PNR 104/PNR104 Exam 2 V2 | Basic Skills,
Quality & Safety in Nursing Practice Q&A
with Rationale | Fortis College
1. A nurse is preparing to provide care for a patient diagnosed with Clostridium difficile.
Which hand hygiene method is mandatory in this situation?
A. Using an alcohol-based hand rub for 15 seconds
B. Using a hydrogen peroxide spray on the hands
C. Wiping hands with a sterile saline gauze
D. Washing hands with antimicrobial soap and water
Correct Answer: D
Expert Explanation: Handwashing with soap and water is required for C. diff because
alcohol-based rubs do not kill the spores. The mechanical action of scrubbing under
running water helps to remove the spores from the skin. This protocol is essential for
preventing the transmission of enteric infections in the clinical setting.
2. When transferring a patient from a bed to a wheelchair, what is the most important safety
action for the nurse to perform first?
A. Lower the bed to its lowest position
B. Lock the wheels on both the bed and the wheelchair
C. Place a gait belt tightly around the patient’s chest
,D. Ask the patient to grab the nurse’s neck for support
Correct Answer: B
Expert Explanation: Locking the wheels ensures that the equipment does not move during
the transfer, which prevents falls. Stability is the primary concern when a patient is
changing positions or transferring between surfaces. Failure to lock the wheels is a
common cause of patient and staff injury.
3. A nurse is assessing a patient’s radial pulse and finds it to be irregular. What should be the
nurse’s next action?
A. Document the finding and recheck in 4 hours
B. Notify the healthcare provider immediately
C. Administer a dose of digoxin as prescribed
D. Assess the apical pulse for one full minute
Correct Answer: D
Expert Explanation: When a peripheral pulse is irregular, an apical pulse must be taken to
ensure accuracy and to check for a pulse deficit. Counting for a full 60 seconds allows the
nurse to identify the exact rhythm and rate of the heart. This is a standard nursing skill
used to gather comprehensive data before notifying the provider.
4. According to Maslow’s Hierarchy of Needs, which patient should the nurse assess first?
A. A patient who is complaining of difficulty breathing
, B. A patient who is expressing concern about their body image
C. A patient who is lonely and requests a visitor
D. A patient who needs help with their discharge planning
Correct Answer: A
Expert Explanation: Physiological needs such as oxygenation and breathing always take
priority over psychosocial needs in Maslow’s hierarchy. Difficulty breathing represents an
immediate threat to life and must be addressed before safety or belongingness.
Prioritization is a critical nursing skill tested on the NCLEX-PN and within Fortis
curriculum.
5. Which of the following is an example of objective data?
A. The patient states they feel dizzy when standing up
B. The patient reports having a headache for two days
C. The nurse observes a 2 cm reddened area on the sacrum
D. The patient rates their pain level as a 6 out of 10
Correct Answer: C
Expert Explanation: Objective data consists of observable and measurable signs that can
be seen, heard, felt, or smelled by the nurse. In this case, the size and color of a skin lesion
are physical findings that can be verified by others. Subjective data, conversely, is what the
patient tells you about their feelings or symptoms.
Quality & Safety in Nursing Practice Q&A
with Rationale | Fortis College
1. A nurse is preparing to provide care for a patient diagnosed with Clostridium difficile.
Which hand hygiene method is mandatory in this situation?
A. Using an alcohol-based hand rub for 15 seconds
B. Using a hydrogen peroxide spray on the hands
C. Wiping hands with a sterile saline gauze
D. Washing hands with antimicrobial soap and water
Correct Answer: D
Expert Explanation: Handwashing with soap and water is required for C. diff because
alcohol-based rubs do not kill the spores. The mechanical action of scrubbing under
running water helps to remove the spores from the skin. This protocol is essential for
preventing the transmission of enteric infections in the clinical setting.
2. When transferring a patient from a bed to a wheelchair, what is the most important safety
action for the nurse to perform first?
A. Lower the bed to its lowest position
B. Lock the wheels on both the bed and the wheelchair
C. Place a gait belt tightly around the patient’s chest
,D. Ask the patient to grab the nurse’s neck for support
Correct Answer: B
Expert Explanation: Locking the wheels ensures that the equipment does not move during
the transfer, which prevents falls. Stability is the primary concern when a patient is
changing positions or transferring between surfaces. Failure to lock the wheels is a
common cause of patient and staff injury.
3. A nurse is assessing a patient’s radial pulse and finds it to be irregular. What should be the
nurse’s next action?
A. Document the finding and recheck in 4 hours
B. Notify the healthcare provider immediately
C. Administer a dose of digoxin as prescribed
D. Assess the apical pulse for one full minute
Correct Answer: D
Expert Explanation: When a peripheral pulse is irregular, an apical pulse must be taken to
ensure accuracy and to check for a pulse deficit. Counting for a full 60 seconds allows the
nurse to identify the exact rhythm and rate of the heart. This is a standard nursing skill
used to gather comprehensive data before notifying the provider.
4. According to Maslow’s Hierarchy of Needs, which patient should the nurse assess first?
A. A patient who is complaining of difficulty breathing
, B. A patient who is expressing concern about their body image
C. A patient who is lonely and requests a visitor
D. A patient who needs help with their discharge planning
Correct Answer: A
Expert Explanation: Physiological needs such as oxygenation and breathing always take
priority over psychosocial needs in Maslow’s hierarchy. Difficulty breathing represents an
immediate threat to life and must be addressed before safety or belongingness.
Prioritization is a critical nursing skill tested on the NCLEX-PN and within Fortis
curriculum.
5. Which of the following is an example of objective data?
A. The patient states they feel dizzy when standing up
B. The patient reports having a headache for two days
C. The nurse observes a 2 cm reddened area on the sacrum
D. The patient rates their pain level as a 6 out of 10
Correct Answer: C
Expert Explanation: Objective data consists of observable and measurable signs that can
be seen, heard, felt, or smelled by the nurse. In this case, the size and color of a skin lesion
are physical findings that can be verified by others. Subjective data, conversely, is what the
patient tells you about their feelings or symptoms.
