NURS 103 Fundamentals of Nursing - Study Guide Exam 2 (West Coast
University)
1. A nurse is preparing to measure a patient’s blood pressure using an electronic
sphygmomanometer. Which action by the nurse would likely result in a falsely
high reading?
A. Using a cuff that is too wide for the patient’s arm.
B. Positioning the patient’s arm above the level of the heart.
C. Wrapping the cuff too loosely around the patient’s arm.
D. Deflating the cuff too slowly during a manual backup check.
Answer: C
Rationale: A cuff that is wrapped too loosely or is too narrow results in a falsely high blood
pressure reading because it requires more pressure to occlude the artery. Positioning the
arm above the heart or using a cuff that is too wide results in a falsely low reading.
2. When assessing a patient for orthostatic hypotension, the nurse should notify
the provider if there is a drop in systolic blood pressure of at least how many
mmHg within three minutes of standing?
A. 20 mmHg
B. 10 mmHg
C. 5 mmHg
D. 30 mmHg
Answer: A
Rationale: Orthostatic hypotension is defined as a drop in systolic blood pressure of at
least 20 mmHg or a drop in diastolic blood pressure of at least 10 mmHg within three
minutes of rising to an upright position.
,3. Which link in the chain of infection is broken when a nurse performs hand
hygiene after touching a contaminated surface?
A. Reservoir
B. Portal of entry
C. Mode of transmission
D. Susceptible host
Answer: C
Rationale: Hand hygiene is the most effective way to break the chain of infection at the
‘mode of transmission’ stage, preventing the transfer of microorganisms from one person
or object to another.
4. A nurse is caring for a patient with Clocstridioides difficile (C. diff). Which
infection control measure is mandatory for this specific pathogen?
A. Using alcohol-based hand sanitizer before leaving the room.
B. Washing hands with soap and water after patient contact.
C. Wearing an N95 respirator mask.
D. Maintaining a distance of 6 feet from the patient.
Answer: B
Rationale: C. diff spores are resistant to alcohol-based sanitizers. Mechanical friction with
soap and water is required to physically remove the spores from the hands.
5. A nurse is donning personal protective equipment (PPE) before entering a
room with a patient on droplet precautions. What is the correct order of
donning?
A. Mask, Gown, Gloves, Goggles
B. Gloves, Goggles, Mask, Gown
C. Gown, Mask, Goggles, Gloves
D. Gown, Gloves, Mask, Goggles
Answer: C
, Rationale: The standard sequence for donning PPE is Gown, then Mask (or respirator),
then Goggles (or face shield), and finally Gloves.
6. While removing PPE after caring for a patient on contact precautions, which
item should the nurse typically remove first?
A. Gown
B. Mask
C. Goggles
D. Gloves
Answer: D
Rationale: Gloves are considered the most contaminated part of PPE and should be
removed first to prevent contaminating other items during the doffing process.
7. Which of the following patients would require Airborne Precautions?
A. A patient with Rubeola (Measles).
B. A patient with Methicillin-resistant Staphylococcus aureus (MRSA).
C. A patient with Seasonal Influenza.
D. A patient with Vancomycin-resistant Enterococcus (VRE).
Answer: A
Rationale: Airborne precautions are required for pathogens transmitted by small droplets
that remain suspended in the air, such as Measles (Rubeola), Varicella (Chickenpox), and
Tuberculosis (TB). MRSA and VRE require Contact precautions.
8. A nurse is maintaining a sterile field. Which action would result in the
contamination of the sterile field?
A. Keeping the sterile field within the line of vision.
B. Placing sterile items at least 1 inch from the edge of the field.
C. Reaching over the sterile field to pick up a gauze pad.
D. Opening the outermost flap of a sterile kit away from the body.
Answer: C
University)
1. A nurse is preparing to measure a patient’s blood pressure using an electronic
sphygmomanometer. Which action by the nurse would likely result in a falsely
high reading?
A. Using a cuff that is too wide for the patient’s arm.
B. Positioning the patient’s arm above the level of the heart.
C. Wrapping the cuff too loosely around the patient’s arm.
D. Deflating the cuff too slowly during a manual backup check.
Answer: C
Rationale: A cuff that is wrapped too loosely or is too narrow results in a falsely high blood
pressure reading because it requires more pressure to occlude the artery. Positioning the
arm above the heart or using a cuff that is too wide results in a falsely low reading.
2. When assessing a patient for orthostatic hypotension, the nurse should notify
the provider if there is a drop in systolic blood pressure of at least how many
mmHg within three minutes of standing?
A. 20 mmHg
B. 10 mmHg
C. 5 mmHg
D. 30 mmHg
Answer: A
Rationale: Orthostatic hypotension is defined as a drop in systolic blood pressure of at
least 20 mmHg or a drop in diastolic blood pressure of at least 10 mmHg within three
minutes of rising to an upright position.
,3. Which link in the chain of infection is broken when a nurse performs hand
hygiene after touching a contaminated surface?
A. Reservoir
B. Portal of entry
C. Mode of transmission
D. Susceptible host
Answer: C
Rationale: Hand hygiene is the most effective way to break the chain of infection at the
‘mode of transmission’ stage, preventing the transfer of microorganisms from one person
or object to another.
4. A nurse is caring for a patient with Clocstridioides difficile (C. diff). Which
infection control measure is mandatory for this specific pathogen?
A. Using alcohol-based hand sanitizer before leaving the room.
B. Washing hands with soap and water after patient contact.
C. Wearing an N95 respirator mask.
D. Maintaining a distance of 6 feet from the patient.
Answer: B
Rationale: C. diff spores are resistant to alcohol-based sanitizers. Mechanical friction with
soap and water is required to physically remove the spores from the hands.
5. A nurse is donning personal protective equipment (PPE) before entering a
room with a patient on droplet precautions. What is the correct order of
donning?
A. Mask, Gown, Gloves, Goggles
B. Gloves, Goggles, Mask, Gown
C. Gown, Mask, Goggles, Gloves
D. Gown, Gloves, Mask, Goggles
Answer: C
, Rationale: The standard sequence for donning PPE is Gown, then Mask (or respirator),
then Goggles (or face shield), and finally Gloves.
6. While removing PPE after caring for a patient on contact precautions, which
item should the nurse typically remove first?
A. Gown
B. Mask
C. Goggles
D. Gloves
Answer: D
Rationale: Gloves are considered the most contaminated part of PPE and should be
removed first to prevent contaminating other items during the doffing process.
7. Which of the following patients would require Airborne Precautions?
A. A patient with Rubeola (Measles).
B. A patient with Methicillin-resistant Staphylococcus aureus (MRSA).
C. A patient with Seasonal Influenza.
D. A patient with Vancomycin-resistant Enterococcus (VRE).
Answer: A
Rationale: Airborne precautions are required for pathogens transmitted by small droplets
that remain suspended in the air, such as Measles (Rubeola), Varicella (Chickenpox), and
Tuberculosis (TB). MRSA and VRE require Contact precautions.
8. A nurse is maintaining a sterile field. Which action would result in the
contamination of the sterile field?
A. Keeping the sterile field within the line of vision.
B. Placing sterile items at least 1 inch from the edge of the field.
C. Reaching over the sterile field to pick up a gauze pad.
D. Opening the outermost flap of a sterile kit away from the body.
Answer: C
