NUR 101 | NUR 101 Nursing Fundamentals Exam 2
Version 1 | Questions with Correct Answers and
Expert Explanation for Each Question | Saint Paul’s
School of Nursing
1. A nurse is preparing to remove personal protective equipment (PPE) after caring for
a patient on isolation. According to standard guidelines, which item should be
removed first?
A. Mask or respirator
B. Gown
C. Goggles or face shield
D. Gloves
Correct Answer: D
Expert Explanation: Gloves are considered the most contaminated piece of PPE
and should be removed first to prevent cross-contamination. Removing gloves first
ensures that the nurse does not spread pathogens to other equipment or their own
skin during the rest of the doffing process. The goggles or face shield are typically
removed next, followed by the gown and finally the mask. This specific sequence is
designed to minimize the risk of self-inoculation with infectious agents. Consistent
adherence to this sequence is a critical component of infection control safety
protocols.
,2. Which clinical manifestation would a nurse expect to find in a patient experiencing
a systemic infection rather than a localized infection?
A. Fever and malaise
B. Swelling and pain
C. Redness and warmth at the site
D. Purulent drainage from a wound
Correct Answer: A
Expert Explanation: Systemic infections affect the entire body and are
characterized by generalized symptoms such as fever, chills, and malaise. Localized
infections are confined to a specific area and typically present with redness,
warmth, and swelling. Fever occurs as a result of the body’s immune response to
pathogens circulating in the bloodstream. While localized symptoms may
accompany a systemic infection, the presence of constitutional symptoms indicates
a broader physiological impact. Monitoring for these systemic signs is vital for early
intervention and preventing sepsis.
3. A nurse is caring for a patient with Clostridium difficile (C. diff). Which hand hygiene
method is mandatory after providing direct care?
A. Alcohol-based hand rub
B. Rinsing with water only
,C. Washing with antimicrobial soap and water
D. Using a dry paper towel to wipe hands
Correct Answer: C
Expert Explanation: Soap and water are required for hand hygiene when dealing
with spore-forming organisms like C. difficile. Alcohol-based hand rubs are
ineffective at killing or removing the hardy spores produced by this bacterium.
Friction from washing with soap and water physically removes the spores from the
surface of the skin. This practice is essential for preventing the transmission of C.
diff between patients in a clinical environment. Failure to use soap and water
contributes significantly to the spread of healthcare-associated infections.
4. While preparing a sterile field for a dressing change, the nurse drops a sterile gauze
pad onto the 1-inch border of the sterile drape. What action should the nurse take?
A. Use the gauze pad as it is still within the drape.
B. Pick up the gauze with sterile forceps and move it to the center.
C. Discard the gauze pad and use a new sterile one.
D. Consider the entire sterile field contaminated and start over.
Correct Answer: C
, Expert Explanation: The 1-inch border around the edge of a sterile field is
considered contaminated. Any item that touches this border is no longer sterile and
must be discarded immediately. The center of the field remains sterile as long as no
other contamination has occurred, so starting over is not yet necessary. This
principle prevents the introduction of non-sterile microorganisms into a surgical
wound or site. Maintaining strict adherence to surgical asepsis is a primary nursing
responsibility during invasive procedures.
5. A patient is placed on Airborne Precautions for suspected pulmonary tuberculosis.
Which of the following is a requirement for this type of isolation?
A. A private room with negative pressure
B. The nurse must wear a surgical mask.
C. A private room with positive pressure
D. Keeping the door open for better ventilation
Correct Answer: A
Expert Explanation: Airborne precautions require a private room with negative air
pressure to prevent contaminated air from flowing into hallways. A HEPA filtration
system is often used to ensure the air is safe before being exhausted outside. Staff
entering the room must wear a fit-tested N95 respirator or a higher-level mask.
Surgical masks are insufficient for airborne particles as they do not provide an
Version 1 | Questions with Correct Answers and
Expert Explanation for Each Question | Saint Paul’s
School of Nursing
1. A nurse is preparing to remove personal protective equipment (PPE) after caring for
a patient on isolation. According to standard guidelines, which item should be
removed first?
A. Mask or respirator
B. Gown
C. Goggles or face shield
D. Gloves
Correct Answer: D
Expert Explanation: Gloves are considered the most contaminated piece of PPE
and should be removed first to prevent cross-contamination. Removing gloves first
ensures that the nurse does not spread pathogens to other equipment or their own
skin during the rest of the doffing process. The goggles or face shield are typically
removed next, followed by the gown and finally the mask. This specific sequence is
designed to minimize the risk of self-inoculation with infectious agents. Consistent
adherence to this sequence is a critical component of infection control safety
protocols.
,2. Which clinical manifestation would a nurse expect to find in a patient experiencing
a systemic infection rather than a localized infection?
A. Fever and malaise
B. Swelling and pain
C. Redness and warmth at the site
D. Purulent drainage from a wound
Correct Answer: A
Expert Explanation: Systemic infections affect the entire body and are
characterized by generalized symptoms such as fever, chills, and malaise. Localized
infections are confined to a specific area and typically present with redness,
warmth, and swelling. Fever occurs as a result of the body’s immune response to
pathogens circulating in the bloodstream. While localized symptoms may
accompany a systemic infection, the presence of constitutional symptoms indicates
a broader physiological impact. Monitoring for these systemic signs is vital for early
intervention and preventing sepsis.
3. A nurse is caring for a patient with Clostridium difficile (C. diff). Which hand hygiene
method is mandatory after providing direct care?
A. Alcohol-based hand rub
B. Rinsing with water only
,C. Washing with antimicrobial soap and water
D. Using a dry paper towel to wipe hands
Correct Answer: C
Expert Explanation: Soap and water are required for hand hygiene when dealing
with spore-forming organisms like C. difficile. Alcohol-based hand rubs are
ineffective at killing or removing the hardy spores produced by this bacterium.
Friction from washing with soap and water physically removes the spores from the
surface of the skin. This practice is essential for preventing the transmission of C.
diff between patients in a clinical environment. Failure to use soap and water
contributes significantly to the spread of healthcare-associated infections.
4. While preparing a sterile field for a dressing change, the nurse drops a sterile gauze
pad onto the 1-inch border of the sterile drape. What action should the nurse take?
A. Use the gauze pad as it is still within the drape.
B. Pick up the gauze with sterile forceps and move it to the center.
C. Discard the gauze pad and use a new sterile one.
D. Consider the entire sterile field contaminated and start over.
Correct Answer: C
, Expert Explanation: The 1-inch border around the edge of a sterile field is
considered contaminated. Any item that touches this border is no longer sterile and
must be discarded immediately. The center of the field remains sterile as long as no
other contamination has occurred, so starting over is not yet necessary. This
principle prevents the introduction of non-sterile microorganisms into a surgical
wound or site. Maintaining strict adherence to surgical asepsis is a primary nursing
responsibility during invasive procedures.
5. A patient is placed on Airborne Precautions for suspected pulmonary tuberculosis.
Which of the following is a requirement for this type of isolation?
A. A private room with negative pressure
B. The nurse must wear a surgical mask.
C. A private room with positive pressure
D. Keeping the door open for better ventilation
Correct Answer: A
Expert Explanation: Airborne precautions require a private room with negative air
pressure to prevent contaminated air from flowing into hallways. A HEPA filtration
system is often used to ensure the air is safe before being exhausted outside. Staff
entering the room must wear a fit-tested N95 respirator or a higher-level mask.
Surgical masks are insufficient for airborne particles as they do not provide an
