NURS 101L Comprehensive Final Exam Study Guide 2026 WCU
1. When assessing a patient for orthostatic hypotension, which finding indicates
a positive result?
A. A decrease in systolic blood pressure of 20 mmHg within three minutes of standing.
B. An increase in heart rate of 10 beats per minute when sitting.
C. A decrease in systolic blood pressure of 10 mmHg when standing.
D. An increase in diastolic blood pressure of 5 mmHg upon changing positions.
Answer: A
Rationale: Orthostatic hypotension is defined as a decrease in systolic blood pressure of at
least 20 mmHg or a decrease in diastolic blood pressure of at least 10 mmHg within three
minutes of standing.
2. Which personal protective equipment (PPE) should the nurse don first when
following standard precautions for a high-risk procedure?
A. Gloves
B. Goggles or Face Shield
C. Mask or Respirator
D. Gown
Answer: D
Rationale: The standard sequence for donning PPE is gown, then mask/respirator, then
goggles/face shield, and finally gloves.
,3. A nurse is caring for a patient with Clostridioides difficile (C. diff). Which hand
hygiene method is mandatory?
A. Alcohol-based hand rub for 15 seconds.
B. Using a 70% isopropyl alcohol wipe.
C. Washing with antimicrobial soap and water.
D. Chlorhexidine gluconate scrub for 30 seconds.
Answer: C
Rationale: Alcohol-based hand rubs are ineffective against C. diff spores; physical
scrubbing with soap and water is required to mechanically remove the spores.
4. What is the width of the sterile border around a sterile field that is
considered contaminated?
A. 1 inch (2.5 cm)
B. 0.5 inch (1.27 cm)
C. 1.5 inches (3.8 cm)
D. 2 inches (5 cm)
Answer: A
Rationale: In sterile technique, the outer 1-inch (2.5 cm) border of a sterile drape or field
is considered unsterile.
5. Which technique is correct when administering an intramuscular (IM)
injection using the Z-track method?
A. Massage the site after injection to distribute the medication.
B. Aspirate for at least 15 seconds to ensure no blood return.
C. Pull the skin laterally or downward 1 to 1.5 inches before needle insertion.
D. Inject the medication at a 45-degree angle to the muscle.
Answer: C
Rationale: The Z-track method involves displacing the skin and subcutaneous tissue 1-1.5
inches laterally to seal the medication in the muscle and minimize irritation.
, 6. A healthcare provider orders 1,000 mL of 0.9% Normal Saline to infuse over 8
hours. The drop factor is 15 gtt/mL. What is the flow rate in gtt/min?
A. 28 gtt/min
B. 42 gtt/min
C. 35 gtt/min
D. 31 gtt/min
Answer: D
Rationale: (1000 mL / 480 min) x 15 gtt/mL = 31.25, rounded to 31 gtt/min.
7. Which of the following is NOT one of the ‘Six Rights’ of medication
administration?
A. Right Documentation
B. Right Reason
C. Right Room Number
D. Right Route
Answer: C
Rationale: The Six Rights are: Right Patient, Right Drug, Right Dose, Right Route, Right
Time, and Right Documentation. Right Room Number is not a formal ‘Right’.
8. A nurse observes a pressure injury with full-thickness skin loss and visible
subcutaneous fat, but no bone or muscle is exposed. How should this be
staged?
A. Stage II
B. Stage IV
C. Stage III
D. Unstageable
Answer: C
Rationale: Stage III pressure injuries involve full-thickness skin loss with visible adipose
(fat), but bone, tendon, and muscle are not yet visible.
1. When assessing a patient for orthostatic hypotension, which finding indicates
a positive result?
A. A decrease in systolic blood pressure of 20 mmHg within three minutes of standing.
B. An increase in heart rate of 10 beats per minute when sitting.
C. A decrease in systolic blood pressure of 10 mmHg when standing.
D. An increase in diastolic blood pressure of 5 mmHg upon changing positions.
Answer: A
Rationale: Orthostatic hypotension is defined as a decrease in systolic blood pressure of at
least 20 mmHg or a decrease in diastolic blood pressure of at least 10 mmHg within three
minutes of standing.
2. Which personal protective equipment (PPE) should the nurse don first when
following standard precautions for a high-risk procedure?
A. Gloves
B. Goggles or Face Shield
C. Mask or Respirator
D. Gown
Answer: D
Rationale: The standard sequence for donning PPE is gown, then mask/respirator, then
goggles/face shield, and finally gloves.
,3. A nurse is caring for a patient with Clostridioides difficile (C. diff). Which hand
hygiene method is mandatory?
A. Alcohol-based hand rub for 15 seconds.
B. Using a 70% isopropyl alcohol wipe.
C. Washing with antimicrobial soap and water.
D. Chlorhexidine gluconate scrub for 30 seconds.
Answer: C
Rationale: Alcohol-based hand rubs are ineffective against C. diff spores; physical
scrubbing with soap and water is required to mechanically remove the spores.
4. What is the width of the sterile border around a sterile field that is
considered contaminated?
A. 1 inch (2.5 cm)
B. 0.5 inch (1.27 cm)
C. 1.5 inches (3.8 cm)
D. 2 inches (5 cm)
Answer: A
Rationale: In sterile technique, the outer 1-inch (2.5 cm) border of a sterile drape or field
is considered unsterile.
5. Which technique is correct when administering an intramuscular (IM)
injection using the Z-track method?
A. Massage the site after injection to distribute the medication.
B. Aspirate for at least 15 seconds to ensure no blood return.
C. Pull the skin laterally or downward 1 to 1.5 inches before needle insertion.
D. Inject the medication at a 45-degree angle to the muscle.
Answer: C
Rationale: The Z-track method involves displacing the skin and subcutaneous tissue 1-1.5
inches laterally to seal the medication in the muscle and minimize irritation.
, 6. A healthcare provider orders 1,000 mL of 0.9% Normal Saline to infuse over 8
hours. The drop factor is 15 gtt/mL. What is the flow rate in gtt/min?
A. 28 gtt/min
B. 42 gtt/min
C. 35 gtt/min
D. 31 gtt/min
Answer: D
Rationale: (1000 mL / 480 min) x 15 gtt/mL = 31.25, rounded to 31 gtt/min.
7. Which of the following is NOT one of the ‘Six Rights’ of medication
administration?
A. Right Documentation
B. Right Reason
C. Right Room Number
D. Right Route
Answer: C
Rationale: The Six Rights are: Right Patient, Right Drug, Right Dose, Right Route, Right
Time, and Right Documentation. Right Room Number is not a formal ‘Right’.
8. A nurse observes a pressure injury with full-thickness skin loss and visible
subcutaneous fat, but no bone or muscle is exposed. How should this be
staged?
A. Stage II
B. Stage IV
C. Stage III
D. Unstageable
Answer: C
Rationale: Stage III pressure injuries involve full-thickness skin loss with visible adipose
(fat), but bone, tendon, and muscle are not yet visible.
