NSG 300 Exam 2 V2 | NSG 300 Foundations of
Nursing | Actual Q&A with Rationale (NSG300
Exam 2) | Grand Canyon University
1. A nurse is assessing a patient for fall risks. Which factors increase the risk of falls? (Select
all that apply)
A. History of falls
B. Age over 65
C. Use of diuretics
D. Orthostatic hypotension
E. Use of an IV pole
F. Properly fitting non-skid footwear
Correct Answer: A, B, C, D, E
Explanation: Fall risk assessment involves evaluating both intrinsic and extrinsic factors.
Factors such as history of falls, advanced age, and physiological symptoms like orthostatic
hypotension are primary indicators. Medical equipment like IV poles and pharmacological
interventions like diuretics also contribute to gait instability. Proper footwear is a
preventative measure, not a risk factor.
,2. When measuring a patient’s blood pressure, which action by the nurse ensures an accurate
reading?
A. Positioning the arm above the level of the heart
B. Deflating the cuff at a rate of 5 to 10 mmHg per second
C. Using a cuff with a bladder width that is 40% of the arm circumference
D. Asking the patient to cross their legs for comfort
Correct Answer: C
Explanation: Correct cuff sizing is essential for accurate blood pressure measurement; the
bladder width should be approximately 40% of the arm circumference. Positioning the arm
above the heart or deflating too rapidly can lead to falsely low readings. The patient should
remain still with legs uncrossed to prevent artificial elevation of pressure.
3. A nurse is performing hand hygiene. Which action is the most effective in preventing the
spread of microorganisms?
A. Applying friction for at least 15 to 20 seconds
B. Using hot water to kill bacteria
C. Rinsing hands with the fingertips pointing upward
D. Drying hands from the elbows to the fingertips
Correct Answer: A
, Explanation: Friction is the most important component of handwashing as it physically
removes microorganisms from the skin. Hot water should be avoided as it can cause
dermatitis, and fingertips should be pointed downward while rinsing. Proper drying occurs
from the cleanest area (fingertips) to the least clean area (wrists).
4. In the nursing process, which step involves the development of patient-centered goals and
expected outcomes?
A. Assessment
B. Diagnosis
C. Implementation
D. Planning
Correct Answer: D
Explanation: The planning phase of the nursing process is where the nurse prioritizes
diagnoses and sets goals. These goals must be SMART: specific, measurable, attainable,
realistic, and timed. This phase serves as the foundation for selecting specific nursing
interventions.
5. A nurse is providing oral care to an unconscious patient. Which action is a priority for
patient safety?
A. Positioning the patient in a side-lying (Sims) position
B. Placing the patient in a supine position
C. Using a large amount of water to rinse the mouth
Nursing | Actual Q&A with Rationale (NSG300
Exam 2) | Grand Canyon University
1. A nurse is assessing a patient for fall risks. Which factors increase the risk of falls? (Select
all that apply)
A. History of falls
B. Age over 65
C. Use of diuretics
D. Orthostatic hypotension
E. Use of an IV pole
F. Properly fitting non-skid footwear
Correct Answer: A, B, C, D, E
Explanation: Fall risk assessment involves evaluating both intrinsic and extrinsic factors.
Factors such as history of falls, advanced age, and physiological symptoms like orthostatic
hypotension are primary indicators. Medical equipment like IV poles and pharmacological
interventions like diuretics also contribute to gait instability. Proper footwear is a
preventative measure, not a risk factor.
,2. When measuring a patient’s blood pressure, which action by the nurse ensures an accurate
reading?
A. Positioning the arm above the level of the heart
B. Deflating the cuff at a rate of 5 to 10 mmHg per second
C. Using a cuff with a bladder width that is 40% of the arm circumference
D. Asking the patient to cross their legs for comfort
Correct Answer: C
Explanation: Correct cuff sizing is essential for accurate blood pressure measurement; the
bladder width should be approximately 40% of the arm circumference. Positioning the arm
above the heart or deflating too rapidly can lead to falsely low readings. The patient should
remain still with legs uncrossed to prevent artificial elevation of pressure.
3. A nurse is performing hand hygiene. Which action is the most effective in preventing the
spread of microorganisms?
A. Applying friction for at least 15 to 20 seconds
B. Using hot water to kill bacteria
C. Rinsing hands with the fingertips pointing upward
D. Drying hands from the elbows to the fingertips
Correct Answer: A
, Explanation: Friction is the most important component of handwashing as it physically
removes microorganisms from the skin. Hot water should be avoided as it can cause
dermatitis, and fingertips should be pointed downward while rinsing. Proper drying occurs
from the cleanest area (fingertips) to the least clean area (wrists).
4. In the nursing process, which step involves the development of patient-centered goals and
expected outcomes?
A. Assessment
B. Diagnosis
C. Implementation
D. Planning
Correct Answer: D
Explanation: The planning phase of the nursing process is where the nurse prioritizes
diagnoses and sets goals. These goals must be SMART: specific, measurable, attainable,
realistic, and timed. This phase serves as the foundation for selecting specific nursing
interventions.
5. A nurse is providing oral care to an unconscious patient. Which action is a priority for
patient safety?
A. Positioning the patient in a side-lying (Sims) position
B. Placing the patient in a supine position
C. Using a large amount of water to rinse the mouth
