NUR 104/NUR104 Exam 2 V1 | Foundations
of Nursing Q&A with Rationale | Fortis
College
1. When performing a physical assessment of the abdomen, in what order should the nurse
perform the assessment techniques?
A. Inspection, Palpation, Percussion, Auscultation
B. Inspection, Auscultation, Percussion, Palpation
C. Auscultation, Inspection, Palpation, Percussion
D. Palpation, Percussion, Auscultation, Inspection
Correct Answer: B
Expert Explanation: The correct sequence for abdominal assessment is inspection,
auscultation, percussion, and then palpation. This specific order is necessary because
palpation and percussion can stimulate bowel activity and alter the bowel sounds. By
auscultating immediately after inspection, the nurse ensures the most accurate assessment
of the client’s natural bowel sounds.
2. A nurse is preparing to measure a client’s blood pressure. Which action should the nurse
take to ensure an accurate reading?
A. Deflate the cuff at a rate of 2 to 3 mmHg per second.
B. Position the client’s arm above the level of the heart.
,C. Use a cuff with a bladder that circles at least 40% of the arm circumference.
D. Wrap the cuff loosely around the upper arm for comfort.
Correct Answer: A
Expert Explanation: Deflating the blood pressure cuff at a steady rate of 2 to 3 mmHg per
second is critical for identifying the Korotkoff sounds accurately. If the cuff is deflated too
quickly, the nurse might miss the systolic or diastolic points, leading to an incorrect
reading. The bladder width should actually be 40% of the arm circumference, while the
length should circle 80% of the arm.
3. The nurse notes a client’s radial pulse is irregular. What is the most appropriate nursing
intervention?
A. Auscultate the apical pulse for 1 full minute.
B. Document the finding and reassess in 4 hours.
C. Count the radial pulse for 30 seconds and multiply by 2.
D. Check the pulse in the opposite radial artery.
Correct Answer: A
Expert Explanation: When a peripheral pulse is found to be irregular, the nurse must
auscultate the apical pulse for a full 60 seconds. This method provides the most accurate
measurement of the heart rate and rhythm when irregularities are present. Assessment of
the apical pulse is the gold standard for clinical decision-making regarding cardiac status.
, 4. A client is diagnosed with Clostridium difficile (C. diff). Which infection control measure is
mandatory for the nurse to perform?
A. Use alcohol-based hand rub after exiting the room.
B. Wear an N95 respirator mask when providing care.
C. Keep the door to the client’s room closed at all times.
D. Wash hands with soap and water after providing care.
Correct Answer: D
Expert Explanation: C. difficile produces spores that are resistant to alcohol-based hand
sanitizers, making soap and water mandatory for hand hygiene. The mechanical friction of
washing hands under running water is required to physically remove the spores from the
skin. Using alcohol-based rubs in this scenario is ineffective and increases the risk of cross-
contamination.
5. A nurse is assessing a client for orthostatic hypotension. Which finding indicates the client
is experiencing this condition?
A. An increase in systolic BP of 10 mmHg when standing.
B. A decrease in heart rate of 15 beats per minute upon standing.
C. A decrease in systolic BP of 20 mmHg when moving from lying to standing.
D. A decrease in diastolic BP of 5 mmHg when sitting up.
Correct Answer: C
of Nursing Q&A with Rationale | Fortis
College
1. When performing a physical assessment of the abdomen, in what order should the nurse
perform the assessment techniques?
A. Inspection, Palpation, Percussion, Auscultation
B. Inspection, Auscultation, Percussion, Palpation
C. Auscultation, Inspection, Palpation, Percussion
D. Palpation, Percussion, Auscultation, Inspection
Correct Answer: B
Expert Explanation: The correct sequence for abdominal assessment is inspection,
auscultation, percussion, and then palpation. This specific order is necessary because
palpation and percussion can stimulate bowel activity and alter the bowel sounds. By
auscultating immediately after inspection, the nurse ensures the most accurate assessment
of the client’s natural bowel sounds.
2. A nurse is preparing to measure a client’s blood pressure. Which action should the nurse
take to ensure an accurate reading?
A. Deflate the cuff at a rate of 2 to 3 mmHg per second.
B. Position the client’s arm above the level of the heart.
,C. Use a cuff with a bladder that circles at least 40% of the arm circumference.
D. Wrap the cuff loosely around the upper arm for comfort.
Correct Answer: A
Expert Explanation: Deflating the blood pressure cuff at a steady rate of 2 to 3 mmHg per
second is critical for identifying the Korotkoff sounds accurately. If the cuff is deflated too
quickly, the nurse might miss the systolic or diastolic points, leading to an incorrect
reading. The bladder width should actually be 40% of the arm circumference, while the
length should circle 80% of the arm.
3. The nurse notes a client’s radial pulse is irregular. What is the most appropriate nursing
intervention?
A. Auscultate the apical pulse for 1 full minute.
B. Document the finding and reassess in 4 hours.
C. Count the radial pulse for 30 seconds and multiply by 2.
D. Check the pulse in the opposite radial artery.
Correct Answer: A
Expert Explanation: When a peripheral pulse is found to be irregular, the nurse must
auscultate the apical pulse for a full 60 seconds. This method provides the most accurate
measurement of the heart rate and rhythm when irregularities are present. Assessment of
the apical pulse is the gold standard for clinical decision-making regarding cardiac status.
, 4. A client is diagnosed with Clostridium difficile (C. diff). Which infection control measure is
mandatory for the nurse to perform?
A. Use alcohol-based hand rub after exiting the room.
B. Wear an N95 respirator mask when providing care.
C. Keep the door to the client’s room closed at all times.
D. Wash hands with soap and water after providing care.
Correct Answer: D
Expert Explanation: C. difficile produces spores that are resistant to alcohol-based hand
sanitizers, making soap and water mandatory for hand hygiene. The mechanical friction of
washing hands under running water is required to physically remove the spores from the
skin. Using alcohol-based rubs in this scenario is ineffective and increases the risk of cross-
contamination.
5. A nurse is assessing a client for orthostatic hypotension. Which finding indicates the client
is experiencing this condition?
A. An increase in systolic BP of 10 mmHg when standing.
B. A decrease in heart rate of 15 beats per minute upon standing.
C. A decrease in systolic BP of 20 mmHg when moving from lying to standing.
D. A decrease in diastolic BP of 5 mmHg when sitting up.
Correct Answer: C
