NURS 101L | Fundamentals of Nursing Skills Lab | Exam 1 2026 |WCU
1. When performing hand hygiene with soap and water, what is the minimum
duration the nurse should rub all surfaces of the hands with friction?
A. 5 to 10 seconds
B. 15 to 20 seconds
C. 10 to 15 seconds
D. 30 to 60 seconds
Answer: B
Rationale: According to CDC and standard nursing guidelines, friction should be applied
for at least 15 to 20 seconds to effectively remove transient microorganisms.
2. A nurse is preparing to measure a client’s blood pressure. Which action will
result in a falsely high reading?
A. Using a cuff that is too narrow
B. Using a cuff that is too wide
C. Positioning the arm at the level of the heart
D. Deflating the cuff at a rate of 2-3 mmHg per second
Answer: A
Rationale: A blood pressure cuff that is too narrow or too small will result in a falsely high
reading. Conversely, a cuff that is too wide will result in a falsely low reading.
,3. Which area is considered contaminated when a nurse is setting up a sterile
field?
A. The outer 1-inch border of the sterile drape
B. The center of the sterile field
C. Both A and C
D. The portion of the drape hanging off the table
Answer: C
Rationale: The outer 1-inch border of a sterile field is considered non-sterile
(contaminated), as is any part of the field that hangs below the level of the table.
4. A fire breaks out in a patient’s room. According to the RACE acronym, which
action should the nurse take first?
A. Activate the fire alarm
B. Confine the fire by closing doors
C. Rescue and remove the patient from immediate danger
D. Extinguish the fire with a portable extinguisher
Answer: C
Rationale: RACE stands for Rescue, Alarm, Confine, Extinguish. The priority is always the
safety of the patient.
5. When measuring the height of a patient for crutches, how many finger-widths
should be between the crutch pad and the patient’s axilla?
A. 1 finger-width
B. The crutch should touch the axilla
C. 4 to 5 finger-widths
D. 2 to 3 finger-widths
Answer: D
Rationale: There should be a 2 to 3 finger-width gap (approximately 1 to 2 inches) to
prevent nerve damage in the axillary region.
, 6. A nurse is providing oral care for an unconscious patient. What is the priority
nursing intervention?
A. Using a firm toothbrush to remove plaque
B. Placing the patient in a side-lying (lateral) position
C. Applying petroleum jelly to the lips
D. Rinsing the mouth with large amounts of water
Answer: B
Rationale: The side-lying position prevents aspiration by allowing fluids to drain out of the
mouth by gravity.
7. After a total hip replacement, what device is typically used to maintain the
surgical leg in a safe position?
A. Trochanter roll
B. Sandbags
C. Footboard
D. Abduction pillow
Answer: D
Rationale: An abduction pillow is used to keep the hips in abduction to prevent dislocation
of the new hip prosthesis.
8. What is the most reliable method for verifying the initial placement of a
nasogastric (NG) tube?
A. Radiographic (X-ray) examination
B. Checking the pH of gastric aspirate
C. Auscultating for an air bolus
D. Observing the patient for coughing
Answer: A
1. When performing hand hygiene with soap and water, what is the minimum
duration the nurse should rub all surfaces of the hands with friction?
A. 5 to 10 seconds
B. 15 to 20 seconds
C. 10 to 15 seconds
D. 30 to 60 seconds
Answer: B
Rationale: According to CDC and standard nursing guidelines, friction should be applied
for at least 15 to 20 seconds to effectively remove transient microorganisms.
2. A nurse is preparing to measure a client’s blood pressure. Which action will
result in a falsely high reading?
A. Using a cuff that is too narrow
B. Using a cuff that is too wide
C. Positioning the arm at the level of the heart
D. Deflating the cuff at a rate of 2-3 mmHg per second
Answer: A
Rationale: A blood pressure cuff that is too narrow or too small will result in a falsely high
reading. Conversely, a cuff that is too wide will result in a falsely low reading.
,3. Which area is considered contaminated when a nurse is setting up a sterile
field?
A. The outer 1-inch border of the sterile drape
B. The center of the sterile field
C. Both A and C
D. The portion of the drape hanging off the table
Answer: C
Rationale: The outer 1-inch border of a sterile field is considered non-sterile
(contaminated), as is any part of the field that hangs below the level of the table.
4. A fire breaks out in a patient’s room. According to the RACE acronym, which
action should the nurse take first?
A. Activate the fire alarm
B. Confine the fire by closing doors
C. Rescue and remove the patient from immediate danger
D. Extinguish the fire with a portable extinguisher
Answer: C
Rationale: RACE stands for Rescue, Alarm, Confine, Extinguish. The priority is always the
safety of the patient.
5. When measuring the height of a patient for crutches, how many finger-widths
should be between the crutch pad and the patient’s axilla?
A. 1 finger-width
B. The crutch should touch the axilla
C. 4 to 5 finger-widths
D. 2 to 3 finger-widths
Answer: D
Rationale: There should be a 2 to 3 finger-width gap (approximately 1 to 2 inches) to
prevent nerve damage in the axillary region.
, 6. A nurse is providing oral care for an unconscious patient. What is the priority
nursing intervention?
A. Using a firm toothbrush to remove plaque
B. Placing the patient in a side-lying (lateral) position
C. Applying petroleum jelly to the lips
D. Rinsing the mouth with large amounts of water
Answer: B
Rationale: The side-lying position prevents aspiration by allowing fluids to drain out of the
mouth by gravity.
7. After a total hip replacement, what device is typically used to maintain the
surgical leg in a safe position?
A. Trochanter roll
B. Sandbags
C. Footboard
D. Abduction pillow
Answer: D
Rationale: An abduction pillow is used to keep the hips in abduction to prevent dislocation
of the new hip prosthesis.
8. What is the most reliable method for verifying the initial placement of a
nasogastric (NG) tube?
A. Radiographic (X-ray) examination
B. Checking the pH of gastric aspirate
C. Auscultating for an air bolus
D. Observing the patient for coughing
Answer: A
