NUR2115/NUR 2115 Exam 4 V3 |
Fundamentals of Professional
Nursing Q&A with Rationale |
Rasmussen University
1. Which action is the single most effective way for a nurse to prevent the spread of
healthcare-associated infections?
A. Wearing a clean gown for every patient encounter
B. Maintaining a distance of at least 3 feet from all patients
C. Administering prophylactic antibiotics to all surgical patients
D. Performing hand hygiene before and after patient contact
Correct Answer: D
Expert Explanation: Hand hygiene is the most fundamental and effective measure to
prevent the transmission of pathogens in healthcare settings. It should be performed
before touching a patient, after touching a patient, and after contact with the patient’s
environment. Consistent hand hygiene significantly reduces the risk of cross-contamination
between patients and staff.
2. A nurse discovers a small fire in a trash can in a patient’s room. Using the RACE acronym,
what is the nurse’s first priority?
A. Pull the fire alarm to alert the hospital staff
,B. Contain the fire by closing the door to the room
C. Extinguish the fire using the nearest extinguisher
D. Rescue the patient from immediate danger
Correct Answer: D
Expert Explanation: The RACE acronym stands for Rescue, Alarm, Contain, and
Extinguish. The nurse’s immediate priority is the safety of the patient, so rescuing the
individual from the room is the first step. Once the patient is safe, the nurse should proceed
to activate the alarm and contain the fire.
3. When assessing a patient’s blood pressure, the nurse notes the cuff is too small for the
patient’s arm. What effect will this have on the reading?
A. The blood pressure reading will be falsely high
B. The blood pressure reading will be falsely low
C. The reading will be accurate if the patient is sitting up
D. The systolic pressure will be low and diastolic will be high
Correct Answer: A
Expert Explanation: Using a blood pressure cuff that is too small or too narrow for the
limb will result in a falsely elevated reading. This occurs because the cuff cannot properly
transmit the pressure to the artery, requiring higher inflation levels. Choosing the correct
cuff size is essential for ensuring clinical accuracy and appropriate treatment decisions.
, 4. A nurse is preparing to administer an intramuscular (IM) injection. Which site is the
preferred location for adults to minimize the risk of nerve damage?
A. Ventrogluteal site
B. Deltoid muscle
C. Dorsogluteal site
D. Vastus lateralis
Correct Answer: A
Expert Explanation: The ventrogluteal site is the preferred location for IM injections in
adults because it is away from major nerves and blood vessels. It is situated in the gluteus
medius muscle, which is large and well-developed. This site also provides a consistent
depth of adipose tissue compared to other gluteal areas.
5. Which of the following describes the ‘Evaluation’ phase of the nursing process?
A. Identifying the patient’s health problems and nursing diagnoses
B. Determining if the patient’s goals and outcomes have been met
C. Carrying out the planned nursing interventions
D. Gathering subjective and objective data from the patient
Correct Answer: B
Expert Explanation: The evaluation phase involves comparing the patient’s current health
status with the desired outcomes established during the planning phase. It allows the nurse
Fundamentals of Professional
Nursing Q&A with Rationale |
Rasmussen University
1. Which action is the single most effective way for a nurse to prevent the spread of
healthcare-associated infections?
A. Wearing a clean gown for every patient encounter
B. Maintaining a distance of at least 3 feet from all patients
C. Administering prophylactic antibiotics to all surgical patients
D. Performing hand hygiene before and after patient contact
Correct Answer: D
Expert Explanation: Hand hygiene is the most fundamental and effective measure to
prevent the transmission of pathogens in healthcare settings. It should be performed
before touching a patient, after touching a patient, and after contact with the patient’s
environment. Consistent hand hygiene significantly reduces the risk of cross-contamination
between patients and staff.
2. A nurse discovers a small fire in a trash can in a patient’s room. Using the RACE acronym,
what is the nurse’s first priority?
A. Pull the fire alarm to alert the hospital staff
,B. Contain the fire by closing the door to the room
C. Extinguish the fire using the nearest extinguisher
D. Rescue the patient from immediate danger
Correct Answer: D
Expert Explanation: The RACE acronym stands for Rescue, Alarm, Contain, and
Extinguish. The nurse’s immediate priority is the safety of the patient, so rescuing the
individual from the room is the first step. Once the patient is safe, the nurse should proceed
to activate the alarm and contain the fire.
3. When assessing a patient’s blood pressure, the nurse notes the cuff is too small for the
patient’s arm. What effect will this have on the reading?
A. The blood pressure reading will be falsely high
B. The blood pressure reading will be falsely low
C. The reading will be accurate if the patient is sitting up
D. The systolic pressure will be low and diastolic will be high
Correct Answer: A
Expert Explanation: Using a blood pressure cuff that is too small or too narrow for the
limb will result in a falsely elevated reading. This occurs because the cuff cannot properly
transmit the pressure to the artery, requiring higher inflation levels. Choosing the correct
cuff size is essential for ensuring clinical accuracy and appropriate treatment decisions.
, 4. A nurse is preparing to administer an intramuscular (IM) injection. Which site is the
preferred location for adults to minimize the risk of nerve damage?
A. Ventrogluteal site
B. Deltoid muscle
C. Dorsogluteal site
D. Vastus lateralis
Correct Answer: A
Expert Explanation: The ventrogluteal site is the preferred location for IM injections in
adults because it is away from major nerves and blood vessels. It is situated in the gluteus
medius muscle, which is large and well-developed. This site also provides a consistent
depth of adipose tissue compared to other gluteal areas.
5. Which of the following describes the ‘Evaluation’ phase of the nursing process?
A. Identifying the patient’s health problems and nursing diagnoses
B. Determining if the patient’s goals and outcomes have been met
C. Carrying out the planned nursing interventions
D. Gathering subjective and objective data from the patient
Correct Answer: B
Expert Explanation: The evaluation phase involves comparing the patient’s current health
status with the desired outcomes established during the planning phase. It allows the nurse
