NUR2115/NUR 2115 Exam 2 V1 |
Fundamentals of Professional
Nursing Q&A with Rationale |
Rasmussen University
1. A nurse is performing hand hygiene. Which action is the most important factor in reducing
the number of microorganisms on the hands?
A. Using very hot water to kill bacteria.
B. Applying an antibiotic ointment after washing.
C. Using a sterile towel to dry the hands.
D. Applying friction for at least 15 to 20 seconds.
Correct Answer: D
Expert Explanation: Friction is the most effective way to mechanically remove transient
bacteria from the skin surface. The Centers for Disease Control and Prevention (CDC)
recommends scrubbing for at least 20 seconds to be effective. Proper hand hygiene is
considered the single most important practice in preventing the spread of infection in
healthcare settings.
2. When preparing to enter the room of a patient on Droplet Precautions for influenza, which
piece of personal protective equipment (PPE) is essential?
A. Surgical mask
,B. N95 respirator mask
C. Goggles and shoe covers
D. Sterile gloves
Correct Answer: A
Expert Explanation: Droplet precautions are used for pathogens transmitted by large-
particle droplets that travel 3 to 6 feet. A standard surgical mask is sufficient to protect the
nurse from inhaling these droplets while providing care. In contrast, N95 respirators are
specifically required for airborne precautions such as Tuberculosis or Measles.
3. A nurse is caring for a patient who is at high risk for falls. Which intervention should the
nurse prioritize to ensure patient safety?
A. Keep all four side rails in the upright position.
B. Apply soft wrist restraints to prevent wandering.
C. Administer a sedative to keep the patient in bed.
D. Place the call light within the patient’s reach.
Correct Answer: D
Expert Explanation: Ensuring the call light is within reach allows the patient to ask for
assistance before attempting to get out of bed alone. Using all four side rails or sedatives
can be considered a restraint and may actually increase the risk of injury if the patient tries
, to climb over them. Safety interventions should always start with the least restrictive
measures possible.
4. During a bed bath, the nurse notices a reddened area on the patient’s sacrum that does not
blanch when pressed. How should this be documented?
A. Stage 1 pressure injury
B. Stage 2 pressure injury
C. Deep tissue injury
D. Normal skin variation
Correct Answer: A
Expert Explanation: A Stage 1 pressure injury is characterized by intact skin with
localized non-blanchable erythema. This indicates that the microcirculation has been
compromised due to pressure, though no skin breakdown has occurred yet. Early
identification of these areas is critical for implementing turning schedules and pressure-
relieving surfaces.
5. A nurse is assessing a patient’s radial pulse and finds it to be irregular. What is the nurse’s
next best action?
A. Document the pulse as ‘normal’ and move on.
B. Wait 5 minutes and re-check the radial pulse for 30 seconds.
C. Assess the apical pulse for one full minute.
Fundamentals of Professional
Nursing Q&A with Rationale |
Rasmussen University
1. A nurse is performing hand hygiene. Which action is the most important factor in reducing
the number of microorganisms on the hands?
A. Using very hot water to kill bacteria.
B. Applying an antibiotic ointment after washing.
C. Using a sterile towel to dry the hands.
D. Applying friction for at least 15 to 20 seconds.
Correct Answer: D
Expert Explanation: Friction is the most effective way to mechanically remove transient
bacteria from the skin surface. The Centers for Disease Control and Prevention (CDC)
recommends scrubbing for at least 20 seconds to be effective. Proper hand hygiene is
considered the single most important practice in preventing the spread of infection in
healthcare settings.
2. When preparing to enter the room of a patient on Droplet Precautions for influenza, which
piece of personal protective equipment (PPE) is essential?
A. Surgical mask
,B. N95 respirator mask
C. Goggles and shoe covers
D. Sterile gloves
Correct Answer: A
Expert Explanation: Droplet precautions are used for pathogens transmitted by large-
particle droplets that travel 3 to 6 feet. A standard surgical mask is sufficient to protect the
nurse from inhaling these droplets while providing care. In contrast, N95 respirators are
specifically required for airborne precautions such as Tuberculosis or Measles.
3. A nurse is caring for a patient who is at high risk for falls. Which intervention should the
nurse prioritize to ensure patient safety?
A. Keep all four side rails in the upright position.
B. Apply soft wrist restraints to prevent wandering.
C. Administer a sedative to keep the patient in bed.
D. Place the call light within the patient’s reach.
Correct Answer: D
Expert Explanation: Ensuring the call light is within reach allows the patient to ask for
assistance before attempting to get out of bed alone. Using all four side rails or sedatives
can be considered a restraint and may actually increase the risk of injury if the patient tries
, to climb over them. Safety interventions should always start with the least restrictive
measures possible.
4. During a bed bath, the nurse notices a reddened area on the patient’s sacrum that does not
blanch when pressed. How should this be documented?
A. Stage 1 pressure injury
B. Stage 2 pressure injury
C. Deep tissue injury
D. Normal skin variation
Correct Answer: A
Expert Explanation: A Stage 1 pressure injury is characterized by intact skin with
localized non-blanchable erythema. This indicates that the microcirculation has been
compromised due to pressure, though no skin breakdown has occurred yet. Early
identification of these areas is critical for implementing turning schedules and pressure-
relieving surfaces.
5. A nurse is assessing a patient’s radial pulse and finds it to be irregular. What is the nurse’s
next best action?
A. Document the pulse as ‘normal’ and move on.
B. Wait 5 minutes and re-check the radial pulse for 30 seconds.
C. Assess the apical pulse for one full minute.
