PNR 106/PNR106 Exam 3 V3 | Foundations
of Nursing Q&A with Rationale | Fortis
College
1. A nurse is preparing to measure a patient’s blood pressure. Which action should the nurse
take to ensure an accurate reading?
A. Deflate the cuff at a rate of 10 mmHg per second.
B. Position the patient’s arm above the level of the heart.
C. Wrap the cuff loosely around the upper arm.
D. Use a cuff with a bladder that covers 40% of the arm circumference.
Correct Answer: D
Expert Explanation: The width of the blood pressure cuff bladder should be
approximately 40% of the circumference of the midpoint of the limb. If the cuff is too
narrow, the reading will be falsely high, whereas a cuff that is too wide results in a falsely
low reading. Proper positioning of the arm at heart level is also critical for diagnostic
accuracy.
2. A nurse is caring for a patient who is at risk for skin breakdown. Which of the following is
the most effective nursing intervention to prevent pressure injuries?
A. Massaging reddened bony prominences daily.
B. Limiting fluid intake to reduce incontinence.
,C. Keeping the head of the bed elevated at 90 degrees.
D. Repositioning the patient at least every 2 hours.
Correct Answer: D
Expert Explanation: Repositioning the patient at least every 2 hours relieves pressure on
bony prominences and restores blood flow to the tissues. Massaging reddened areas is
contraindicated as it can cause further tissue damage. High Fowler’s position increases
shearing force and pressure on the sacrum, which should be avoided in high-risk patients.
3. When performing a physical assessment, the nurse notes a patient’s apical pulse is 110
beats per minute. How should the nurse document this finding?
A. Bradycardia
B. Tachycardia
C. Normal sinus rhythm
D. Pulse deficit
Correct Answer: B
Expert Explanation: Tachycardia is defined as an adult heart rate greater than 100 beats
per minute. This condition can be caused by various factors such as pain, fever, exercise, or
anxiety. The nurse should continue to monitor the patient and investigate the underlying
cause of the elevated heart rate.
, 4. Which personal protective equipment (PPE) should the nurse don first when following
standard precautions for a sterile procedure?
A. Gloves
B. Goggles
C. Mask
D. Gown
Correct Answer: D
Expert Explanation: The standard sequence for donning PPE starts with the gown to
provide full coverage of the torso and arms. This is followed by the mask or respirator, then
goggles or face shield, and finally the gloves. This specific order ensures that the nurse is
protected and that the sterile field remains uncontaminated.
5. A patient with a suspected C. difficile infection is placed on contact precautions. Which
action is mandatory for the nurse when performing hand hygiene?
A. Washing hands with soap and water.
B. Using an alcohol-based hand rub for 15 seconds.
C. Applying sterile gloves before entering the room.
D. Wiping hands with a dry paper towel.
Correct Answer: A
of Nursing Q&A with Rationale | Fortis
College
1. A nurse is preparing to measure a patient’s blood pressure. Which action should the nurse
take to ensure an accurate reading?
A. Deflate the cuff at a rate of 10 mmHg per second.
B. Position the patient’s arm above the level of the heart.
C. Wrap the cuff loosely around the upper arm.
D. Use a cuff with a bladder that covers 40% of the arm circumference.
Correct Answer: D
Expert Explanation: The width of the blood pressure cuff bladder should be
approximately 40% of the circumference of the midpoint of the limb. If the cuff is too
narrow, the reading will be falsely high, whereas a cuff that is too wide results in a falsely
low reading. Proper positioning of the arm at heart level is also critical for diagnostic
accuracy.
2. A nurse is caring for a patient who is at risk for skin breakdown. Which of the following is
the most effective nursing intervention to prevent pressure injuries?
A. Massaging reddened bony prominences daily.
B. Limiting fluid intake to reduce incontinence.
,C. Keeping the head of the bed elevated at 90 degrees.
D. Repositioning the patient at least every 2 hours.
Correct Answer: D
Expert Explanation: Repositioning the patient at least every 2 hours relieves pressure on
bony prominences and restores blood flow to the tissues. Massaging reddened areas is
contraindicated as it can cause further tissue damage. High Fowler’s position increases
shearing force and pressure on the sacrum, which should be avoided in high-risk patients.
3. When performing a physical assessment, the nurse notes a patient’s apical pulse is 110
beats per minute. How should the nurse document this finding?
A. Bradycardia
B. Tachycardia
C. Normal sinus rhythm
D. Pulse deficit
Correct Answer: B
Expert Explanation: Tachycardia is defined as an adult heart rate greater than 100 beats
per minute. This condition can be caused by various factors such as pain, fever, exercise, or
anxiety. The nurse should continue to monitor the patient and investigate the underlying
cause of the elevated heart rate.
, 4. Which personal protective equipment (PPE) should the nurse don first when following
standard precautions for a sterile procedure?
A. Gloves
B. Goggles
C. Mask
D. Gown
Correct Answer: D
Expert Explanation: The standard sequence for donning PPE starts with the gown to
provide full coverage of the torso and arms. This is followed by the mask or respirator, then
goggles or face shield, and finally the gloves. This specific order ensures that the nurse is
protected and that the sterile field remains uncontaminated.
5. A patient with a suspected C. difficile infection is placed on contact precautions. Which
action is mandatory for the nurse when performing hand hygiene?
A. Washing hands with soap and water.
B. Using an alcohol-based hand rub for 15 seconds.
C. Applying sterile gloves before entering the room.
D. Wiping hands with a dry paper towel.
Correct Answer: A
