NSG 300 Exam 3 V3 | NSG 300 Foundations of
Nursing | Actual Q&A with Rationale (NSG300
Exam 3) | Grand Canyon University
1. A nurse is caring for a patient who is at high risk for falls. Which interventions should the
nurse include in the plan of care? Select all that apply.
A. Maintain the bed in the lowest position.
B. Keep all four side rails up at all times.
C. Provide non-skid footwear.
D. Ensure the call light is within reach.
E. Place a ‘Fall Risk’ sign on the door.
F. Keep the room cluttered to encourage focus.
Correct Answer: A, C, D, E
Explanation: Safety protocols require the bed to be in the lowest position and for the call
light to be reachable to prevent patients from overreaching. Non-skid footwear provides
traction during ambulation which is a primary prevention strategy. Keeping four side rails
up is considered a restraint and should be avoided unless specifically ordered, and a
cluttered room increases hazards rather than reducing them.
,2. When assessing a patient’s blood pressure, the nurse notes that the cuff is too small for the
patient’s arm. Which result should the nurse anticipate?
A. A reading that only affects the diastolic pressure
B. A falsely low reading
C. An accurate reading if the patient is relaxed
D. A falsely high reading
Correct Answer: D
Explanation: Using a blood pressure cuff that is too narrow or small for the limb results in
a falsely high blood pressure reading because the cuff must be inflated more to occlude the
artery. Conversely, a cuff that is too large will provide a falsely low reading. Proper cuff
sizing is a fundamental nursing skill to ensure accurate hemodynamic monitoring and
clinical decision-making.
3. A nurse is preparing to administer an intramuscular injection. Which angle of insertion
should the nurse use?
A. 15 degrees
B. 90 degrees
C. 45 degrees
D. 180 degrees
Correct Answer: B
,Explanation: Intramuscular injections are administered at a 90-degree angle to ensure the
medication reaches the muscle tissue below the subcutaneous layer. Subcutaneous
injections are typically given at 45 to 90 degrees depending on the patient’s adipose tissue,
while intradermal injections are given at 5 to 15 degrees. Correct technique is vital to
ensure appropriate absorption rates and to minimize tissue trauma or discomfort.
4. The nurse is practicing the ethical principle of autonomy. Which action best demonstrates
this principle?
A. Ensuring the patient receives the correct medication dose.
B. Respecting the patient’s decision to refuse a recommended treatment.
C. Providing the same quality of care to all patients regardless of status.
D. Keeping a promise to return to the patient’s room in 10 minutes.
Correct Answer: B
Explanation: Autonomy refers to the right of patients to make their own decisions about
their healthcare, including the right to refuse treatment. Beneficence involves doing good,
while fidelity involves keeping promises to the patient. By respecting a refusal, the nurse
acknowledges the patient’s self-determination and legal right to control their own body.
5. Which clinical manifestation is a late sign of hypoxia?
A. Restlessness
B. Tachycardia
C. Apprehension
, D. Cyanosis
Correct Answer: D
Explanation: Cyanosis, a bluish discoloration of the skin and mucous membranes, is a late
sign of hypoxia indicating significantly decreased oxygen saturation. Early signs of hypoxia
include restlessness, anxiety, and tachycardia as the body attempts to compensate for
falling oxygen levels. Nurses must recognize early signs to intervene before the patient’s
condition deteriorates to the point of cyanosis.
6. The nurse is caring for a patient on contact precautions. Which personal protective
equipment (PPE) is required? Select all that apply.
A. Gloves
B. Gown
C. N95 Respirator
D. Surgical Mask
E. Goggles or face shield if splashing is expected
Correct Answer: A, B, E
Explanation: Contact precautions specifically require the use of gloves and a gown to
prevent the transmission of pathogens through direct or indirect contact. An N95
respirator is reserved for airborne precautions, such as for tuberculosis, while a surgical
mask is used for droplet precautions. The nurse should also use eye protection if there is a
risk of body fluid splashing during care activities.
Nursing | Actual Q&A with Rationale (NSG300
Exam 3) | Grand Canyon University
1. A nurse is caring for a patient who is at high risk for falls. Which interventions should the
nurse include in the plan of care? Select all that apply.
A. Maintain the bed in the lowest position.
B. Keep all four side rails up at all times.
C. Provide non-skid footwear.
D. Ensure the call light is within reach.
E. Place a ‘Fall Risk’ sign on the door.
F. Keep the room cluttered to encourage focus.
Correct Answer: A, C, D, E
Explanation: Safety protocols require the bed to be in the lowest position and for the call
light to be reachable to prevent patients from overreaching. Non-skid footwear provides
traction during ambulation which is a primary prevention strategy. Keeping four side rails
up is considered a restraint and should be avoided unless specifically ordered, and a
cluttered room increases hazards rather than reducing them.
,2. When assessing a patient’s blood pressure, the nurse notes that the cuff is too small for the
patient’s arm. Which result should the nurse anticipate?
A. A reading that only affects the diastolic pressure
B. A falsely low reading
C. An accurate reading if the patient is relaxed
D. A falsely high reading
Correct Answer: D
Explanation: Using a blood pressure cuff that is too narrow or small for the limb results in
a falsely high blood pressure reading because the cuff must be inflated more to occlude the
artery. Conversely, a cuff that is too large will provide a falsely low reading. Proper cuff
sizing is a fundamental nursing skill to ensure accurate hemodynamic monitoring and
clinical decision-making.
3. A nurse is preparing to administer an intramuscular injection. Which angle of insertion
should the nurse use?
A. 15 degrees
B. 90 degrees
C. 45 degrees
D. 180 degrees
Correct Answer: B
,Explanation: Intramuscular injections are administered at a 90-degree angle to ensure the
medication reaches the muscle tissue below the subcutaneous layer. Subcutaneous
injections are typically given at 45 to 90 degrees depending on the patient’s adipose tissue,
while intradermal injections are given at 5 to 15 degrees. Correct technique is vital to
ensure appropriate absorption rates and to minimize tissue trauma or discomfort.
4. The nurse is practicing the ethical principle of autonomy. Which action best demonstrates
this principle?
A. Ensuring the patient receives the correct medication dose.
B. Respecting the patient’s decision to refuse a recommended treatment.
C. Providing the same quality of care to all patients regardless of status.
D. Keeping a promise to return to the patient’s room in 10 minutes.
Correct Answer: B
Explanation: Autonomy refers to the right of patients to make their own decisions about
their healthcare, including the right to refuse treatment. Beneficence involves doing good,
while fidelity involves keeping promises to the patient. By respecting a refusal, the nurse
acknowledges the patient’s self-determination and legal right to control their own body.
5. Which clinical manifestation is a late sign of hypoxia?
A. Restlessness
B. Tachycardia
C. Apprehension
, D. Cyanosis
Correct Answer: D
Explanation: Cyanosis, a bluish discoloration of the skin and mucous membranes, is a late
sign of hypoxia indicating significantly decreased oxygen saturation. Early signs of hypoxia
include restlessness, anxiety, and tachycardia as the body attempts to compensate for
falling oxygen levels. Nurses must recognize early signs to intervene before the patient’s
condition deteriorates to the point of cyanosis.
6. The nurse is caring for a patient on contact precautions. Which personal protective
equipment (PPE) is required? Select all that apply.
A. Gloves
B. Gown
C. N95 Respirator
D. Surgical Mask
E. Goggles or face shield if splashing is expected
Correct Answer: A, B, E
Explanation: Contact precautions specifically require the use of gloves and a gown to
prevent the transmission of pathogens through direct or indirect contact. An N95
respirator is reserved for airborne precautions, such as for tuberculosis, while a surgical
mask is used for droplet precautions. The nurse should also use eye protection if there is a
risk of body fluid splashing during care activities.
