NURS 100 Exam 2: Fundamentals of Nursing
Questions & Answers | Grade A | 100% Correct -
WCU
1. A nurse is performing hand hygiene. What is the minimum recommended
time to rub hands together with soap and water?
A. 5 to 10 seconds
B. 45 seconds
C. 20 seconds
D. 2 minutes
Answer: C
Explanation: The CDC recommends scrubbing hands for at least 20 seconds to effectively
remove microorganisms.
2. When assessing a patient’s blood pressure, the nurse uses a cuff that 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 accurate if the patient is supine
C. The reading will be falsely high
D. The reading will be unaffected
Answer: C
Explanation: Using a blood pressure cuff that is too small or narrow results in a falsely
high reading because the cuff must generate more pressure to compress the artery.
,3. Which of the following is the most important action to prevent the spread of
infection in a healthcare setting?
A. Wearing gloves for all patient contact
B. Administering prophylactic antibiotics
C. Keeping the patient’s room door closed
D. Proper hand hygiene
Answer: D
Explanation: Hand hygiene is documented as the single most effective way to prevent the
transmission of healthcare-associated infections.
4. A nurse is preparing to transfer a patient from the bed to a chair. Which
principle of body mechanics should the nurse apply?
A. Keep the feet close together
B. Bend at the waist to lift
C. Keep the weight as close to the body as possible
D. Twist the torso while moving the patient
Answer: C
Explanation: Keeping the load close to the center of gravity reduces strain on the back
muscles and prevents injury.
5. A patient has a suspected Clostridium difficile (C. diff) infection. What type of
precautions should the nurse implement?
A. Standard precautions only
B. Droplet precautions
C. Contact precautions
D. Airborne precautions
Answer: C
Explanation: C. diff is transmitted through direct or indirect contact with contaminated
surfaces or stool, requiring contact precautions and handwashing with soap and water.
, 6. The nurse is assessing a patient’s apical pulse. Where should the stethoscope
be placed?
A. Second intercostal space, right sternal border
B. Fourth intercostal space, left sternal border
C. Fifth intercostal space, left midclavicular line
D. Second intercostal space, left sternal border
Answer: C
Explanation: The apical pulse (PMI) is located at the fifth intercostal space at the left
midclavicular line.
7. Which stage of the nursing process involves setting patient-centered goals
and expected outcomes?
A. Assessment
B. Planning
C. Diagnosis
D. Implementation
Answer: B
Explanation: Planning involves the prioritization of nursing diagnoses and the formulation
of measurable goals and outcomes.
8. A nurse is caring for an immobile patient. To prevent pressure injury
development, how often should the nurse reposition the patient?
A. Every 2 hours
B. Every 4 hours
C. Once per shift
D. When the patient requests it
Answer: A
Explanation: Standard practice is to reposition immobile patients at least every 2 hours to
relieve pressure on bony prominences.
Questions & Answers | Grade A | 100% Correct -
WCU
1. A nurse is performing hand hygiene. What is the minimum recommended
time to rub hands together with soap and water?
A. 5 to 10 seconds
B. 45 seconds
C. 20 seconds
D. 2 minutes
Answer: C
Explanation: The CDC recommends scrubbing hands for at least 20 seconds to effectively
remove microorganisms.
2. When assessing a patient’s blood pressure, the nurse uses a cuff that 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 accurate if the patient is supine
C. The reading will be falsely high
D. The reading will be unaffected
Answer: C
Explanation: Using a blood pressure cuff that is too small or narrow results in a falsely
high reading because the cuff must generate more pressure to compress the artery.
,3. Which of the following is the most important action to prevent the spread of
infection in a healthcare setting?
A. Wearing gloves for all patient contact
B. Administering prophylactic antibiotics
C. Keeping the patient’s room door closed
D. Proper hand hygiene
Answer: D
Explanation: Hand hygiene is documented as the single most effective way to prevent the
transmission of healthcare-associated infections.
4. A nurse is preparing to transfer a patient from the bed to a chair. Which
principle of body mechanics should the nurse apply?
A. Keep the feet close together
B. Bend at the waist to lift
C. Keep the weight as close to the body as possible
D. Twist the torso while moving the patient
Answer: C
Explanation: Keeping the load close to the center of gravity reduces strain on the back
muscles and prevents injury.
5. A patient has a suspected Clostridium difficile (C. diff) infection. What type of
precautions should the nurse implement?
A. Standard precautions only
B. Droplet precautions
C. Contact precautions
D. Airborne precautions
Answer: C
Explanation: C. diff is transmitted through direct or indirect contact with contaminated
surfaces or stool, requiring contact precautions and handwashing with soap and water.
, 6. The nurse is assessing a patient’s apical pulse. Where should the stethoscope
be placed?
A. Second intercostal space, right sternal border
B. Fourth intercostal space, left sternal border
C. Fifth intercostal space, left midclavicular line
D. Second intercostal space, left sternal border
Answer: C
Explanation: The apical pulse (PMI) is located at the fifth intercostal space at the left
midclavicular line.
7. Which stage of the nursing process involves setting patient-centered goals
and expected outcomes?
A. Assessment
B. Planning
C. Diagnosis
D. Implementation
Answer: B
Explanation: Planning involves the prioritization of nursing diagnoses and the formulation
of measurable goals and outcomes.
8. A nurse is caring for an immobile patient. To prevent pressure injury
development, how often should the nurse reposition the patient?
A. Every 2 hours
B. Every 4 hours
C. Once per shift
D. When the patient requests it
Answer: A
Explanation: Standard practice is to reposition immobile patients at least every 2 hours to
relieve pressure on bony prominences.
