NSG 300 Exam 2 V3 | NSG 300 Foundations of
Nursing | Actual Q&A with Rationale (NSG300
Exam 2) | Grand Canyon University
1. A nurse is preparing to enter the room of a client diagnosed with Clostridium difficile (C.
diff). Which infection control measures are required for this client? Select all that apply.
A. Wear a N95 respirator mask
B. Perform hand hygiene using soap and water only
C. Wear non-sterile gloves
D. Wear a moisture-resistant gown
E. Maintain a negative-pressure airflow room
F. Use dedicated medical equipment for the room
Correct Answer: B, C, D, F
Explanation: C. difficile requires contact precautions because the spores are highly
resistant. Alcohol-based hand sanitizers are ineffective against these spores, so soap and
water must be used for hand hygiene. Contact precautions specifically include the use of
gloves, gowns, and dedicated equipment to prevent cross-contamination between patients.
2. When assessing a patient’s blood pressure, the nurse notes that the cuff is too small for the
patient’s arm circumference. Which result should the nurse expect?
A. A falsely low systolic reading
,B. An accurate reading if the cuff is wrapped tightly
C. A falsely high systolic and diastolic reading
D. No change in the diastolic reading
Correct Answer: C
Explanation: Using a blood pressure cuff that is too small or too narrow for the limb
results in a falsely high reading. This occurs because the pressure is not distributed evenly,
requiring more pressure to occlude the artery. Proper cuff sizing is essential for accurate
cardiovascular assessment and diagnostic reliability.
3. A nurse is performing an admission assessment. The patient states, ‘I have been feeling
very short of breath for the last two days.’ This information is categorized as which of the
following?
A. Objective data
B. A medical diagnosis
C. Secondary source data
D. Subjective data
Correct Answer: D
Explanation: Subjective data consists of information provided by the patient that cannot
be directly observed or measured by the nurse, such as feelings or symptoms. In this
scenario, the patient’s report of shortness of breath is their personal perception of their
,health status. Objective data, by contrast, would involve measurable findings like
respiratory rate or oxygen saturation levels.
4. During the evaluation phase of the nursing process, the nurse determines that the patient
has not met the expected goal of walking 50 feet by the end of the shift. What is the nurse’s
next appropriate action?
A. Discontinue the nursing care plan entirely
B. Document the goal as ‘met’ since the patient tried
C. Reassess the patient and revise the care plan
D. Notify the physician to change the activity order
Correct Answer: C
Explanation: The evaluation phase is a continuous process that involves comparing the
patient’s current status with the desired outcomes. If a goal is not met, the nurse must
reassess the patient’s condition and the interventions used to identify barriers to progress.
Based on this reassessment, the care plan is modified to better suit the patient’s needs and
capabilities.
5. Which of the following interventions are appropriate for a patient at high risk for falls?
Select all that apply.
A. Keeping the bed in the lowest position
B. Raising all four side rails for safety
C. Placing a fall-risk identification band on the wrist
, D. Ensuring the call light is within reach
E. Using a bedside commode if the patient has urgency
F. Providing non-skid footwear
Correct Answer: A, C, D, E, F
Explanation: Fall prevention involves environmental modifications and individualized
safety measures. Raising all four side rails is generally considered a physical restraint and
can increase injury risk if the patient attempts to climb over them. Effective interventions
include maintaining a low bed height, providing clear identification, and ensuring easy
access to assistance and elimination needs.
6. A nurse discovers a fire in a trash can in a patient’s room. According to the RACE acronym,
which action should the nurse take first?
A. Activate the fire alarm
B. Extinguish the fire with a portable extinguisher
C. Close the door to contain the fire
D. Rescue the patient from immediate danger
Correct Answer: D
Explanation: The RACE acronym stands for Rescue, Alarm, Confine, and
Extinguish/Evacuate. The priority in any fire situation is always the safety of the
Nursing | Actual Q&A with Rationale (NSG300
Exam 2) | Grand Canyon University
1. A nurse is preparing to enter the room of a client diagnosed with Clostridium difficile (C.
diff). Which infection control measures are required for this client? Select all that apply.
A. Wear a N95 respirator mask
B. Perform hand hygiene using soap and water only
C. Wear non-sterile gloves
D. Wear a moisture-resistant gown
E. Maintain a negative-pressure airflow room
F. Use dedicated medical equipment for the room
Correct Answer: B, C, D, F
Explanation: C. difficile requires contact precautions because the spores are highly
resistant. Alcohol-based hand sanitizers are ineffective against these spores, so soap and
water must be used for hand hygiene. Contact precautions specifically include the use of
gloves, gowns, and dedicated equipment to prevent cross-contamination between patients.
2. When assessing a patient’s blood pressure, the nurse notes that the cuff is too small for the
patient’s arm circumference. Which result should the nurse expect?
A. A falsely low systolic reading
,B. An accurate reading if the cuff is wrapped tightly
C. A falsely high systolic and diastolic reading
D. No change in the diastolic reading
Correct Answer: C
Explanation: Using a blood pressure cuff that is too small or too narrow for the limb
results in a falsely high reading. This occurs because the pressure is not distributed evenly,
requiring more pressure to occlude the artery. Proper cuff sizing is essential for accurate
cardiovascular assessment and diagnostic reliability.
3. A nurse is performing an admission assessment. The patient states, ‘I have been feeling
very short of breath for the last two days.’ This information is categorized as which of the
following?
A. Objective data
B. A medical diagnosis
C. Secondary source data
D. Subjective data
Correct Answer: D
Explanation: Subjective data consists of information provided by the patient that cannot
be directly observed or measured by the nurse, such as feelings or symptoms. In this
scenario, the patient’s report of shortness of breath is their personal perception of their
,health status. Objective data, by contrast, would involve measurable findings like
respiratory rate or oxygen saturation levels.
4. During the evaluation phase of the nursing process, the nurse determines that the patient
has not met the expected goal of walking 50 feet by the end of the shift. What is the nurse’s
next appropriate action?
A. Discontinue the nursing care plan entirely
B. Document the goal as ‘met’ since the patient tried
C. Reassess the patient and revise the care plan
D. Notify the physician to change the activity order
Correct Answer: C
Explanation: The evaluation phase is a continuous process that involves comparing the
patient’s current status with the desired outcomes. If a goal is not met, the nurse must
reassess the patient’s condition and the interventions used to identify barriers to progress.
Based on this reassessment, the care plan is modified to better suit the patient’s needs and
capabilities.
5. Which of the following interventions are appropriate for a patient at high risk for falls?
Select all that apply.
A. Keeping the bed in the lowest position
B. Raising all four side rails for safety
C. Placing a fall-risk identification band on the wrist
, D. Ensuring the call light is within reach
E. Using a bedside commode if the patient has urgency
F. Providing non-skid footwear
Correct Answer: A, C, D, E, F
Explanation: Fall prevention involves environmental modifications and individualized
safety measures. Raising all four side rails is generally considered a physical restraint and
can increase injury risk if the patient attempts to climb over them. Effective interventions
include maintaining a low bed height, providing clear identification, and ensuring easy
access to assistance and elimination needs.
6. A nurse discovers a fire in a trash can in a patient’s room. According to the RACE acronym,
which action should the nurse take first?
A. Activate the fire alarm
B. Extinguish the fire with a portable extinguisher
C. Close the door to contain the fire
D. Rescue the patient from immediate danger
Correct Answer: D
Explanation: The RACE acronym stands for Rescue, Alarm, Confine, and
Extinguish/Evacuate. The priority in any fire situation is always the safety of the
