NSG 122 Exam 2 V3 | NSG 122 Nursing
Fundamental Concepts | Herzing | 2026
Q&A with Rationale (Herzing NSG122
Exam 2 2026)
1. A nurse is preparing to perform hand hygiene after providing care to a patient with C.
difficile. Which action is most appropriate?
A. Use an alcohol-based hand rub for at least 15 seconds.
B. Apply sterile gloves before touching the patient’s bedding.
C. Wash hands with antimicrobial soap and water.
D. Use a chlorine-based disinfectant on the skin.
Correct Answer: C
Rationale: Hand hygiene for patients with C. difficile must be performed with soap and
water because alcohol-based rubs are ineffective against spores. The mechanical action of
washing and rinsing is necessary to remove the spores from the skin surface. This
intervention is a critical component of contact precautions and prevents healthcare-
associated transmission.
2. When measuring a patient’s blood pressure, the nurse notices the cuff is too narrow for the
patient’s arm. What effect will this have on the reading?
A. The reading will be falsely low.
,B. The reading will be falsely high.
C. The systolic pressure will be accurate but diastolic will be low.
D. The reading will be unaffected if the patient is relaxed.
Correct Answer: B
Rationale: Using a blood pressure cuff that is too small or narrow for the patient’s limb
circumference will result in a false high reading. This occurs because the cuff must be over-
inflated to occlude the artery effectively. Accurate cuff sizing is essential to ensure the
bladder width is approximately 40% of the arm circumference.
3. A nurse is assessing a patient for orthostatic hypotension. Which finding indicates a
positive result?
A. A decrease in systolic pressure by 10 mmHg when standing.
B. An increase in heart rate by 5 beats per minute when sitting.
C. An increase in diastolic pressure by 10 mmHg after walking.
D. A decrease in systolic pressure by 20 mmHg when changing positions.
Correct Answer: D
Rationale: Orthostatic hypotension is defined as a drop in systolic blood pressure of at
least 20 mmHg or a drop in diastolic pressure of at least 10 mmHg within three minutes of
standing. This condition often results from peripheral vasodilation without a compensatory
, increase in cardiac output. It puts the patient at significant risk for falls and requires safety
interventions like dangling the feet before standing.
4. The nurse is caring for a patient on fall precautions. Which nursing intervention is the
priority?
A. Keeping all four side rails in the upright position.
B. Placing the bed in the lowest position with wheels locked.
C. Assisting the patient to the bathroom every 4 hours.
D. Providing a bedside commode for all voiding needs.
Correct Answer: B
Rationale: Placing the bed in the lowest position and locking the wheels is a fundamental
safety measure to prevent injury during a fall. Using four side rails is often considered a
restraint and requires a specific provider order. The nurse must also ensure the call light is
within reach to facilitate safe communication for assistance.
5. A nurse is providing oral care for an unconscious patient. Which position is safest for this
procedure?
A. High-Fowler’s position.
B. Supine with the head of the bed flat.
C. Side-lying (lateral) position.
D. Semi-Fowler’s with the head turned to the side.
Fundamental Concepts | Herzing | 2026
Q&A with Rationale (Herzing NSG122
Exam 2 2026)
1. A nurse is preparing to perform hand hygiene after providing care to a patient with C.
difficile. Which action is most appropriate?
A. Use an alcohol-based hand rub for at least 15 seconds.
B. Apply sterile gloves before touching the patient’s bedding.
C. Wash hands with antimicrobial soap and water.
D. Use a chlorine-based disinfectant on the skin.
Correct Answer: C
Rationale: Hand hygiene for patients with C. difficile must be performed with soap and
water because alcohol-based rubs are ineffective against spores. The mechanical action of
washing and rinsing is necessary to remove the spores from the skin surface. This
intervention is a critical component of contact precautions and prevents healthcare-
associated transmission.
2. When measuring a patient’s blood pressure, the nurse notices the cuff is too narrow for the
patient’s arm. What effect will this have on the reading?
A. The reading will be falsely low.
,B. The reading will be falsely high.
C. The systolic pressure will be accurate but diastolic will be low.
D. The reading will be unaffected if the patient is relaxed.
Correct Answer: B
Rationale: Using a blood pressure cuff that is too small or narrow for the patient’s limb
circumference will result in a false high reading. This occurs because the cuff must be over-
inflated to occlude the artery effectively. Accurate cuff sizing is essential to ensure the
bladder width is approximately 40% of the arm circumference.
3. A nurse is assessing a patient for orthostatic hypotension. Which finding indicates a
positive result?
A. A decrease in systolic pressure by 10 mmHg when standing.
B. An increase in heart rate by 5 beats per minute when sitting.
C. An increase in diastolic pressure by 10 mmHg after walking.
D. A decrease in systolic pressure by 20 mmHg when changing positions.
Correct Answer: D
Rationale: Orthostatic hypotension is defined as a drop in systolic blood pressure of at
least 20 mmHg or a drop in diastolic pressure of at least 10 mmHg within three minutes of
standing. This condition often results from peripheral vasodilation without a compensatory
, increase in cardiac output. It puts the patient at significant risk for falls and requires safety
interventions like dangling the feet before standing.
4. The nurse is caring for a patient on fall precautions. Which nursing intervention is the
priority?
A. Keeping all four side rails in the upright position.
B. Placing the bed in the lowest position with wheels locked.
C. Assisting the patient to the bathroom every 4 hours.
D. Providing a bedside commode for all voiding needs.
Correct Answer: B
Rationale: Placing the bed in the lowest position and locking the wheels is a fundamental
safety measure to prevent injury during a fall. Using four side rails is often considered a
restraint and requires a specific provider order. The nurse must also ensure the call light is
within reach to facilitate safe communication for assistance.
5. A nurse is providing oral care for an unconscious patient. Which position is safest for this
procedure?
A. High-Fowler’s position.
B. Supine with the head of the bed flat.
C. Side-lying (lateral) position.
D. Semi-Fowler’s with the head turned to the side.
