NUR2115/NUR 2115 Final Exam V3 |
Fundamentals of Professional Nursing
Q&A with Rationale | Rasmussen
University
1. A nurse is preparing to perform hand hygiene. When should the nurse use soap and water
instead of an alcohol-based hand rub?
A. Before direct contact with a patient
B. After removing gloves following a procedure
C. After touching a patient’s intact skin
D. When the hands are visibly soiled with blood or body fluids
Correct Answer: D
Expert Explanation: Soap and water must be used when hands are visibly dirty or
contaminated with proteinaceous material, blood, or other body fluids. Alcohol-based rubs
are effective for many organisms but do not physically remove soil or spores like C. difficile.
The friction and rinsing involved in handwashing are necessary for physical
decontamination.
2. Which stage of the nursing process involves the nurse collecting data to determine the
patient’s health status?
A. Implementation
,B. Planning
C. Assessment
D. Diagnosis
Correct Answer: C
Expert Explanation: Assessment is the first step of the nursing process where the nurse
gathers subjective and objective data. This phase provides the foundation for identifying
patient problems and creating a care plan. Without accurate assessment, the subsequent
steps of diagnosis and planning cannot be properly addressed.
3. A nurse is caring for a patient who is at high risk for falls. Which intervention is most
appropriate to ensure patient safety?
A. Keep all four side rails up at all times
B. Provide the patient with non-skid footwear
C. Place the bed in the highest position for easier exit
D. Administer a sedative to keep the patient in bed
Correct Answer: B
Expert Explanation: Non-skid footwear provides traction and helps prevent slipping
during ambulation or transfers. Keeping all four side rails up is often considered a restraint
and can increase the risk of injury if the patient tries to climb over. The bed should always
be kept in the lowest position to minimize the distance to the floor in case of a fall.
, 4. What is the primary purpose of an incident report in a healthcare setting?
A. To punish the staff member involved in the error
B. To provide a permanent record for the patient’s chart
C. To identify system failures and improve quality of care
D. To inform the patient’s family of the mistake
Correct Answer: C
Expert Explanation: Incident reports are internal documents used for quality
improvement and risk management to identify trends or system flaws. They are not meant
to be punitive toward employees but rather to prevent future occurrences. Notably,
incident reports should never be documented or referenced in the patient’s medical record.
5. A nurse is measuring a patient’s blood pressure and finds the cuff is too small for the
patient’s arm. What effect will this have on the reading?
A. The reading will be falsely high
B. The reading will be falsely low
C. The systolic pressure will be high but diastolic will be low
D. There will be no effect on the reading
Correct Answer: A
Expert Explanation: Using a blood pressure cuff that is too narrow or small results in a
reading that is inaccurately high. The small cuff requires more pressure to occlude the
Fundamentals of Professional Nursing
Q&A with Rationale | Rasmussen
University
1. A nurse is preparing to perform hand hygiene. When should the nurse use soap and water
instead of an alcohol-based hand rub?
A. Before direct contact with a patient
B. After removing gloves following a procedure
C. After touching a patient’s intact skin
D. When the hands are visibly soiled with blood or body fluids
Correct Answer: D
Expert Explanation: Soap and water must be used when hands are visibly dirty or
contaminated with proteinaceous material, blood, or other body fluids. Alcohol-based rubs
are effective for many organisms but do not physically remove soil or spores like C. difficile.
The friction and rinsing involved in handwashing are necessary for physical
decontamination.
2. Which stage of the nursing process involves the nurse collecting data to determine the
patient’s health status?
A. Implementation
,B. Planning
C. Assessment
D. Diagnosis
Correct Answer: C
Expert Explanation: Assessment is the first step of the nursing process where the nurse
gathers subjective and objective data. This phase provides the foundation for identifying
patient problems and creating a care plan. Without accurate assessment, the subsequent
steps of diagnosis and planning cannot be properly addressed.
3. A nurse is caring for a patient who is at high risk for falls. Which intervention is most
appropriate to ensure patient safety?
A. Keep all four side rails up at all times
B. Provide the patient with non-skid footwear
C. Place the bed in the highest position for easier exit
D. Administer a sedative to keep the patient in bed
Correct Answer: B
Expert Explanation: Non-skid footwear provides traction and helps prevent slipping
during ambulation or transfers. Keeping all four side rails up is often considered a restraint
and can increase the risk of injury if the patient tries to climb over. The bed should always
be kept in the lowest position to minimize the distance to the floor in case of a fall.
, 4. What is the primary purpose of an incident report in a healthcare setting?
A. To punish the staff member involved in the error
B. To provide a permanent record for the patient’s chart
C. To identify system failures and improve quality of care
D. To inform the patient’s family of the mistake
Correct Answer: C
Expert Explanation: Incident reports are internal documents used for quality
improvement and risk management to identify trends or system flaws. They are not meant
to be punitive toward employees but rather to prevent future occurrences. Notably,
incident reports should never be documented or referenced in the patient’s medical record.
5. A nurse is measuring a patient’s blood pressure and finds the cuff is too small for the
patient’s arm. What effect will this have on the reading?
A. The reading will be falsely high
B. The reading will be falsely low
C. The systolic pressure will be high but diastolic will be low
D. There will be no effect on the reading
Correct Answer: A
Expert Explanation: Using a blood pressure cuff that is too narrow or small results in a
reading that is inaccurately high. The small cuff requires more pressure to occlude the
