NURS 121L-B | Introduction to Medical-Surgical Nursing Practicum -
Module 1 Exam (Week 3) 2026 |WCU
1. A nurse is preparing to administer an intramuscular injection to an adult
patient. Which site is considered the safest and preferred site due to being away
from major blood vessels and nerves?
A. Dorsogluteal
B. Ventrogluteal
C. Deltoid
D. Vastus lateralis
Answer: B
Rationale: The ventrogluteal site is the preferred and safest site for IM injections in adults
because it is located away from major nerves and blood vessels.
2. During a physical assessment, the nurse notes the patient has a pressure
injury with full-thickness tissue loss. The subcutaneous fat is visible, but bone
and muscle are not. How should this be staged?
A. Stage III
B. Stage II
C. Stage I
D. Stage IV
Answer: A
Rationale: Stage III pressure injuries involve full-thickness skin loss with visible
subcutaneous fat, but without exposure of bone, tendon, or muscle.
,3. A patient with a history of heart failure presents with crackles in the lungs
and 2+ pitting edema. Which fluid volume state is the patient likely
experiencing?
A. Hypovolemia
B. Isotonic dehydration
C. Hyponatremia
D. Hypervolemia
Answer: D
Rationale: Hypervolemia (fluid volume excess) is characterized by symptoms such as
crackles in the lungs, peripheral edema, and jugular venous distention.
4. Which of the following is the priority nursing action when a patient’s surgical
wound eviscerates?
A. Apply pressure to the wound with a dry dressing
B. Place the patient in a high-Fowler’s position
C. Attempt to gently push the organs back into the abdominal cavity
D. Cover the protruding organs with sterile towels soaked in normal saline
Answer: D
Rationale: Evisceration is a medical emergency. The nurse must cover the exposed organs
with sterile, saline-soaked dressings to keep them moist and prevent infection while
notifying the surgeon immediately.
5. A nurse is performing an abdominal assessment. In which order should the
nurse perform the assessment techniques?
A. Inspection, Palpation, Percussion, Auscultation
B. Auscultation, Inspection, Palpation, Percussion
C. Palpation, Percussion, Auscultation, Inspection
D. Inspection, Auscultation, Percussion, Palpation
Answer: D
, Rationale: For abdominal assessment, the order is Inspection, Auscultation, Percussion,
then Palpation. Auscultation is done before percussion and palpation to avoid altering
bowel sounds.
6. A patient is prescribed 0.9% Normal Saline at 125 mL/hr. What type of
solution is this?
A. Hypotonic
B. Hypertonic
C. Isotonic
D. Colloid
Answer: C
Rationale: 0.9% Sodium Chloride (Normal Saline) is an isotonic solution because its
osmolarity is similar to that of blood plasma.
7. When assessing a patient for orthostatic hypotension, which drop in systolic
blood pressure is considered significant?
A. 20 mmHg
B. 10 mmHg
C. 5 mmHg
D. 15 mmHg
Answer: A
Rationale: Orthostatic hypotension is defined as a decrease of at least 20 mmHg in systolic
pressure or 10 mmHg in diastolic pressure within 3 minutes of standing.
Module 1 Exam (Week 3) 2026 |WCU
1. A nurse is preparing to administer an intramuscular injection to an adult
patient. Which site is considered the safest and preferred site due to being away
from major blood vessels and nerves?
A. Dorsogluteal
B. Ventrogluteal
C. Deltoid
D. Vastus lateralis
Answer: B
Rationale: The ventrogluteal site is the preferred and safest site for IM injections in adults
because it is located away from major nerves and blood vessels.
2. During a physical assessment, the nurse notes the patient has a pressure
injury with full-thickness tissue loss. The subcutaneous fat is visible, but bone
and muscle are not. How should this be staged?
A. Stage III
B. Stage II
C. Stage I
D. Stage IV
Answer: A
Rationale: Stage III pressure injuries involve full-thickness skin loss with visible
subcutaneous fat, but without exposure of bone, tendon, or muscle.
,3. A patient with a history of heart failure presents with crackles in the lungs
and 2+ pitting edema. Which fluid volume state is the patient likely
experiencing?
A. Hypovolemia
B. Isotonic dehydration
C. Hyponatremia
D. Hypervolemia
Answer: D
Rationale: Hypervolemia (fluid volume excess) is characterized by symptoms such as
crackles in the lungs, peripheral edema, and jugular venous distention.
4. Which of the following is the priority nursing action when a patient’s surgical
wound eviscerates?
A. Apply pressure to the wound with a dry dressing
B. Place the patient in a high-Fowler’s position
C. Attempt to gently push the organs back into the abdominal cavity
D. Cover the protruding organs with sterile towels soaked in normal saline
Answer: D
Rationale: Evisceration is a medical emergency. The nurse must cover the exposed organs
with sterile, saline-soaked dressings to keep them moist and prevent infection while
notifying the surgeon immediately.
5. A nurse is performing an abdominal assessment. In which order should the
nurse perform the assessment techniques?
A. Inspection, Palpation, Percussion, Auscultation
B. Auscultation, Inspection, Palpation, Percussion
C. Palpation, Percussion, Auscultation, Inspection
D. Inspection, Auscultation, Percussion, Palpation
Answer: D
, Rationale: For abdominal assessment, the order is Inspection, Auscultation, Percussion,
then Palpation. Auscultation is done before percussion and palpation to avoid altering
bowel sounds.
6. A patient is prescribed 0.9% Normal Saline at 125 mL/hr. What type of
solution is this?
A. Hypotonic
B. Hypertonic
C. Isotonic
D. Colloid
Answer: C
Rationale: 0.9% Sodium Chloride (Normal Saline) is an isotonic solution because its
osmolarity is similar to that of blood plasma.
7. When assessing a patient for orthostatic hypotension, which drop in systolic
blood pressure is considered significant?
A. 20 mmHg
B. 10 mmHg
C. 5 mmHg
D. 15 mmHg
Answer: A
Rationale: Orthostatic hypotension is defined as a decrease of at least 20 mmHg in systolic
pressure or 10 mmHg in diastolic pressure within 3 minutes of standing.
