NSG 300/NSG300 Exam 2 V3 | Foundations
of Nursing Q&A with Rationale | Grand
Canyon University
1. A nurse is performing hand hygiene before a sterile procedure. Which action is most critical
for the mechanical removal of microorganisms?
A. Applying friction for at least 20 seconds
B. Rinsing with the hands higher than the elbows
C. Using hot water to kill bacteria
D. Applying an oil-based lotion after drying
Correct Answer: A
Expert Explanation: Friction is the most important factor in the mechanical removal of
transient flora from the skin. The nurse should rub all surfaces of the hands vigorously with
soap and water for a minimum of 20 seconds. This process physically dislodges pathogens
and allows them to be rinsed away.
2. When assessing a patient’s blood pressure, the nurse notes that the cuff is too wide for the
patient’s arm. What is the likely result of this measurement?
A. A falsely low reading
B. A falsely high reading
C. An accurate reading
,D. A variable reading
Correct Answer: A
Expert Explanation: If a blood pressure cuff is too wide for the extremity, the pressure is
distributed over a larger area, resulting in a falsely low reading. Conversely, a cuff that is
too narrow will result in a falsely high reading. The nurse must select the appropriate cuff
size based on the patient’s arm circumference for clinical accuracy.
3. A patient is placed on Airborne Precautions. Which piece of personal protective equipment
(PPE) is specific to this type of isolation?
A. N95 respirator
B. Surgical mask
C. Face shield
D. Sterile gloves
Correct Answer: A
Expert Explanation: Airborne precautions require the use of an N95 respirator to filter
out small droplet nuclei that remain suspended in the air. The patient must also be placed
in a private room with negative airflow to prevent the spread of pathogens. Surgical masks
are only sufficient for droplet precautions where particles are larger and do not remain
airborne.
, 4. Which stage of the nursing process involves the nurse determining if the patient’s goals
were met?
A. Assessment
B. Implementation
C. Diagnosis
D. Evaluation
Correct Answer: D
Expert Explanation: Evaluation is the final step of the nursing process where the nurse
measures the patient’s progress toward achieving expected outcomes. This step
determines the effectiveness of the nursing care plan and whether interventions need to be
modified. It involves comparing the patient’s current status with the predefined criteria
established during the planning phase.
5. The nurse is using the SBAR tool to communicate with a healthcare provider. What does
the ‘B’ in SBAR stand for?
A. Behavior
B. Beliefs
C. Background
D. Boundary
Correct Answer: C
of Nursing Q&A with Rationale | Grand
Canyon University
1. A nurse is performing hand hygiene before a sterile procedure. Which action is most critical
for the mechanical removal of microorganisms?
A. Applying friction for at least 20 seconds
B. Rinsing with the hands higher than the elbows
C. Using hot water to kill bacteria
D. Applying an oil-based lotion after drying
Correct Answer: A
Expert Explanation: Friction is the most important factor in the mechanical removal of
transient flora from the skin. The nurse should rub all surfaces of the hands vigorously with
soap and water for a minimum of 20 seconds. This process physically dislodges pathogens
and allows them to be rinsed away.
2. When assessing a patient’s blood pressure, the nurse notes that the cuff is too wide for the
patient’s arm. What is the likely result of this measurement?
A. A falsely low reading
B. A falsely high reading
C. An accurate reading
,D. A variable reading
Correct Answer: A
Expert Explanation: If a blood pressure cuff is too wide for the extremity, the pressure is
distributed over a larger area, resulting in a falsely low reading. Conversely, a cuff that is
too narrow will result in a falsely high reading. The nurse must select the appropriate cuff
size based on the patient’s arm circumference for clinical accuracy.
3. A patient is placed on Airborne Precautions. Which piece of personal protective equipment
(PPE) is specific to this type of isolation?
A. N95 respirator
B. Surgical mask
C. Face shield
D. Sterile gloves
Correct Answer: A
Expert Explanation: Airborne precautions require the use of an N95 respirator to filter
out small droplet nuclei that remain suspended in the air. The patient must also be placed
in a private room with negative airflow to prevent the spread of pathogens. Surgical masks
are only sufficient for droplet precautions where particles are larger and do not remain
airborne.
, 4. Which stage of the nursing process involves the nurse determining if the patient’s goals
were met?
A. Assessment
B. Implementation
C. Diagnosis
D. Evaluation
Correct Answer: D
Expert Explanation: Evaluation is the final step of the nursing process where the nurse
measures the patient’s progress toward achieving expected outcomes. This step
determines the effectiveness of the nursing care plan and whether interventions need to be
modified. It involves comparing the patient’s current status with the predefined criteria
established during the planning phase.
5. The nurse is using the SBAR tool to communicate with a healthcare provider. What does
the ‘B’ in SBAR stand for?
A. Behavior
B. Beliefs
C. Background
D. Boundary
Correct Answer: C
