NRSG 100 Final Exam V1 | NRSG 100 Fundamentals
of Nursing | Actual Q&A with Rationale (NRSG100
Final Exam) | Ivy Tech
1. A nurse is preparing to perform a physical assessment on a newly admitted patient. Which
phase of the nursing process involves the systematic collection of patient data?
A. Planning
B. Implementation
C. Assessment
D. Diagnosis
Correct Answer: C
Explanation: Assessment is the first step of the nursing process and involves collecting,
validating, and communicating patient data. This phase sets the foundation for all
subsequent steps in providing individualized care. Accurate assessment ensures that the
nurse identifies the patient’s actual and potential health needs effectively.
2. When assessing a patient’s blood pressure, the nurse notices the cuff is too small for the
patient’s arm. What effect will this have on the reading?
A. The blood pressure reading will be falsely high.
B. The blood pressure reading will be falsely low.
C. The reading will be unaffected but difficult to hear.
,D. The diastolic pressure will be accurate, but the systolic will be low.
Correct Answer: A
Explanation: Using a blood pressure cuff that is too narrow or small for the patient’s arm
circumference will result in a reading that is falsely elevated. This occurs because the cuff
must be inflated to a higher pressure to occlude the artery in a larger arm. Ensuring correct
cuff size is critical for diagnostic accuracy and patient safety in clinical practice.
3. A nurse discovers a fire in a patient’s trash can. According to the RACE acronym, which
action should the nurse perform first?
A. Rescue the patient from immediate danger.
B. Activate the fire alarm system.
C. Extinguish the fire using a portable extinguisher.
D. Close the doors to the patient’s room.
Correct Answer: A
Explanation: The RACE acronym stands for Rescue, Alarm, Contain, and
Extinguish/Evacuate. In any fire situation, the primary priority is the safety of the patients
who are in immediate danger. Once patients are moved to safety, the nurse should proceed
to activate the alarm and contain the fire.
4. Which nursing intervention is the most effective way to prevent the spread of healthcare-
associated infections?
A. Wearing gloves for all patient contact.
, B. Performing consistent and thorough hand hygiene.
C. Administering prophylactic antibiotics.
D. Ensuring all patients are in private rooms.
Correct Answer: B
Explanation: Hand hygiene is widely recognized as the single most effective method for
preventing the transmission of pathogens in the healthcare environment. It should be
performed before and after patient contact, after removing gloves, and when moving from
a contaminated body site to a clean one. Adherence to hand hygiene protocols significantly
reduces the incidence of hospital-acquired infections.
5. A nurse is caring for a patient who is at high risk for falls. Which of the following is the most
appropriate nursing intervention?
A. Apply wrist restraints to keep the patient in bed.
B. Place all four side rails in the upright position.
C. Keep the bed in the lowest position and ensure the call light is within reach.
D. Instruct the patient to wait at least 30 minutes before getting out of bed after calling for
help.
Correct Answer: C
Explanation: Safety measures such as keeping the bed low and the call light accessible are
standard nursing interventions to reduce fall risks. These actions empower the patient to
of Nursing | Actual Q&A with Rationale (NRSG100
Final Exam) | Ivy Tech
1. A nurse is preparing to perform a physical assessment on a newly admitted patient. Which
phase of the nursing process involves the systematic collection of patient data?
A. Planning
B. Implementation
C. Assessment
D. Diagnosis
Correct Answer: C
Explanation: Assessment is the first step of the nursing process and involves collecting,
validating, and communicating patient data. This phase sets the foundation for all
subsequent steps in providing individualized care. Accurate assessment ensures that the
nurse identifies the patient’s actual and potential health needs effectively.
2. When assessing a patient’s blood pressure, the nurse notices the cuff is too small for the
patient’s arm. What effect will this have on the reading?
A. The blood pressure reading will be falsely high.
B. The blood pressure reading will be falsely low.
C. The reading will be unaffected but difficult to hear.
,D. The diastolic pressure will be accurate, but the systolic will be low.
Correct Answer: A
Explanation: Using a blood pressure cuff that is too narrow or small for the patient’s arm
circumference will result in a reading that is falsely elevated. This occurs because the cuff
must be inflated to a higher pressure to occlude the artery in a larger arm. Ensuring correct
cuff size is critical for diagnostic accuracy and patient safety in clinical practice.
3. A nurse discovers a fire in a patient’s trash can. According to the RACE acronym, which
action should the nurse perform first?
A. Rescue the patient from immediate danger.
B. Activate the fire alarm system.
C. Extinguish the fire using a portable extinguisher.
D. Close the doors to the patient’s room.
Correct Answer: A
Explanation: The RACE acronym stands for Rescue, Alarm, Contain, and
Extinguish/Evacuate. In any fire situation, the primary priority is the safety of the patients
who are in immediate danger. Once patients are moved to safety, the nurse should proceed
to activate the alarm and contain the fire.
4. Which nursing intervention is the most effective way to prevent the spread of healthcare-
associated infections?
A. Wearing gloves for all patient contact.
, B. Performing consistent and thorough hand hygiene.
C. Administering prophylactic antibiotics.
D. Ensuring all patients are in private rooms.
Correct Answer: B
Explanation: Hand hygiene is widely recognized as the single most effective method for
preventing the transmission of pathogens in the healthcare environment. It should be
performed before and after patient contact, after removing gloves, and when moving from
a contaminated body site to a clean one. Adherence to hand hygiene protocols significantly
reduces the incidence of hospital-acquired infections.
5. A nurse is caring for a patient who is at high risk for falls. Which of the following is the most
appropriate nursing intervention?
A. Apply wrist restraints to keep the patient in bed.
B. Place all four side rails in the upright position.
C. Keep the bed in the lowest position and ensure the call light is within reach.
D. Instruct the patient to wait at least 30 minutes before getting out of bed after calling for
help.
Correct Answer: C
Explanation: Safety measures such as keeping the bed low and the call light accessible are
standard nursing interventions to reduce fall risks. These actions empower the patient to
