NSG 300 Exam 2 V1 | NSG 300 Foundations of
Nursing | Actual Q&A with Rationale (NSG300
Exam 2) | Grand Canyon University
1. Which of the following are components of the chain of infection? (Select all that apply)
A. Infectious agent
B. Reservoir
C. Portal of exit
D. Mode of transmission
E. Portal of entry
F. Susceptible host
Correct Answer: A, B, C, D, E, F
Explanation: The chain of infection consists of six distinct links that must all be present for
an infection to occur. These include the infectious agent, the reservoir where it lives, the
portal of exit from the reservoir, the mode of transmission, the portal of entry into a host,
and the susceptible host itself. Nursing interventions are primarily designed to break at
least one of these links to prevent the spread of illness.
2. When assessing a patient’s blood pressure, the nurse notes the cuff is too small for the
patient’s arm. What impact will this have on the reading?
A. The systolic pressure will be low and the diastolic will be high.
,B. The blood pressure reading will be falsely low.
C. The reading will be accurate if the patient is lying down.
D. The blood pressure reading will be falsely high.
Correct Answer: D
Explanation: Using a blood pressure cuff that is too small for the patient’s arm
circumference will result in a falsely elevated blood pressure reading. This occurs because
the small bladder cannot distribute pressure evenly, requiring more pressure to occlude
the artery. Proper cuff sizing is critical for obtaining an accurate measurement and making
appropriate clinical decisions.
3. The nurse is preparing to perform hand hygiene. Which action is most effective in removing
microorganisms?
A. Using hot water to kill bacteria on the skin surface.
B. Applying friction while washing for at least 20 seconds.
C. Rinsing hands with the fingers pointing upward toward the elbows.
D. Using a towel to turn off the faucet before washing hands.
Correct Answer: B
Explanation: Friction is the most important component of handwashing because it
mechanically loosens and removes dirt and microorganisms from the skin. The CDC
recommends scrubbing all surfaces of the hands for at least 20 seconds to be effective.
,While water temperature and rinsing technique matter, they do not replace the mechanical
action of friction.
4. A nurse is identifying patients at high risk for falls. Which factors increase a patient’s risk?
(Select all that apply)
A. History of previous falls
B. Age over 65 years
C. Urgency or frequency of urination
D. Use of multiple medications (polypharmacy)
E. Being oriented to person, place, and time
Correct Answer: A, B, C, D
Explanation: Risk factors for falls include intrinsic factors like advanced age and a history
of falling, as well as extrinsic factors like polypharmacy and elimination needs. Patients
who experience urgency are more likely to attempt to reach the bathroom quickly and
unsafely. Orientation to person, place, and time is a protective factor rather than a risk
factor for falling.
5. Which complications are associated with prolonged immobility? (Select all that apply)
A. Deep vein thrombosis (DVT)
B. Muscle atrophy
C. Pressure injuries
, D. Increased cardiac output
E. Urinary stasis
Correct Answer: A, B, C, E
Explanation: Immobility affects nearly every body system, leading to venous stasis, muscle
wasting, and skin breakdown. Prolonged bed rest decreases cardiac output and increases
the workload on the heart rather than improving it. Nurses must implement early
mobilization and range-of-motion exercises to mitigate these serious physiological risks.
6. A nurse is caring for a patient who requires soft wrist restraints. What is a priority legal
requirement for this intervention?
A. The nurse must obtain a verbal order within 24 hours of application.
B. Restraints should be tied to the side rails for easy access.
C. A face-to-face assessment by the provider must occur within one hour of application.
D. The family must sign a consent form before the nurse can apply restraints.
Correct Answer: C
Explanation: Federal and state regulations require a face-to-face assessment by a licensed
provider within one hour of applying restraints for behavioral management. Restraints
should always be tied to the bed frame using a quick-release knot, never the side rails, to
ensure safety when the bed is adjusted. Documentation must reflect that less restrictive
measures were attempted and failed prior to restraint use.
Nursing | Actual Q&A with Rationale (NSG300
Exam 2) | Grand Canyon University
1. Which of the following are components of the chain of infection? (Select all that apply)
A. Infectious agent
B. Reservoir
C. Portal of exit
D. Mode of transmission
E. Portal of entry
F. Susceptible host
Correct Answer: A, B, C, D, E, F
Explanation: The chain of infection consists of six distinct links that must all be present for
an infection to occur. These include the infectious agent, the reservoir where it lives, the
portal of exit from the reservoir, the mode of transmission, the portal of entry into a host,
and the susceptible host itself. Nursing interventions are primarily designed to break at
least one of these links to prevent the spread of illness.
2. When assessing a patient’s blood pressure, the nurse notes the cuff is too small for the
patient’s arm. What impact will this have on the reading?
A. The systolic pressure will be low and the diastolic will be high.
,B. The blood pressure reading will be falsely low.
C. The reading will be accurate if the patient is lying down.
D. The blood pressure reading will be falsely high.
Correct Answer: D
Explanation: Using a blood pressure cuff that is too small for the patient’s arm
circumference will result in a falsely elevated blood pressure reading. This occurs because
the small bladder cannot distribute pressure evenly, requiring more pressure to occlude
the artery. Proper cuff sizing is critical for obtaining an accurate measurement and making
appropriate clinical decisions.
3. The nurse is preparing to perform hand hygiene. Which action is most effective in removing
microorganisms?
A. Using hot water to kill bacteria on the skin surface.
B. Applying friction while washing for at least 20 seconds.
C. Rinsing hands with the fingers pointing upward toward the elbows.
D. Using a towel to turn off the faucet before washing hands.
Correct Answer: B
Explanation: Friction is the most important component of handwashing because it
mechanically loosens and removes dirt and microorganisms from the skin. The CDC
recommends scrubbing all surfaces of the hands for at least 20 seconds to be effective.
,While water temperature and rinsing technique matter, they do not replace the mechanical
action of friction.
4. A nurse is identifying patients at high risk for falls. Which factors increase a patient’s risk?
(Select all that apply)
A. History of previous falls
B. Age over 65 years
C. Urgency or frequency of urination
D. Use of multiple medications (polypharmacy)
E. Being oriented to person, place, and time
Correct Answer: A, B, C, D
Explanation: Risk factors for falls include intrinsic factors like advanced age and a history
of falling, as well as extrinsic factors like polypharmacy and elimination needs. Patients
who experience urgency are more likely to attempt to reach the bathroom quickly and
unsafely. Orientation to person, place, and time is a protective factor rather than a risk
factor for falling.
5. Which complications are associated with prolonged immobility? (Select all that apply)
A. Deep vein thrombosis (DVT)
B. Muscle atrophy
C. Pressure injuries
, D. Increased cardiac output
E. Urinary stasis
Correct Answer: A, B, C, E
Explanation: Immobility affects nearly every body system, leading to venous stasis, muscle
wasting, and skin breakdown. Prolonged bed rest decreases cardiac output and increases
the workload on the heart rather than improving it. Nurses must implement early
mobilization and range-of-motion exercises to mitigate these serious physiological risks.
6. A nurse is caring for a patient who requires soft wrist restraints. What is a priority legal
requirement for this intervention?
A. The nurse must obtain a verbal order within 24 hours of application.
B. Restraints should be tied to the side rails for easy access.
C. A face-to-face assessment by the provider must occur within one hour of application.
D. The family must sign a consent form before the nurse can apply restraints.
Correct Answer: C
Explanation: Federal and state regulations require a face-to-face assessment by a licensed
provider within one hour of applying restraints for behavioral management. Restraints
should always be tied to the bed frame using a quick-release knot, never the side rails, to
ensure safety when the bed is adjusted. Documentation must reflect that less restrictive
measures were attempted and failed prior to restraint use.
