PNR 106/PNR106 Exam 2 V3 | Foundations
of Nursing Q&A with Rationale | Fortis
College
1. When measuring the apical pulse of a patient, where should the nurse ideally place the
stethoscope?
A. Second intercostal space at the right sternal border.
B. Fourth intercostal space at the left midaxillary line.
C. Fifth intercostal space at the left midclavicular line.
D. Third intercostal space at the left sternal border.
Correct Answer: C
Expert Explanation: The apical pulse is located at the apex of the heart, which is found at
the fifth intercostal space at the midclavicular line. This site provides the most direct
assessment of the heart’s contraction and rhythm. Nurses must auscultate this site for a full
60 seconds if the patient has a history of cardiac irregularities.
2. A nurse is measuring a patient’s blood pressure and uses a cuff that is too narrow for the
patient’s arm. What effect will this have on the reading?
A. The diastolic pressure will be low and systolic will be high.
B. The blood pressure reading will be falsely low.
C. The reading will be accurate regardless of cuff size.
,D. The blood pressure reading will be falsely high.
Correct Answer: D
Expert Explanation: Using a blood pressure cuff that is too small or narrow results in a
falsely elevated blood pressure reading because the pressure is not distributed evenly. The
cuff should cover approximately 40 percent of the arm circumference for accurate results.
Proper equipment selection is vital to clinical decision-making and patient safety.
3. During the evaluation phase of the nursing process, what is the primary focus of the nurse?
A. Collecting initial data to formulate a nursing diagnosis.
B. Developing a prioritized list of nursing interventions.
C. Determining if the patient outcomes and goals have been met.
D. Carrying out the prescribed medical treatments.
Correct Answer: C
Expert Explanation: Evaluation is the final step of the nursing process where the nurse
assesses whether the patient achieved the desired goals. If the outcomes were not met, the
nurse must analyze the reasons and modify the care plan accordingly. This step ensures
that nursing care remains effective and patient-centered over time.
4. What is the most effective way for a nurse to prevent the spread of infection between
patients?
A. Wearing clean gloves for all patient interactions.
, B. Administering prophylactic antibiotics as ordered.
C. Performing thorough hand hygiene before and after contact.
D. Keeping the patient in a private room at all times.
Correct Answer: C
Expert Explanation: Hand hygiene is recognized as the single most effective method for
preventing healthcare-associated infections. This practice should occur before touching a
patient, before clean procedures, and after exposure to body fluids. Consistent
handwashing protects both the healthcare provider and the patient from cross-
contamination.
5. A nurse asks a patient, ‘Can you describe the pain you are feeling in your chest?’ This is an
example of what type of data collection?
A. Subjective data collection.
B. Objective data collection.
C. Secondary data collection.
D. Quantitative data collection.
Correct Answer: A
Expert Explanation: Subjective data consists of information that the patient perceives and
reports directly to the nurse, such as pain levels or feelings of anxiety. Unlike objective
data, subjective data cannot be measured by a scale or observed through physical
of Nursing Q&A with Rationale | Fortis
College
1. When measuring the apical pulse of a patient, where should the nurse ideally place the
stethoscope?
A. Second intercostal space at the right sternal border.
B. Fourth intercostal space at the left midaxillary line.
C. Fifth intercostal space at the left midclavicular line.
D. Third intercostal space at the left sternal border.
Correct Answer: C
Expert Explanation: The apical pulse is located at the apex of the heart, which is found at
the fifth intercostal space at the midclavicular line. This site provides the most direct
assessment of the heart’s contraction and rhythm. Nurses must auscultate this site for a full
60 seconds if the patient has a history of cardiac irregularities.
2. A nurse is measuring a patient’s blood pressure and uses a cuff that is too narrow for the
patient’s arm. What effect will this have on the reading?
A. The diastolic pressure will be low and systolic will be high.
B. The blood pressure reading will be falsely low.
C. The reading will be accurate regardless of cuff size.
,D. The blood pressure reading will be falsely high.
Correct Answer: D
Expert Explanation: Using a blood pressure cuff that is too small or narrow results in a
falsely elevated blood pressure reading because the pressure is not distributed evenly. The
cuff should cover approximately 40 percent of the arm circumference for accurate results.
Proper equipment selection is vital to clinical decision-making and patient safety.
3. During the evaluation phase of the nursing process, what is the primary focus of the nurse?
A. Collecting initial data to formulate a nursing diagnosis.
B. Developing a prioritized list of nursing interventions.
C. Determining if the patient outcomes and goals have been met.
D. Carrying out the prescribed medical treatments.
Correct Answer: C
Expert Explanation: Evaluation is the final step of the nursing process where the nurse
assesses whether the patient achieved the desired goals. If the outcomes were not met, the
nurse must analyze the reasons and modify the care plan accordingly. This step ensures
that nursing care remains effective and patient-centered over time.
4. What is the most effective way for a nurse to prevent the spread of infection between
patients?
A. Wearing clean gloves for all patient interactions.
, B. Administering prophylactic antibiotics as ordered.
C. Performing thorough hand hygiene before and after contact.
D. Keeping the patient in a private room at all times.
Correct Answer: C
Expert Explanation: Hand hygiene is recognized as the single most effective method for
preventing healthcare-associated infections. This practice should occur before touching a
patient, before clean procedures, and after exposure to body fluids. Consistent
handwashing protects both the healthcare provider and the patient from cross-
contamination.
5. A nurse asks a patient, ‘Can you describe the pain you are feeling in your chest?’ This is an
example of what type of data collection?
A. Subjective data collection.
B. Objective data collection.
C. Secondary data collection.
D. Quantitative data collection.
Correct Answer: A
Expert Explanation: Subjective data consists of information that the patient perceives and
reports directly to the nurse, such as pain levels or feelings of anxiety. Unlike objective
data, subjective data cannot be measured by a scale or observed through physical
