PNR 104/PNR104 Exam 2 V1 | Basic Skills,
Quality & Safety in Nursing Practice Q&A
with Rationale | Fortis College
1. A nurse is preparing to enter the room of a patient diagnosed with Clostridium difficile (C.
diff). Which infection control measure is most appropriate?
A. Perform hand hygiene using alcohol-based hand sanitizer.
B. Wear a N95 respirator and goggles.
C. Wash hands with soap and water after removing gloves.
D. Keep the door closed to maintain negative pressure.
Correct Answer: C
Expert Explanation: C. diff spores are resistant to alcohol-based hand rubs and require
physical removal through friction and water. The nurse must use soap and water to ensure
effective decontamination and prevent transmission within the healthcare facility. Hand
hygiene is a fundamental pillar of patient safety and quality care.
2. When assessing a patient’s apical pulse, where should the nurse place the stethoscope?
A. Fifth intercostal space, left midclavicular line.
B. Second intercostal space, right sternal border.
C. Fourth intercostal space, left sternal border.
D. Second intercostal space, left sternal border.
,Correct Answer: A
Expert Explanation: The apical pulse is best heard at the apex of the heart, which is
typically located at the fifth intercostal space at the left midclavicular line. This site
provides the most accurate assessment of heart rate and rhythm in patients with
cardiovascular concerns. Accurate pulse assessment is a critical skill for monitoring
hemodynamic stability.
3. A nurse is caring for an older adult patient who is at high risk for falls. Which intervention
should be prioritized?
A. Keep all four side rails in the upright position.
B. Place the bed in the lowest position with wheels locked.
C. Instruct the patient to use the call light only for emergencies.
D. Apply soft wrist restraints to prevent the patient from getting up.
Correct Answer: B
Expert Explanation: Keeping the bed in the lowest position minimizes the distance to the
floor if a fall occurs, and locking the wheels prevents unexpected movement. Using four
side rails is often considered a restraint and may lead to more severe injuries if a patient
tries to climb over them. Safety protocols emphasize using the least restrictive measures to
maintain patient autonomy and security.
4. What is the first action a nurse should take if a fire is discovered in a patient’s room?
A. Activate the fire alarm system.
, B. Move the patient to a safe area away from the fire.
C. Extinguish the fire using the nearest extinguisher.
D. Close all doors and windows to contain the fire.
Correct Answer: B
Expert Explanation: According to the RACE acronym (Rescue, Alarm, Contain, Extinguish),
the priority is always to rescue individuals in immediate danger. Moving the patient to
safety prevents injury from smoke inhalation or flames. Following established safety
sequences is essential for effective emergency management in nursing practice.
5. A nurse is performing a physical assessment and notices the patient’s skin is pale and cool.
Which technique did the nurse use to determine the temperature?
A. Palpation using the fingertips.
B. Percussion of the extremities.
C. Palpation using the dorsal surface of the hand.
D. Inspection using a penlight.
Correct Answer: C
Expert Explanation: The dorsal surface (back) of the hand is more sensitive to
temperature variations than the palms or fingertips. This technique allows the nurse to
accurately identify localized or systemic changes in skin temperature. Physical assessment
skills require specific anatomical use of the hands to gather valid data.
Quality & Safety in Nursing Practice Q&A
with Rationale | Fortis College
1. A nurse is preparing to enter the room of a patient diagnosed with Clostridium difficile (C.
diff). Which infection control measure is most appropriate?
A. Perform hand hygiene using alcohol-based hand sanitizer.
B. Wear a N95 respirator and goggles.
C. Wash hands with soap and water after removing gloves.
D. Keep the door closed to maintain negative pressure.
Correct Answer: C
Expert Explanation: C. diff spores are resistant to alcohol-based hand rubs and require
physical removal through friction and water. The nurse must use soap and water to ensure
effective decontamination and prevent transmission within the healthcare facility. Hand
hygiene is a fundamental pillar of patient safety and quality care.
2. When assessing a patient’s apical pulse, where should the nurse place the stethoscope?
A. Fifth intercostal space, left midclavicular line.
B. Second intercostal space, right sternal border.
C. Fourth intercostal space, left sternal border.
D. Second intercostal space, left sternal border.
,Correct Answer: A
Expert Explanation: The apical pulse is best heard at the apex of the heart, which is
typically located at the fifth intercostal space at the left midclavicular line. This site
provides the most accurate assessment of heart rate and rhythm in patients with
cardiovascular concerns. Accurate pulse assessment is a critical skill for monitoring
hemodynamic stability.
3. A nurse is caring for an older adult patient who is at high risk for falls. Which intervention
should be prioritized?
A. Keep all four side rails in the upright position.
B. Place the bed in the lowest position with wheels locked.
C. Instruct the patient to use the call light only for emergencies.
D. Apply soft wrist restraints to prevent the patient from getting up.
Correct Answer: B
Expert Explanation: Keeping the bed in the lowest position minimizes the distance to the
floor if a fall occurs, and locking the wheels prevents unexpected movement. Using four
side rails is often considered a restraint and may lead to more severe injuries if a patient
tries to climb over them. Safety protocols emphasize using the least restrictive measures to
maintain patient autonomy and security.
4. What is the first action a nurse should take if a fire is discovered in a patient’s room?
A. Activate the fire alarm system.
, B. Move the patient to a safe area away from the fire.
C. Extinguish the fire using the nearest extinguisher.
D. Close all doors and windows to contain the fire.
Correct Answer: B
Expert Explanation: According to the RACE acronym (Rescue, Alarm, Contain, Extinguish),
the priority is always to rescue individuals in immediate danger. Moving the patient to
safety prevents injury from smoke inhalation or flames. Following established safety
sequences is essential for effective emergency management in nursing practice.
5. A nurse is performing a physical assessment and notices the patient’s skin is pale and cool.
Which technique did the nurse use to determine the temperature?
A. Palpation using the fingertips.
B. Percussion of the extremities.
C. Palpation using the dorsal surface of the hand.
D. Inspection using a penlight.
Correct Answer: C
Expert Explanation: The dorsal surface (back) of the hand is more sensitive to
temperature variations than the palms or fingertips. This technique allows the nurse to
accurately identify localized or systemic changes in skin temperature. Physical assessment
skills require specific anatomical use of the hands to gather valid data.
