PNR 104/PNR104 Exam 1 V2 | Basic Skills,
Quality & Safety in Nursing Practice Q&A
with Rationale | Fortis College
1. A nurse discovers a small fire in a trash can in a patient’s room. According to the RACE
acronym, which action should the nurse perform first?
A. Extinguish the fire using a fire extinguisher.
B. Rescue the patient from immediate danger.
C. Close the door to the patient’s room.
D. Pull the fire alarm to notify the facility.
Correct Answer: B
Expert Explanation: The ‘R’ in the RACE acronym stands for Rescue, which must always
be the first priority. Ensuring the safety of the patient is the most critical step before
performing any other actions. Once the patient is safe, the nurse can proceed to alarm,
contain, and extinguish.
2. When performing hand hygiene with an alcohol-based hand rub, which action should the
nurse take?
A. Rinse hands under warm water after rubbing.
B. Use the rub only if hands are visibly soiled.
C. Dry hands thoroughly with a paper towel.
,D. Rub hands together until the solution is dry.
Correct Answer: D
Expert Explanation: Alcohol-based hand rubs are effective only if allowed to air dry
completely through the rubbing process. Rinsing or drying with a towel would remove the
antiseptic before it has completed its antimicrobial action. If hands are visibly soiled, the
nurse must use soap and water instead.
3. A nurse is caring for a client with a diagnosis of Clostridium difficile. Which infection
control measure is mandatory for this specific client?
A. Wearing an N95 respirator mask during care.
B. Performing hand hygiene with soap and water.
C. Using alcohol-based sanitizer for all hygiene.
D. Maintaining a distance of 6 feet from the client.
Correct Answer: B
Expert Explanation: Clostridium difficile forms spores that are resistant to alcohol-based
hand sanitizers. Physical removal of the spores through vigorous handwashing with soap
and water is the only effective way to prevent transmission. The nurse must also follow
contact precautions, including the use of gloves and gowns.
4. A nurse is preparing to measure a client’s blood pressure. Which of the following cuff sizes
would result in a falsely high reading?
A. A cuff that is too wide for the arm.
, B. A cuff that is applied over thick clothing.
C. A cuff that is too narrow for the arm.
D. A cuff that is placed at the level of the heart.
Correct Answer: C
Expert Explanation: A blood pressure cuff that is too narrow or too small for the client’s
arm will require more pressure to occlude the artery, resulting in a falsely high reading.
Conversely, a cuff that is too wide will result in a falsely low reading. Proper fit is essential
for diagnostic accuracy in vital sign assessment.
5. The nurse is assessing a client’s apical pulse. At which anatomical location should the nurse
place the stethoscope?
A. Second intercostal space at the right sternal border.
B. Second intercostal space at the left sternal border.
C. Fourth intercostal space at the left sternal border.
D. Fifth intercostal space at the left midclavicular line.
Correct Answer: D
Expert Explanation: The apical pulse, or the point of maximal impulse, is best heard at the
apex of the heart. This is anatomically located at the fifth intercostal space, left
midclavicular line. This site provides the most accurate assessment of the heart’s rate and
rhythm.
Quality & Safety in Nursing Practice Q&A
with Rationale | Fortis College
1. A nurse discovers a small fire in a trash can in a patient’s room. According to the RACE
acronym, which action should the nurse perform first?
A. Extinguish the fire using a fire extinguisher.
B. Rescue the patient from immediate danger.
C. Close the door to the patient’s room.
D. Pull the fire alarm to notify the facility.
Correct Answer: B
Expert Explanation: The ‘R’ in the RACE acronym stands for Rescue, which must always
be the first priority. Ensuring the safety of the patient is the most critical step before
performing any other actions. Once the patient is safe, the nurse can proceed to alarm,
contain, and extinguish.
2. When performing hand hygiene with an alcohol-based hand rub, which action should the
nurse take?
A. Rinse hands under warm water after rubbing.
B. Use the rub only if hands are visibly soiled.
C. Dry hands thoroughly with a paper towel.
,D. Rub hands together until the solution is dry.
Correct Answer: D
Expert Explanation: Alcohol-based hand rubs are effective only if allowed to air dry
completely through the rubbing process. Rinsing or drying with a towel would remove the
antiseptic before it has completed its antimicrobial action. If hands are visibly soiled, the
nurse must use soap and water instead.
3. A nurse is caring for a client with a diagnosis of Clostridium difficile. Which infection
control measure is mandatory for this specific client?
A. Wearing an N95 respirator mask during care.
B. Performing hand hygiene with soap and water.
C. Using alcohol-based sanitizer for all hygiene.
D. Maintaining a distance of 6 feet from the client.
Correct Answer: B
Expert Explanation: Clostridium difficile forms spores that are resistant to alcohol-based
hand sanitizers. Physical removal of the spores through vigorous handwashing with soap
and water is the only effective way to prevent transmission. The nurse must also follow
contact precautions, including the use of gloves and gowns.
4. A nurse is preparing to measure a client’s blood pressure. Which of the following cuff sizes
would result in a falsely high reading?
A. A cuff that is too wide for the arm.
, B. A cuff that is applied over thick clothing.
C. A cuff that is too narrow for the arm.
D. A cuff that is placed at the level of the heart.
Correct Answer: C
Expert Explanation: A blood pressure cuff that is too narrow or too small for the client’s
arm will require more pressure to occlude the artery, resulting in a falsely high reading.
Conversely, a cuff that is too wide will result in a falsely low reading. Proper fit is essential
for diagnostic accuracy in vital sign assessment.
5. The nurse is assessing a client’s apical pulse. At which anatomical location should the nurse
place the stethoscope?
A. Second intercostal space at the right sternal border.
B. Second intercostal space at the left sternal border.
C. Fourth intercostal space at the left sternal border.
D. Fifth intercostal space at the left midclavicular line.
Correct Answer: D
Expert Explanation: The apical pulse, or the point of maximal impulse, is best heard at the
apex of the heart. This is anatomically located at the fifth intercostal space, left
midclavicular line. This site provides the most accurate assessment of the heart’s rate and
rhythm.
