NURS 104L Fundamentals of Nursing Skills Lab Exam 1 2026 |WCU
1. When assessing a patient’s radial pulse, the nurse notes the rhythm is
irregular. What is the most appropriate next action?
A. Document the finding and reassess in 4 hours
B. Count the radial pulse for a full 60 seconds
C. Notify the healthcare provider immediately
D. Assess the apical pulse for one full minute
Answer: D
Rationale: If a peripheral pulse is irregular, the apical pulse should be assessed for one full
minute to determine the actual heart rate and identify any pulse deficit.
2. The nurse is preparing to perform hand hygiene. Which of the following is the
most important factor in reducing the number of microorganisms on the hands?
A. The temperature of the water
B. The type of soap used
C. The use of a sterile towel
D. The duration and friction of rubbing
Answer: D
Rationale: Friction and the duration of the wash are the most effective components of
hand hygiene for removing transient microorganisms.
,3. A patient requires droplet precautions. Which piece of personal protective
equipment (PPE) is mandatory for the nurse to wear when entering the room?
A. Surgical mask
B. N95 respirator
C. Gown and gloves only
D. Face shield and shoe covers
Answer: A
Rationale: Droplet precautions require a surgical mask within 3 feet of the patient to
prevent transmission of large-particle droplets.
4. When measuring blood pressure, the nurse uses a cuff that is too small for
the patient’s arm. What is the likely result?
A. An accurately measured pressure
B. A falsely low systolic reading
C. A falsely high reading
D. A reading that only affects the diastolic pressure
Answer: C
Rationale: A cuff that is too narrow or small will result in a falsely high blood pressure
reading because the pressure is not evenly distributed.
5. Which assessment technique should the nurse perform first when assessing a
patient’s abdomen?
A. Palpation
B. Percussion
C. Auscultation
D. Inspection
Answer: D
Rationale: The correct sequence for abdominal assessment is Inspection, Auscultation,
Percussion, and then Palpation to avoid altering bowel sounds.
, 6. A nurse is moving a patient up in bed. Which principle of body mechanics
should the nurse follow?
A. Keep the knees straight and bend at the waist
B. Flex the knees and use the leg muscles
C. Place the bed in the lowest position
D. Maintain a narrow base of support
Answer: B
Rationale: Flexing the knees and using the large muscles of the legs provides power and
protects the nurse’s back from injury.
7. What is the first step the nurse should take when a fire is discovered in a
patient’s room?
A. Activate the fire alarm
B. Extinguish the fire
C. Remove the patient from the room
D. Close the doors to contain the fire
Answer: C
Rationale: According to the RACE acronym, ‘R’ stands for Rescue/Remove the patient from
immediate danger first.
8. The nurse is performing a bed bath for a patient. In what direction should the
nurse wash the patient’s extremities?
A. From proximal to distal to improve comfort
B. From distal to proximal to promote venous return
C. In a circular motion to increase friction
D. In whatever direction is most efficient
Answer: B
Rationale: Washing from distal to proximal (fingers to shoulder, toes to groin) promotes
venous blood flow back toward the heart.
1. When assessing a patient’s radial pulse, the nurse notes the rhythm is
irregular. What is the most appropriate next action?
A. Document the finding and reassess in 4 hours
B. Count the radial pulse for a full 60 seconds
C. Notify the healthcare provider immediately
D. Assess the apical pulse for one full minute
Answer: D
Rationale: If a peripheral pulse is irregular, the apical pulse should be assessed for one full
minute to determine the actual heart rate and identify any pulse deficit.
2. The nurse is preparing to perform hand hygiene. Which of the following is the
most important factor in reducing the number of microorganisms on the hands?
A. The temperature of the water
B. The type of soap used
C. The use of a sterile towel
D. The duration and friction of rubbing
Answer: D
Rationale: Friction and the duration of the wash are the most effective components of
hand hygiene for removing transient microorganisms.
,3. A patient requires droplet precautions. Which piece of personal protective
equipment (PPE) is mandatory for the nurse to wear when entering the room?
A. Surgical mask
B. N95 respirator
C. Gown and gloves only
D. Face shield and shoe covers
Answer: A
Rationale: Droplet precautions require a surgical mask within 3 feet of the patient to
prevent transmission of large-particle droplets.
4. When measuring blood pressure, the nurse uses a cuff that is too small for
the patient’s arm. What is the likely result?
A. An accurately measured pressure
B. A falsely low systolic reading
C. A falsely high reading
D. A reading that only affects the diastolic pressure
Answer: C
Rationale: A cuff that is too narrow or small will result in a falsely high blood pressure
reading because the pressure is not evenly distributed.
5. Which assessment technique should the nurse perform first when assessing a
patient’s abdomen?
A. Palpation
B. Percussion
C. Auscultation
D. Inspection
Answer: D
Rationale: The correct sequence for abdominal assessment is Inspection, Auscultation,
Percussion, and then Palpation to avoid altering bowel sounds.
, 6. A nurse is moving a patient up in bed. Which principle of body mechanics
should the nurse follow?
A. Keep the knees straight and bend at the waist
B. Flex the knees and use the leg muscles
C. Place the bed in the lowest position
D. Maintain a narrow base of support
Answer: B
Rationale: Flexing the knees and using the large muscles of the legs provides power and
protects the nurse’s back from injury.
7. What is the first step the nurse should take when a fire is discovered in a
patient’s room?
A. Activate the fire alarm
B. Extinguish the fire
C. Remove the patient from the room
D. Close the doors to contain the fire
Answer: C
Rationale: According to the RACE acronym, ‘R’ stands for Rescue/Remove the patient from
immediate danger first.
8. The nurse is performing a bed bath for a patient. In what direction should the
nurse wash the patient’s extremities?
A. From proximal to distal to improve comfort
B. From distal to proximal to promote venous return
C. In a circular motion to increase friction
D. In whatever direction is most efficient
Answer: B
Rationale: Washing from distal to proximal (fingers to shoulder, toes to groin) promotes
venous blood flow back toward the heart.
