NRSG 100 Final Exam V2 | NRSG 100 Fundamentals
of Nursing | Actual Q&A with Rationale (NRSG100
Final Exam) | Ivy Tech
1. Which phase of the nursing process involves the nurse prioritizing diagnoses and setting
patient-centered goals?
A. Planning
B. Diagnosis
C. Assessment
D. Implementation
Correct Answer: A
Explanation: Planning is the third step of the nursing process where the nurse develops a
care plan based on the identified nursing diagnoses. During this phase, goals and expected
outcomes are established to guide interventions. It requires collaboration with the patient
and the healthcare team to ensure the goals are realistic and measurable.
2. A patient is diagnosed with Clostridium difficile (C. diff). Which infection control measure is
most appropriate for the nurse to implement?
A. Perform hand hygiene with soap and water only
B. Use an alcohol-based hand sanitizer
C. Wear a mask when entering the room
,D. Place the patient in a room with negative pressure
Correct Answer: A
Explanation: Soap and water are required for hand hygiene when caring for patients with
C. diff because alcohol-based sanitizers do not kill the spores. Contact precautions are
necessary to prevent the spread of the bacteria to other patients and staff. The mechanical
friction of handwashing is essential for removing the hardy spores from the skin surface.
3. While assessing a patient’s blood pressure, the nurse notes the cuff is too small for the
patient’s arm. What effect will this have on the reading?
A. The reading will be falsely low
B. The systolic reading will be unaffected
C. The diastolic reading will be unaffected
D. The reading will be falsely high
Correct Answer: D
Explanation: Using a blood pressure cuff that is too narrow or small results in a falsely
high reading because the cuff cannot properly compress the artery. The nurse must select a
cuff width that is approximately 40% of the arm circumference to ensure accuracy. Proper
equipment sizing is a critical component of obtaining reliable vital signs.
4. A nurse is caring for a patient who is at high risk for falls. Which intervention is the priority
according to safety standards?
A. Place the bed in the lowest position
, B. Keep all four side rails in the up position
C. Apply soft wrist restraints
D. Administer a sedative to keep the patient in bed
Correct Answer: A
Explanation: Placing the bed in the lowest position reduces the distance of a potential fall
and is a standard safety intervention. Restraints should only be used as a last resort and
require a physician’s order. Using four side rails is considered a form of restraint and can
increase the risk of injury if the patient tries to climb over them.
5. Which ethical principle is the nurse upholding when they advocate for a patient’s right to
refuse a recommended treatment?
A. Beneficence
B. Justice
C. Autonomy
D. Fidelity
Correct Answer: C
Explanation: Autonomy refers to the patient’s right to make their own decisions regarding
their healthcare without interference. The nurse’s role as an advocate is to ensure the
patient’s choices are respected by the medical team. This principle is foundational to
informed consent and patient-centered care.
of Nursing | Actual Q&A with Rationale (NRSG100
Final Exam) | Ivy Tech
1. Which phase of the nursing process involves the nurse prioritizing diagnoses and setting
patient-centered goals?
A. Planning
B. Diagnosis
C. Assessment
D. Implementation
Correct Answer: A
Explanation: Planning is the third step of the nursing process where the nurse develops a
care plan based on the identified nursing diagnoses. During this phase, goals and expected
outcomes are established to guide interventions. It requires collaboration with the patient
and the healthcare team to ensure the goals are realistic and measurable.
2. A patient is diagnosed with Clostridium difficile (C. diff). Which infection control measure is
most appropriate for the nurse to implement?
A. Perform hand hygiene with soap and water only
B. Use an alcohol-based hand sanitizer
C. Wear a mask when entering the room
,D. Place the patient in a room with negative pressure
Correct Answer: A
Explanation: Soap and water are required for hand hygiene when caring for patients with
C. diff because alcohol-based sanitizers do not kill the spores. Contact precautions are
necessary to prevent the spread of the bacteria to other patients and staff. The mechanical
friction of handwashing is essential for removing the hardy spores from the skin surface.
3. While assessing a patient’s blood pressure, the nurse notes the cuff is too small for the
patient’s arm. What effect will this have on the reading?
A. The reading will be falsely low
B. The systolic reading will be unaffected
C. The diastolic reading will be unaffected
D. The reading will be falsely high
Correct Answer: D
Explanation: Using a blood pressure cuff that is too narrow or small results in a falsely
high reading because the cuff cannot properly compress the artery. The nurse must select a
cuff width that is approximately 40% of the arm circumference to ensure accuracy. Proper
equipment sizing is a critical component of obtaining reliable vital signs.
4. A nurse is caring for a patient who is at high risk for falls. Which intervention is the priority
according to safety standards?
A. Place the bed in the lowest position
, B. Keep all four side rails in the up position
C. Apply soft wrist restraints
D. Administer a sedative to keep the patient in bed
Correct Answer: A
Explanation: Placing the bed in the lowest position reduces the distance of a potential fall
and is a standard safety intervention. Restraints should only be used as a last resort and
require a physician’s order. Using four side rails is considered a form of restraint and can
increase the risk of injury if the patient tries to climb over them.
5. Which ethical principle is the nurse upholding when they advocate for a patient’s right to
refuse a recommended treatment?
A. Beneficence
B. Justice
C. Autonomy
D. Fidelity
Correct Answer: C
Explanation: Autonomy refers to the patient’s right to make their own decisions regarding
their healthcare without interference. The nurse’s role as an advocate is to ensure the
patient’s choices are respected by the medical team. This principle is foundational to
informed consent and patient-centered care.
