PNR 106/PNR106 Exam 2 V1 | Foundations
of Nursing Q&A with Rationale | Fortis
College
1. A nurse is assessing a patient for orthostatic hypotension. Which of the following findings
would indicate this condition?
A. A decrease in systolic blood pressure of 20 mm Hg when moving from lying to standing.
B. An increase in diastolic blood pressure of 10 mm Hg when sitting up.
C. A decrease in heart rate of 15 beats per minute when changing positions.
D. An increase in systolic blood pressure of 5 mm Hg when standing.
Correct Answer: A
Expert Explanation: Orthostatic hypotension is defined as a drop in systolic blood
pressure of at least 20 mm Hg or a drop in diastolic blood pressure of at least 10 mm Hg
within three minutes of standing. This condition occurs because the peripheral vasculature
fails to constrict appropriately in response to gravity. The nurse should always monitor the
patient for dizziness or syncope during this assessment to ensure safety.
2. Which stage of the nursing process involves the nurse determining the effectiveness of the
interventions implemented?
A. Assessment
B. Evaluation
,C. Implementation
D. Planning
Correct Answer: B
Expert Explanation: Evaluation is the final step of the nursing process where the nurse
compares the patient’s current status with the desired outcomes. During this phase, the
nurse determines if the goals were met, partially met, or not met at all. If the goals were not
met, the nurse must revise the plan of care to better address the patient’s needs.
3. While performing hand hygiene, how long should a nurse scrub their hands with soap and
water?
A. At least 15 to 20 seconds
B. At least 5 seconds
C. Exactly 1 minute
D. 3 minutes
Correct Answer: A
Expert Explanation: According to standard infection control guidelines, friction should be
applied for at least 15 to 20 seconds to effectively remove transient microorganisms. This
process involves scrubbing all surfaces of the hands, including between fingers and under
fingernails. Proper hand hygiene is the most effective way to prevent the spread of
healthcare-associated infections.
, 4. A patient is placed on Droplet Precautions. Which of the following personal protective
equipment (PPE) is required for a nurse entering the room?
A. Surgical mask
B. N95 respirator
C. Goggles only
D. Shoe covers
Correct Answer: A
Expert Explanation: Droplet precautions are used for pathogens transmitted by large-
particle droplets that travel short distances, usually within 3 to 6 feet. A surgical mask is
the primary requirement for healthcare workers entering the room to prevent inhalation of
these droplets. Unlike airborne precautions, a specialized N95 respirator is not mandatory
unless an aerosol-generating procedure is being performed.
5. A nurse is using the RACE acronym for fire safety. What does the ‘C’ stand for?
A. Contain the fire
B. Call for help
C. Carry the patient
D. Clear the hallway
Correct Answer: A
of Nursing Q&A with Rationale | Fortis
College
1. A nurse is assessing a patient for orthostatic hypotension. Which of the following findings
would indicate this condition?
A. A decrease in systolic blood pressure of 20 mm Hg when moving from lying to standing.
B. An increase in diastolic blood pressure of 10 mm Hg when sitting up.
C. A decrease in heart rate of 15 beats per minute when changing positions.
D. An increase in systolic blood pressure of 5 mm Hg when standing.
Correct Answer: A
Expert Explanation: Orthostatic hypotension is defined as a drop in systolic blood
pressure of at least 20 mm Hg or a drop in diastolic blood pressure of at least 10 mm Hg
within three minutes of standing. This condition occurs because the peripheral vasculature
fails to constrict appropriately in response to gravity. The nurse should always monitor the
patient for dizziness or syncope during this assessment to ensure safety.
2. Which stage of the nursing process involves the nurse determining the effectiveness of the
interventions implemented?
A. Assessment
B. Evaluation
,C. Implementation
D. Planning
Correct Answer: B
Expert Explanation: Evaluation is the final step of the nursing process where the nurse
compares the patient’s current status with the desired outcomes. During this phase, the
nurse determines if the goals were met, partially met, or not met at all. If the goals were not
met, the nurse must revise the plan of care to better address the patient’s needs.
3. While performing hand hygiene, how long should a nurse scrub their hands with soap and
water?
A. At least 15 to 20 seconds
B. At least 5 seconds
C. Exactly 1 minute
D. 3 minutes
Correct Answer: A
Expert Explanation: According to standard infection control guidelines, friction should be
applied for at least 15 to 20 seconds to effectively remove transient microorganisms. This
process involves scrubbing all surfaces of the hands, including between fingers and under
fingernails. Proper hand hygiene is the most effective way to prevent the spread of
healthcare-associated infections.
, 4. A patient is placed on Droplet Precautions. Which of the following personal protective
equipment (PPE) is required for a nurse entering the room?
A. Surgical mask
B. N95 respirator
C. Goggles only
D. Shoe covers
Correct Answer: A
Expert Explanation: Droplet precautions are used for pathogens transmitted by large-
particle droplets that travel short distances, usually within 3 to 6 feet. A surgical mask is
the primary requirement for healthcare workers entering the room to prevent inhalation of
these droplets. Unlike airborne precautions, a specialized N95 respirator is not mandatory
unless an aerosol-generating procedure is being performed.
5. A nurse is using the RACE acronym for fire safety. What does the ‘C’ stand for?
A. Contain the fire
B. Call for help
C. Carry the patient
D. Clear the hallway
Correct Answer: A
