NURS 104L Fundamentals of Nursing Skills Lab - Exam 1 Study Guide
2026 |WCU
1. When assessing a patient’s blood pressure, the nurse notes that the cuff is
too narrow for the patient’s arm. Which of the following results should the
nurse expect?
A. A falsely high reading
B. A falsely low systolic reading
C. An accurate reading as long as it is tight
D. A reading that only affects the diastolic pressure
Answer: A
Rationale: A blood pressure cuff that is too narrow or too small for the limb will result in a
falsely high reading because the cuff must be inflated more to occlude the artery.
2. A nurse is performing hand hygiene before a sterile procedure. Which action
is most critical for maintaining surgical asepsis?
A. Keeping hands lower than the elbows during rinsing
B. Drying hands starting from the elbows down to the fingers
C. Keeping hands above the elbows at all times during the scrub
D. Using a regular towel to turn off the faucet
Answer: C
Rationale: In surgical hand hygiene, hands must be kept above the elbows so that water
flows from the cleanest area (hands) to the less clean area (elbows).
,3. The nurse is preparing to move a patient up in bed. Which principle of body
mechanics should the nurse prioritize to prevent injury?
A. Keep the knees straight and bend at the waist
B. Tighten the abdominal muscles and gluteal muscles
C. Position the feet close together for a narrow base of support
D. Lower the bed to the lowest possible position before moving
Answer: B
Rationale: Tightening the core (abdominal and gluteal muscles) stabilizes the pelvis and
protects the back. The bed should be at waist height, and the nurse should use a wide base
of support.
4. Which of the following is the correct sequence for removing Personal
Protective Equipment (PPE) according to CDC guidelines?
A. Gloves, Goggles, Gown, Mask
B. Gown, Mask, Goggles, Gloves
C. Mask, Gown, Goggles, Gloves
D. Gloves, Mask, Goggles, Gown
Answer: A
Rationale: The standard sequence for doffing (removing) PPE is gloves, followed by eye
protection (goggles/shield), gown, and finally the mask or respirator.
5. A nurse is assessing a client’s radial pulse and notes it is irregular. What is the
most appropriate next action?
A. Document the finding and check again in 4 hours
B. Count the radial pulse for a full 60 seconds
C. Assess the apical pulse for one full minute
D. Notify the healthcare provider immediately
Answer: C
, Rationale: If a peripheral pulse is irregular, the apical pulse should be assessed for a full 60
seconds to obtain the most accurate heart rate and rhythm.
6. Which patient position is most appropriate for a nurse to facilitate maximum
chest expansion for a patient with acute respiratory distress?
A. Sims’ position
B. High-Fowler’s position
C. Prone position
D. Supine position
Answer: B
Rationale: High-Fowler’s (90 degrees) allows the diaphragm to drop via gravity, providing
maximum space for lung expansion.
7. While preparing a sterile field, the nurse drops a sterile gauze pad onto the
field, but it lands within the 1-inch border. What should the nurse do?
A. Proceed with the procedure as it is on the sterile drape
B. Use sterile forceps to move it to the center
C. Consider the gauze contaminated and discard it
D. Consider the entire sterile field contaminated and start over
Answer: C
Rationale: The 1-inch (2.5 cm) border of a sterile field is considered contaminated. Any
item touching that border is no longer sterile and must be discarded.
8. A patient has been placed on Droplet Precautions. Which of the following is a
requirement for the nurse when entering the room?
A. N95 respirator mask
B. Negative pressure room
C. Gown and gloves only
D. Surgical mask
Answer: D
2026 |WCU
1. When assessing a patient’s blood pressure, the nurse notes that the cuff is
too narrow for the patient’s arm. Which of the following results should the
nurse expect?
A. A falsely high reading
B. A falsely low systolic reading
C. An accurate reading as long as it is tight
D. A reading that only affects the diastolic pressure
Answer: A
Rationale: A blood pressure cuff that is too narrow or too small for the limb will result in a
falsely high reading because the cuff must be inflated more to occlude the artery.
2. A nurse is performing hand hygiene before a sterile procedure. Which action
is most critical for maintaining surgical asepsis?
A. Keeping hands lower than the elbows during rinsing
B. Drying hands starting from the elbows down to the fingers
C. Keeping hands above the elbows at all times during the scrub
D. Using a regular towel to turn off the faucet
Answer: C
Rationale: In surgical hand hygiene, hands must be kept above the elbows so that water
flows from the cleanest area (hands) to the less clean area (elbows).
,3. The nurse is preparing to move a patient up in bed. Which principle of body
mechanics should the nurse prioritize to prevent injury?
A. Keep the knees straight and bend at the waist
B. Tighten the abdominal muscles and gluteal muscles
C. Position the feet close together for a narrow base of support
D. Lower the bed to the lowest possible position before moving
Answer: B
Rationale: Tightening the core (abdominal and gluteal muscles) stabilizes the pelvis and
protects the back. The bed should be at waist height, and the nurse should use a wide base
of support.
4. Which of the following is the correct sequence for removing Personal
Protective Equipment (PPE) according to CDC guidelines?
A. Gloves, Goggles, Gown, Mask
B. Gown, Mask, Goggles, Gloves
C. Mask, Gown, Goggles, Gloves
D. Gloves, Mask, Goggles, Gown
Answer: A
Rationale: The standard sequence for doffing (removing) PPE is gloves, followed by eye
protection (goggles/shield), gown, and finally the mask or respirator.
5. A nurse is assessing a client’s radial pulse and notes it is irregular. What is the
most appropriate next action?
A. Document the finding and check again in 4 hours
B. Count the radial pulse for a full 60 seconds
C. Assess the apical pulse for one full minute
D. Notify the healthcare provider immediately
Answer: C
, Rationale: If a peripheral pulse is irregular, the apical pulse should be assessed for a full 60
seconds to obtain the most accurate heart rate and rhythm.
6. Which patient position is most appropriate for a nurse to facilitate maximum
chest expansion for a patient with acute respiratory distress?
A. Sims’ position
B. High-Fowler’s position
C. Prone position
D. Supine position
Answer: B
Rationale: High-Fowler’s (90 degrees) allows the diaphragm to drop via gravity, providing
maximum space for lung expansion.
7. While preparing a sterile field, the nurse drops a sterile gauze pad onto the
field, but it lands within the 1-inch border. What should the nurse do?
A. Proceed with the procedure as it is on the sterile drape
B. Use sterile forceps to move it to the center
C. Consider the gauze contaminated and discard it
D. Consider the entire sterile field contaminated and start over
Answer: C
Rationale: The 1-inch (2.5 cm) border of a sterile field is considered contaminated. Any
item touching that border is no longer sterile and must be discarded.
8. A patient has been placed on Droplet Precautions. Which of the following is a
requirement for the nurse when entering the room?
A. N95 respirator mask
B. Negative pressure room
C. Gown and gloves only
D. Surgical mask
Answer: D
