NURS 104L Fundamentals of Nursing Skills Lab Module Exam 1 2026
|WCU
1. When assessing a patient’s blood pressure, the nurse notices the cuff is too
small for the patient’s arm. Which result should the nurse anticipate?
A. The systolic reading will be accurate, but diastolic will be low.
B. The blood pressure reading will be falsely low.
C. The blood pressure reading will be falsely high.
D. The reading will be unaffected as long as the bladder is centered.
Answer: C
Rationale: A blood pressure cuff that is too narrow or too small will yield a falsely high
reading because the pressure is not distributed evenly over the artery.
2. In which order should a nurse perform a physical assessment of the
abdomen?
A. Inspection, Palpation, Percussion, Auscultation
B. Auscultation, Inspection, Palpation, Percussion
C. Palpation, Percussion, Auscultation, Inspection
D. Inspection, Auscultation, Percussion, Palpation
Answer: D
Rationale: The correct sequence for abdominal assessment is Inspection, Auscultation,
Percussion, then Palpation to avoid stimulating bowel sounds before listening.
,3. A nurse is preparing to enter the room of a patient on Airborne Precautions.
Which piece of personal protective equipment (PPE) is specific to this type of
precaution?
A. Surgical mask
B. N95 respirator
C. Goggles
D. Gown
Answer: B
Rationale: Airborne precautions require the use of an N95 respirator or higher-level
respirator to filter out small droplets that remain suspended in the air.
4. Which of the following is the most effective way to prevent the spread of
healthcare-associated infections?
A. Wearing gloves for all patient contact
B. Administering prophylactic antibiotics
C. Performing thorough hand hygiene
D. Restricting visitors to the unit
Answer: C
Rationale: Hand hygiene is the single most important and effective action to prevent the
transmission of microorganisms and infections in healthcare settings.
5. While measuring a patient’s apical pulse, where should the nurse place the
stethoscope?
A. Fifth intercostal space, left midclavicular line
B. Second intercostal space, left sternal border
C. Second intercostal space, right sternal border
D. Fourth intercostal space, left sternal border
Answer: A
, Rationale: The apical pulse (PMI) is located at the fifth intercostal space at the left
midclavicular line.
6. A patient has a pulse rate of 120 beats per minute. How should the nurse
document this finding?
A. Bradycardia
B. Eupnea
C. Tachycardia
D. Pulse deficit
Answer: C
Rationale: Tachycardia is defined as a heart rate greater than 100 beats per minute in an
adult.
7. When maintaining a sterile field, which action by the nurse would result in
contamination?
A. Keeping sterile objects above the waist level
B. Keeping a 1-inch border around the sterile field
C. Opening the sterile drape away from the body first
D. Reaching over the sterile field to pick up a gauze
Answer: D
Rationale: Reaching over a sterile field contaminates it because microorganisms can drop
from clothing or skin onto the sterile surface.
8. The nurse is assessing a patient’s respiration and notes the rate is 8 breaths
per minute. This is known as:
A. Bradypnea
B. Tachypnea
C. Apnea
D. Orthopnea
Answer: A
|WCU
1. When assessing a patient’s blood pressure, the nurse notices the cuff is too
small for the patient’s arm. Which result should the nurse anticipate?
A. The systolic reading will be accurate, but diastolic will be low.
B. The blood pressure reading will be falsely low.
C. The blood pressure reading will be falsely high.
D. The reading will be unaffected as long as the bladder is centered.
Answer: C
Rationale: A blood pressure cuff that is too narrow or too small will yield a falsely high
reading because the pressure is not distributed evenly over the artery.
2. In which order should a nurse perform a physical assessment of the
abdomen?
A. Inspection, Palpation, Percussion, Auscultation
B. Auscultation, Inspection, Palpation, Percussion
C. Palpation, Percussion, Auscultation, Inspection
D. Inspection, Auscultation, Percussion, Palpation
Answer: D
Rationale: The correct sequence for abdominal assessment is Inspection, Auscultation,
Percussion, then Palpation to avoid stimulating bowel sounds before listening.
,3. A nurse is preparing to enter the room of a patient on Airborne Precautions.
Which piece of personal protective equipment (PPE) is specific to this type of
precaution?
A. Surgical mask
B. N95 respirator
C. Goggles
D. Gown
Answer: B
Rationale: Airborne precautions require the use of an N95 respirator or higher-level
respirator to filter out small droplets that remain suspended in the air.
4. Which of the following is the most effective way to prevent the spread of
healthcare-associated infections?
A. Wearing gloves for all patient contact
B. Administering prophylactic antibiotics
C. Performing thorough hand hygiene
D. Restricting visitors to the unit
Answer: C
Rationale: Hand hygiene is the single most important and effective action to prevent the
transmission of microorganisms and infections in healthcare settings.
5. While measuring a patient’s apical pulse, where should the nurse place the
stethoscope?
A. Fifth intercostal space, left midclavicular line
B. Second intercostal space, left sternal border
C. Second intercostal space, right sternal border
D. Fourth intercostal space, left sternal border
Answer: A
, Rationale: The apical pulse (PMI) is located at the fifth intercostal space at the left
midclavicular line.
6. A patient has a pulse rate of 120 beats per minute. How should the nurse
document this finding?
A. Bradycardia
B. Eupnea
C. Tachycardia
D. Pulse deficit
Answer: C
Rationale: Tachycardia is defined as a heart rate greater than 100 beats per minute in an
adult.
7. When maintaining a sterile field, which action by the nurse would result in
contamination?
A. Keeping sterile objects above the waist level
B. Keeping a 1-inch border around the sterile field
C. Opening the sterile drape away from the body first
D. Reaching over the sterile field to pick up a gauze
Answer: D
Rationale: Reaching over a sterile field contaminates it because microorganisms can drop
from clothing or skin onto the sterile surface.
8. The nurse is assessing a patient’s respiration and notes the rate is 8 breaths
per minute. This is known as:
A. Bradypnea
B. Tachypnea
C. Apnea
D. Orthopnea
Answer: A
