NURS 104L Fundamentals of Nursing Skills Lab Module Exam 2 2026
|WCU
1. When measuring a patient’s blood pressure, the nurse notes that the cuff
width is too narrow for the patient’s arm circumference. What effect will this
have on the reading?
A. The reading will be falsely low.
B. The cuff size does not significantly impact blood pressure readings.
C. The systolic reading will be accurate, but the diastolic will be high.
D. The reading will be falsely high.
Answer: D
Rationale: A blood pressure cuff that is too narrow or too small for the patient’s arm will
result in a falsely high reading because it requires more pressure to occlude the artery.
2. A nurse is preparing to perform a sterile procedure. Which action would
violate the principles of surgical asepsis?
A. Keeping sterile gloved hands above the waist level.
B. Opening the outer wrapper of a sterile kit away from the body.
C. Reaching over the sterile field to pick up a specimen container.
D. Discarding a sterile item that touched the 1-inch border of the field.
Answer: C
Rationale: Reaching over a sterile field is a violation of surgical asepsis because
microorganisms can drop from the nurse’s sleeves or skin onto the sterile surface.
,3. The nurse is assessing a patient for orthostatic hypotension. After measuring
the BP and heart rate in the supine position, what is the next priority action?
A. Assist the patient to a sitting position and wait 1 to 3 minutes before measuring.
B. Wait 10 minutes before moving the patient to a sitting position.
C. Assist the patient to stand immediately and take the BP.
D. Measure the BP while the patient is performing a Valsalva maneuver.
Answer: A
Rationale: To assess for orthostatic hypotension, the nurse should allow the patient to sit
or stand for 1 to 3 minutes before taking the next reading to allow for physiological
adjustment.
4. When performing an abdominal assessment, in which order should the nurse
perform the physical examination techniques?
A. Inspection, Palpation, Percussion, Auscultation
B. Auscultation, Inspection, Palpation, Percussion
C. Palpation, Percussion, Auscultation, Inspection
D. Inspection, Auscultation, Percussion, Palpation
Answer: D
Rationale: For the abdomen, the order is Inspection, Auscultation, Percussion, and then
Palpation. Auscultation is done second because palpation and percussion can alter bowel
sounds.
5. A nurse is caring for a patient with Clostridioides difficile (C. diff). Which
infection control measure is mandatory for this specific pathogen?
A. Washing hands with soap and water rather than hand sanitizer.
B. Wearing an N95 respirator when entering the room.
C. Using alcohol-based hand sanitizer after patient contact.
D. Placing the patient in a room with positive airflow.
Answer: A
, Rationale: C. diff spores are resistant to alcohol-based sanitizers. Handwashing with soap
and water is required to mechanically remove the spores from the hands.
6. The nurse calculates a pulse deficit. Which method is correct?
A. Subtract the carotid pulse rate from the radial pulse rate.
B. Add the radial pulse rate to the apical pulse rate and divide by two.
C. Subtract the radial pulse rate from the apical pulse rate.
D. Measure the apical pulse for 30 seconds and the radial for 30 seconds, then multiply by 2.
Answer: C
Rationale: Pulse deficit is the difference between the apical pulse and the radial pulse. It
indicates that some heart contractions are not reaching the peripheral arteries.
7. Which documentation entry is the most objective and accurate regarding a
patient’s wound?
A. 2 cm x 3 cm stage II pressure injury on sacrum; no drainage noted.
B. Wound appears infected; patient seems to be in a lot of pain.
C. The wound looks like it is healing well and is much smaller.
D. Nurse changed the dressing on the large wound on the patient’s back.
Answer: A
Rationale: Objective documentation uses specific measurements and anatomical locations
rather than subjective terms like ‘looks like’ or ‘seems’.
8. While assessing an adult patient’s tympanic temperature, how should the
nurse manipulate the pinna?
A. Pull the pinna down and back.
B. Pull the pinna up and back.
C. Pull the pinna straight back.
D. Pull the pinna down and forward.
Answer: B
|WCU
1. When measuring a patient’s blood pressure, the nurse notes that the cuff
width is too narrow for the patient’s arm circumference. What effect will this
have on the reading?
A. The reading will be falsely low.
B. The cuff size does not significantly impact blood pressure readings.
C. The systolic reading will be accurate, but the diastolic will be high.
D. The reading will be falsely high.
Answer: D
Rationale: A blood pressure cuff that is too narrow or too small for the patient’s arm will
result in a falsely high reading because it requires more pressure to occlude the artery.
2. A nurse is preparing to perform a sterile procedure. Which action would
violate the principles of surgical asepsis?
A. Keeping sterile gloved hands above the waist level.
B. Opening the outer wrapper of a sterile kit away from the body.
C. Reaching over the sterile field to pick up a specimen container.
D. Discarding a sterile item that touched the 1-inch border of the field.
Answer: C
Rationale: Reaching over a sterile field is a violation of surgical asepsis because
microorganisms can drop from the nurse’s sleeves or skin onto the sterile surface.
,3. The nurse is assessing a patient for orthostatic hypotension. After measuring
the BP and heart rate in the supine position, what is the next priority action?
A. Assist the patient to a sitting position and wait 1 to 3 minutes before measuring.
B. Wait 10 minutes before moving the patient to a sitting position.
C. Assist the patient to stand immediately and take the BP.
D. Measure the BP while the patient is performing a Valsalva maneuver.
Answer: A
Rationale: To assess for orthostatic hypotension, the nurse should allow the patient to sit
or stand for 1 to 3 minutes before taking the next reading to allow for physiological
adjustment.
4. When performing an abdominal assessment, in which order should the nurse
perform the physical examination techniques?
A. Inspection, Palpation, Percussion, Auscultation
B. Auscultation, Inspection, Palpation, Percussion
C. Palpation, Percussion, Auscultation, Inspection
D. Inspection, Auscultation, Percussion, Palpation
Answer: D
Rationale: For the abdomen, the order is Inspection, Auscultation, Percussion, and then
Palpation. Auscultation is done second because palpation and percussion can alter bowel
sounds.
5. A nurse is caring for a patient with Clostridioides difficile (C. diff). Which
infection control measure is mandatory for this specific pathogen?
A. Washing hands with soap and water rather than hand sanitizer.
B. Wearing an N95 respirator when entering the room.
C. Using alcohol-based hand sanitizer after patient contact.
D. Placing the patient in a room with positive airflow.
Answer: A
, Rationale: C. diff spores are resistant to alcohol-based sanitizers. Handwashing with soap
and water is required to mechanically remove the spores from the hands.
6. The nurse calculates a pulse deficit. Which method is correct?
A. Subtract the carotid pulse rate from the radial pulse rate.
B. Add the radial pulse rate to the apical pulse rate and divide by two.
C. Subtract the radial pulse rate from the apical pulse rate.
D. Measure the apical pulse for 30 seconds and the radial for 30 seconds, then multiply by 2.
Answer: C
Rationale: Pulse deficit is the difference between the apical pulse and the radial pulse. It
indicates that some heart contractions are not reaching the peripheral arteries.
7. Which documentation entry is the most objective and accurate regarding a
patient’s wound?
A. 2 cm x 3 cm stage II pressure injury on sacrum; no drainage noted.
B. Wound appears infected; patient seems to be in a lot of pain.
C. The wound looks like it is healing well and is much smaller.
D. Nurse changed the dressing on the large wound on the patient’s back.
Answer: A
Rationale: Objective documentation uses specific measurements and anatomical locations
rather than subjective terms like ‘looks like’ or ‘seems’.
8. While assessing an adult patient’s tympanic temperature, how should the
nurse manipulate the pinna?
A. Pull the pinna down and back.
B. Pull the pinna up and back.
C. Pull the pinna straight back.
D. Pull the pinna down and forward.
Answer: B
