NUR 155 Exam 2 V1 | NUR 155
Foundations of Nursing | Q&A with
Rationale (NUR155 Exam 2) | Galen
College of Nursing
1. A nurse is preparing to perform hand hygiene. Which action is the most important for the
nurse to take to prevent the spread of microorganisms?
A. Using very hot water to kill bacteria on the skin surface.
B. Rinsing hands from the fingertips toward the wrists.
C. Washing hands for at least 20 seconds with friction.
D. Drying hands with a shared cloth towel to save resources.
Answer: C
Rationale: Friction is the most effective component of handwashing because it physically
removes transient microbes from the skin. The Centers for Disease Control and Prevention
recommends scrubbing for at least 20 seconds to ensure adequate cleansing. Using hot
water can damage the skin, while rinsing should occur from the least contaminated area
(wrist) to the most (fingertips) depending on the technique used, but friction remains the
primary mechanical agent of decontamination.
2. The nurse is preparing to enter the room of a patient on Contact Precautions for MRSA. In
which order should the nurse don Personal Protective Equipment (PPE)?
A. Gloves, Mask, Gown, Goggles
,B. Goggles, Gown, Mask, Gloves
C. Gown, Mask, Goggles, Gloves
D. Mask, Goggles, Gloves, Gown
Answer: C
Rationale: The standard sequence for donning PPE begins with the gown to cover the
clothing fully. This is followed by the mask or respirator, then goggles or a face shield to
protect the mucous membranes. Gloves are donned last and should be pulled over the cuffs
of the gown to ensure a complete barrier against pathogens.
3. A patient is diagnosed with Pulmonary Tuberculosis. Which type of transmission-based
precaution must the nurse implement?
A. Airborne Precautions
B. Contact Precautions
C. Droplet Precautions
D. Standard Precautions only
Answer: A
Rationale: Tuberculosis is transmitted through small droplets that remain suspended in
the air for long periods, requiring airborne precautions. These precautions include a
private room with negative air pressure and the use of an N95 respirator mask by
, healthcare workers. Standard precautions are always used, but they are insufficient for the
specific transmission route of TB.
4. During a physical assessment, the nurse notes the patient’s radial pulse is irregular. What
should be the nurse’s next action?
A. Document the finding as normal for an older adult.
B. Re-check the radial pulse for 15 seconds.
C. Assess the apical pulse for one full minute.
D. Wait 30 minutes and reassess the patient’s blood pressure.
Answer: C
Rationale: If a peripheral pulse is irregular, the apical pulse must be assessed to determine
the actual heart rate and rhythm more accurately. Counting the apical pulse for a full
minute is the gold standard for verifying cardiac irregularities. This allows the nurse to
identify pulse deficits where the heart is beating but the peripheral pulse is not palpable.
5. The nurse is taking a blood pressure reading and the first sound heard is at 140 mmHg and
the last sound is heard at 88 mmHg. What is the pulse pressure?
A. 52 mmHg
B. 88 mmHg
C. 228 mmHg
D. 140 mmHg
Foundations of Nursing | Q&A with
Rationale (NUR155 Exam 2) | Galen
College of Nursing
1. A nurse is preparing to perform hand hygiene. Which action is the most important for the
nurse to take to prevent the spread of microorganisms?
A. Using very hot water to kill bacteria on the skin surface.
B. Rinsing hands from the fingertips toward the wrists.
C. Washing hands for at least 20 seconds with friction.
D. Drying hands with a shared cloth towel to save resources.
Answer: C
Rationale: Friction is the most effective component of handwashing because it physically
removes transient microbes from the skin. The Centers for Disease Control and Prevention
recommends scrubbing for at least 20 seconds to ensure adequate cleansing. Using hot
water can damage the skin, while rinsing should occur from the least contaminated area
(wrist) to the most (fingertips) depending on the technique used, but friction remains the
primary mechanical agent of decontamination.
2. The nurse is preparing to enter the room of a patient on Contact Precautions for MRSA. In
which order should the nurse don Personal Protective Equipment (PPE)?
A. Gloves, Mask, Gown, Goggles
,B. Goggles, Gown, Mask, Gloves
C. Gown, Mask, Goggles, Gloves
D. Mask, Goggles, Gloves, Gown
Answer: C
Rationale: The standard sequence for donning PPE begins with the gown to cover the
clothing fully. This is followed by the mask or respirator, then goggles or a face shield to
protect the mucous membranes. Gloves are donned last and should be pulled over the cuffs
of the gown to ensure a complete barrier against pathogens.
3. A patient is diagnosed with Pulmonary Tuberculosis. Which type of transmission-based
precaution must the nurse implement?
A. Airborne Precautions
B. Contact Precautions
C. Droplet Precautions
D. Standard Precautions only
Answer: A
Rationale: Tuberculosis is transmitted through small droplets that remain suspended in
the air for long periods, requiring airborne precautions. These precautions include a
private room with negative air pressure and the use of an N95 respirator mask by
, healthcare workers. Standard precautions are always used, but they are insufficient for the
specific transmission route of TB.
4. During a physical assessment, the nurse notes the patient’s radial pulse is irregular. What
should be the nurse’s next action?
A. Document the finding as normal for an older adult.
B. Re-check the radial pulse for 15 seconds.
C. Assess the apical pulse for one full minute.
D. Wait 30 minutes and reassess the patient’s blood pressure.
Answer: C
Rationale: If a peripheral pulse is irregular, the apical pulse must be assessed to determine
the actual heart rate and rhythm more accurately. Counting the apical pulse for a full
minute is the gold standard for verifying cardiac irregularities. This allows the nurse to
identify pulse deficits where the heart is beating but the peripheral pulse is not palpable.
5. The nurse is taking a blood pressure reading and the first sound heard is at 140 mmHg and
the last sound is heard at 88 mmHg. What is the pulse pressure?
A. 52 mmHg
B. 88 mmHg
C. 228 mmHg
D. 140 mmHg
