NRSG 100 Exam 2 V3 | NRSG 100 Fundamentals of
Nursing | Actual Q&A with Rationale (NRSG100
Exam 2) | Ivy Tech
1. When a nurse is performing hand hygiene, which action is considered the most critical for
the removal of transient microorganisms?
A. Using hot water to kill bacteria
B. Applying friction for at least 20 seconds
C. Using antibacterial soap exclusively
D. Drying hands from wrists to fingers
Correct Answer: B
Explanation: Friction is the most effective way to mechanically loosen and remove
transient bacteria from the skin surface. The CDC recommends scrubbing for at least 20
seconds to ensure adequate coverage. This process is essential in preventing healthcare-
associated infections.
2. A nurse is caring for a patient with Clostridioides difficile (C. diff). Which infection control
measure is mandatory for this specific pathogen?
A. Wearing an N95 respirator
B. Using alcohol-based hand sanitizer after care
C. Keeping the room door closed at all times
,D. Performing hand hygiene with soap and water
Correct Answer: D
Explanation: C. diff spores are resistant to alcohol-based sanitizers, requiring mechanical
removal through soap and water. Scrubbing and rinsing are necessary to physically wash
the spores off the hands. This is a core competency in contact-plus precautions for Ivy Tech
nursing students.
3. Which assessment finding should the nurse prioritize as a risk factor for falls using the
Morse Fall Scale?
A. History of falling within the last 3 months
B. Age greater than 65 years
C. A diagnosis of hypertension
D. Patient request for a bedside commode
Correct Answer: A
Explanation: A history of recent falls is the strongest predictor of future falls according to
standardized scales. This factor receives high point values when calculating a patient’s risk
level. Identifying this history allows the nurse to implement specific safety interventions
immediately.
4. When assessing a patient’s blood pressure, the nurse notes the cuff is too small for the
patient’s arm. What is the most likely result of this measurement?
A. A false low systolic reading
, B. A false high systolic and diastolic reading
C. A reading that is only accurate for the diastolic pressure
D. An inability to auscultate Korotkoff sounds
Correct Answer: B
Explanation: A cuff that is too small requires more pressure to occlude the artery,
resulting in an artificially elevated reading. Proper cuff sizing involves the bladder
encircling 80 percent of the arm. This is a common vital signs error tested in fundamental
nursing courses.
5. A nurse is preparing to transfer a patient from the bed to a chair. Which principle of body
mechanics should the nurse implement?
A. Keep the feet close together for stability
B. Pivot the feet rather than twisting the spine
C. Bend at the waist to reach the patient
D. Hold the patient at arm’s length
Correct Answer: B
Explanation: Pivoting prevents spinal strain and potential injury to the nurse’s back
during transfers. Keeping the center of gravity low and the base of support wide further
enhances safety. These principles are fundamental to protecting both the healthcare
worker and the patient.
Nursing | Actual Q&A with Rationale (NRSG100
Exam 2) | Ivy Tech
1. When a nurse is performing hand hygiene, which action is considered the most critical for
the removal of transient microorganisms?
A. Using hot water to kill bacteria
B. Applying friction for at least 20 seconds
C. Using antibacterial soap exclusively
D. Drying hands from wrists to fingers
Correct Answer: B
Explanation: Friction is the most effective way to mechanically loosen and remove
transient bacteria from the skin surface. The CDC recommends scrubbing for at least 20
seconds to ensure adequate coverage. This process is essential in preventing healthcare-
associated infections.
2. A nurse is caring for a patient with Clostridioides difficile (C. diff). Which infection control
measure is mandatory for this specific pathogen?
A. Wearing an N95 respirator
B. Using alcohol-based hand sanitizer after care
C. Keeping the room door closed at all times
,D. Performing hand hygiene with soap and water
Correct Answer: D
Explanation: C. diff spores are resistant to alcohol-based sanitizers, requiring mechanical
removal through soap and water. Scrubbing and rinsing are necessary to physically wash
the spores off the hands. This is a core competency in contact-plus precautions for Ivy Tech
nursing students.
3. Which assessment finding should the nurse prioritize as a risk factor for falls using the
Morse Fall Scale?
A. History of falling within the last 3 months
B. Age greater than 65 years
C. A diagnosis of hypertension
D. Patient request for a bedside commode
Correct Answer: A
Explanation: A history of recent falls is the strongest predictor of future falls according to
standardized scales. This factor receives high point values when calculating a patient’s risk
level. Identifying this history allows the nurse to implement specific safety interventions
immediately.
4. When assessing a patient’s blood pressure, the nurse notes the cuff is too small for the
patient’s arm. What is the most likely result of this measurement?
A. A false low systolic reading
, B. A false high systolic and diastolic reading
C. A reading that is only accurate for the diastolic pressure
D. An inability to auscultate Korotkoff sounds
Correct Answer: B
Explanation: A cuff that is too small requires more pressure to occlude the artery,
resulting in an artificially elevated reading. Proper cuff sizing involves the bladder
encircling 80 percent of the arm. This is a common vital signs error tested in fundamental
nursing courses.
5. A nurse is preparing to transfer a patient from the bed to a chair. Which principle of body
mechanics should the nurse implement?
A. Keep the feet close together for stability
B. Pivot the feet rather than twisting the spine
C. Bend at the waist to reach the patient
D. Hold the patient at arm’s length
Correct Answer: B
Explanation: Pivoting prevents spinal strain and potential injury to the nurse’s back
during transfers. Keeping the center of gravity low and the base of support wide further
enhances safety. These principles are fundamental to protecting both the healthcare
worker and the patient.
