NURS 104L Fundamentals of Nursing Skills Lab - Week 2
Comprehensive Quiz 2026 |WCU
1. When assessing a patient’s blood pressure, the nurse notes that the cuff used
is too narrow for the patient’s arm circumference. Which of the following
results should the nurse expect?
A. A reading that is unaffected by the cuff size
B. A falsely low blood pressure reading
C. A falsely elevated blood pressure reading
D. An inability to auscultate Korotkoff sounds
Answer: C
Rationale: A cuff that is too small or too narrow causes the bladder to be inflated more to
compress the artery, resulting in a falsely high blood pressure reading.
2. The nurse is caring for a patient diagnosed with Clostridium difficile. Which
hand hygiene method is mandatory according to the Centers for Disease Control
and Prevention (CDC)?
A. Applying alcohol-based hand rub until dry
B. Washing hands with non-antimicrobial soap and water
C. Washing hands with antimicrobial soap and water
D. Using chlorhexidine gluconate (CHG) wipes
Answer: B
Rationale: Alcohol-based rubs are ineffective against C. difficile spores; physical friction
and rinsing with soap and water are required to mechanically remove the spores.
,3. Where should the nurse place the stethoscope to auscultate the apical pulse
of an adult patient?
A. Second intercostal space, right sternal border
B. Fifth intercostal space, left midclavicular line
C. Second intercostal space, left sternal border
D. Fourth intercostal space, left sternal border
Answer: B
Rationale: The apical pulse (Point of Maximal Impulse) is found at the fifth intercostal
space at the left midclavicular line in adults.
4. A nurse is preparing to assess a patient for orthostatic hypotension. Which
sequence of positions is correct for this assessment?
A. Sitting, standing, then lying down
B. Lying down, standing, then sitting
C. Supine, sitting, then standing
D. Standing, sitting, then lying down
Answer: C
Rationale: Orthostatic vitals are measured by taking BP and pulse while the patient is
supine, then sitting, and finally standing, with a 1-3 minute rest between each.
5. Which of the following actions violates the principles of surgical asepsis when
maintaining a sterile field?
A. Keeping the sterile field within the line of vision
B. Holding sterile gloved hands above the waist level
C. Reaching over the sterile field to pick up a tool
D. Dropping sterile items onto the center of the field
Answer: C
Rationale: Reaching over a sterile field is a violation because dander or microbes from the
nurse’s non-sterile clothing or arms can fall onto the field.
, 6. When removing Personal Protective Equipment (PPE) after caring for a
patient in isolation, which item should the nurse typically remove first?
A. Mask or respirator
B. Gloves
C. Goggles or face shield
D. Gown
Answer: B
Rationale: Gloves are considered the most contaminated and should be removed first to
prevent contaminating the skin or other items during removal.
7. The nurse is preparing to take a rectal temperature on an adult patient. How
far should the thermometer probe be inserted into the rectum?
A. 0.5 inches (1.2 cm)
B. 2.0 inches (5.0 cm)
C.
D. 3.0 inches (7.5 cm)
E. 1.5 inches (3.5 cm)
Answer: E
Rationale: For an adult, the rectal thermometer should be inserted approximately 1.5
inches (3.5 cm) toward the umbilicus.
8. A patient is using a cane for the first time due to left-sided weakness. Which
instruction should the nurse provide?
A. Hold the cane in the left hand and move it with the right leg
B. Hold the cane in the right hand and move it with the left leg
C. Hold the cane in the left hand and move it with the left leg
D. Hold the cane in the right hand and move it with the right leg
Answer: B
Comprehensive Quiz 2026 |WCU
1. When assessing a patient’s blood pressure, the nurse notes that the cuff used
is too narrow for the patient’s arm circumference. Which of the following
results should the nurse expect?
A. A reading that is unaffected by the cuff size
B. A falsely low blood pressure reading
C. A falsely elevated blood pressure reading
D. An inability to auscultate Korotkoff sounds
Answer: C
Rationale: A cuff that is too small or too narrow causes the bladder to be inflated more to
compress the artery, resulting in a falsely high blood pressure reading.
2. The nurse is caring for a patient diagnosed with Clostridium difficile. Which
hand hygiene method is mandatory according to the Centers for Disease Control
and Prevention (CDC)?
A. Applying alcohol-based hand rub until dry
B. Washing hands with non-antimicrobial soap and water
C. Washing hands with antimicrobial soap and water
D. Using chlorhexidine gluconate (CHG) wipes
Answer: B
Rationale: Alcohol-based rubs are ineffective against C. difficile spores; physical friction
and rinsing with soap and water are required to mechanically remove the spores.
,3. Where should the nurse place the stethoscope to auscultate the apical pulse
of an adult patient?
A. Second intercostal space, right sternal border
B. Fifth intercostal space, left midclavicular line
C. Second intercostal space, left sternal border
D. Fourth intercostal space, left sternal border
Answer: B
Rationale: The apical pulse (Point of Maximal Impulse) is found at the fifth intercostal
space at the left midclavicular line in adults.
4. A nurse is preparing to assess a patient for orthostatic hypotension. Which
sequence of positions is correct for this assessment?
A. Sitting, standing, then lying down
B. Lying down, standing, then sitting
C. Supine, sitting, then standing
D. Standing, sitting, then lying down
Answer: C
Rationale: Orthostatic vitals are measured by taking BP and pulse while the patient is
supine, then sitting, and finally standing, with a 1-3 minute rest between each.
5. Which of the following actions violates the principles of surgical asepsis when
maintaining a sterile field?
A. Keeping the sterile field within the line of vision
B. Holding sterile gloved hands above the waist level
C. Reaching over the sterile field to pick up a tool
D. Dropping sterile items onto the center of the field
Answer: C
Rationale: Reaching over a sterile field is a violation because dander or microbes from the
nurse’s non-sterile clothing or arms can fall onto the field.
, 6. When removing Personal Protective Equipment (PPE) after caring for a
patient in isolation, which item should the nurse typically remove first?
A. Mask or respirator
B. Gloves
C. Goggles or face shield
D. Gown
Answer: B
Rationale: Gloves are considered the most contaminated and should be removed first to
prevent contaminating the skin or other items during removal.
7. The nurse is preparing to take a rectal temperature on an adult patient. How
far should the thermometer probe be inserted into the rectum?
A. 0.5 inches (1.2 cm)
B. 2.0 inches (5.0 cm)
C.
D. 3.0 inches (7.5 cm)
E. 1.5 inches (3.5 cm)
Answer: E
Rationale: For an adult, the rectal thermometer should be inserted approximately 1.5
inches (3.5 cm) toward the umbilicus.
8. A patient is using a cane for the first time due to left-sided weakness. Which
instruction should the nurse provide?
A. Hold the cane in the left hand and move it with the right leg
B. Hold the cane in the right hand and move it with the left leg
C. Hold the cane in the left hand and move it with the left leg
D. Hold the cane in the right hand and move it with the right leg
Answer: B
