expert Explanation: Maslow’s Hierarchy identifies physiological needs as the foundation
of human health and survival. Oxygenation, fluids, and nutrition are at the base of the
pyramid and must be addressed before higher-level needs. Therefore, a patient with a
respiratory issue takes priority over patients seeking social or emotional support.
of Nursing Q&A with Rationale | Fortis
College
1. When measuring a patient’s blood pressure, which action by the nurse ensures an accurate
reading?
A. Placing the cuff over the patient’s thick sweater sleeve.
B. Deflating the cuff quickly at a rate of 10 mmHg per second.
C. Positioning the patient’s arm above the level of the heart.
D. Using a cuff with a bladder width that is 40% of the arm circumference.
Correct Answer: D
Expert Explanation: The nurse must use a blood pressure cuff of the correct size to ensure
diagnostic accuracy. A bladder width of approximately 40% of the arm circumference is the
clinical standard for adult patients. Using a cuff that is too small or too large will result in
false high or false low readings respectively.
2. A nurse is caring for a client who is under contact precautions. Which of the following
items of personal protective equipment (PPE) should the nurse put on first?
A. Gloves
B. Goggles
C. Mask
,D. Gown
Correct Answer: D
Expert Explanation: When donning PPE for contact precautions, the nurse should follow
the standard sequence starting with the gown. The gown provides the largest area of
protection for the nurse’s clothing from contaminated surfaces. Following this, the mask,
goggles, and finally gloves are applied to ensure full coverage.
3. A nurse is documenting patient care in a medical record. Which of the following entries is
an example of objective data?
A. ‘The patient states that their leg feels like it is burning.’
B. ‘The patient reports feeling nauseated after eating breakfast.’
C. ‘The patient says they are worried about the upcoming surgery.’
D. ‘The patient’s skin is warm and dry to the touch.’
Correct Answer: D
Expert Explanation: Objective data consists of observable and measurable signs that the
nurse can see, hear, feel, or smell. In this case, skin temperature and moisture are physical
findings gathered through palpation. Subjective data, by contrast, includes the patient’s
personal perceptions and feelings that cannot be verified by the nurse.
4. A nurse discovers a small fire in a trash can in a patient’s room. According to the RACE
acronym, which action should the nurse perform first?
A. Activate the fire alarm system.
, B. Extinguish the fire with a portable extinguisher.
C. Confine the fire by closing the door.
D. Rescue the patient from immediate danger.
Correct Answer: D
Expert Explanation: The RACE acronym stands for Rescue, Alarm, Confine, and
Extinguish. The nurse’s immediate priority in any fire situation is the safety of the patients
in the immediate area. Once the patient is moved to safety, the nurse can proceed to
activate the alarm and contain the fire.
5. According to Maslow’s Hierarchy of Needs, which of the following patient needs should the
nurse prioritize?
A. A patient’s need for social interaction with family.
B. A patient’s need for oxygenation and airway patency.
C. A patient’s need for self-esteem and recognition.
D. A patient’s need for a safe and secure environment.
Correct Answer: B
Expert Explanation: Maslow’s Hierarchy identifies physiological needs as the foundation
of human health and survival. Oxygenation, fluids, and nutrition are at the base of the
pyramid and must be addressed before higher-level needs. Therefore, a patient with a
respiratory issue takes priority over patients seeking social or emotional support.
