NURS 101L Fundamentals of Nursing Skills Lab Exam 2 2026 |WCU
1. A nurse is preparing to administer an intramuscular injection to an infant.
Which site is most appropriate for this patient population?
A. Vastus lateralis
B. Dorsogluteal
C. Deltoid
D. Ventrogluteal
Answer: A
Rationale: The vastus lateralis is the preferred site for IM injections in infants and toddlers
because it is the most developed muscle at that age.
2. When measuring blood pressure, if the cuff used is too narrow for the
patient’s arm, how will the reading be affected?
A. The reading will be falsely low
B. The systolic reading will be accurate, but diastolic will be low
C. The reading will be falsely high
D. The reading will not be affected
Answer: C
Rationale: A blood pressure cuff that is too small or too narrow will result in a falsely high
reading because the pressure is not distributed evenly.
,3. What is the correct sequence for physical assessment of the abdomen?
A. Inspection, Palpation, Percussion, Auscultation
B. Inspection, Auscultation, Percussion, Palpation
C. Auscultation, Inspection, Palpation, Percussion
D. Percussion, Inspection, Auscultation, Palpation
Answer: B
Rationale: For the abdomen, auscultation is performed before percussion and palpation to
avoid stimulating bowel sounds that were not originally present.
4. A nurse is performing a sterile dressing change. While reaching for a gauze,
the nurse’s sleeve touches the edge of the sterile field. What should the nurse
do next?
A. Continue the procedure as long as the sleeve didn’t touch the wound
B. Use a sterile marker to outline the contaminated area
C. Discard the entire sterile field and start over
D. Spray the area with antiseptic solution
Answer: C
Rationale: If any part of the sterile field is touched by a non-sterile object (like a sleeve),
the field is considered contaminated and must be discarded.
5. Which heart sound is caused by the closure of the mitral and tricuspid (AV)
valves?
A. S4
B. S2
C. S3
D. S1
Answer: D
Rationale: The S1 sound (lub) marks the beginning of systole and is produced by the
closure of the AV valves.
, 6. A patient is on contact precautions. Which of the following sets of personal
protective equipment (PPE) is required?
A. Gown and gloves
B. Mask and goggles
C. N95 respirator and gloves
D. Gown, gloves, and mask
Answer: A
Rationale: Contact precautions primarily require the use of gloves and a gown to prevent
the spread of pathogens through direct contact.
7. When assessing an apical pulse, where should the nurse place the
stethoscope?
A. Fifth intercostal space, midclavicular line
B. Second intercostal space, left sternal border
C. Second intercostal space, right sternal border
D. Fourth intercostal space, midaxillary line
Answer: A
Rationale: The apical pulse (PMI) is located at the fifth intercostal space at the left
midclavicular line.
8. A nurse is caring for a patient with a Stage 2 pressure injury. What is the
characteristic of this stage?
A. Non-blanchable erythema of intact skin
B. Full-thickness skin loss with visible adipose tissue
C. Full-thickness skin and tissue loss with exposed bone
D. Partial-thickness skin loss with exposed dermis
Answer: D
Rationale: Stage 2 pressure injuries involve partial-thickness loss of skin with exposed
dermis, often presenting as a blister or shallow open ulcer.
1. A nurse is preparing to administer an intramuscular injection to an infant.
Which site is most appropriate for this patient population?
A. Vastus lateralis
B. Dorsogluteal
C. Deltoid
D. Ventrogluteal
Answer: A
Rationale: The vastus lateralis is the preferred site for IM injections in infants and toddlers
because it is the most developed muscle at that age.
2. When measuring blood pressure, if the cuff used is too narrow for the
patient’s arm, how will the reading be affected?
A. The reading will be falsely low
B. The systolic reading will be accurate, but diastolic will be low
C. The reading will be falsely high
D. The reading will not be affected
Answer: C
Rationale: A blood pressure cuff that is too small or too narrow will result in a falsely high
reading because the pressure is not distributed evenly.
,3. What is the correct sequence for physical assessment of the abdomen?
A. Inspection, Palpation, Percussion, Auscultation
B. Inspection, Auscultation, Percussion, Palpation
C. Auscultation, Inspection, Palpation, Percussion
D. Percussion, Inspection, Auscultation, Palpation
Answer: B
Rationale: For the abdomen, auscultation is performed before percussion and palpation to
avoid stimulating bowel sounds that were not originally present.
4. A nurse is performing a sterile dressing change. While reaching for a gauze,
the nurse’s sleeve touches the edge of the sterile field. What should the nurse
do next?
A. Continue the procedure as long as the sleeve didn’t touch the wound
B. Use a sterile marker to outline the contaminated area
C. Discard the entire sterile field and start over
D. Spray the area with antiseptic solution
Answer: C
Rationale: If any part of the sterile field is touched by a non-sterile object (like a sleeve),
the field is considered contaminated and must be discarded.
5. Which heart sound is caused by the closure of the mitral and tricuspid (AV)
valves?
A. S4
B. S2
C. S3
D. S1
Answer: D
Rationale: The S1 sound (lub) marks the beginning of systole and is produced by the
closure of the AV valves.
, 6. A patient is on contact precautions. Which of the following sets of personal
protective equipment (PPE) is required?
A. Gown and gloves
B. Mask and goggles
C. N95 respirator and gloves
D. Gown, gloves, and mask
Answer: A
Rationale: Contact precautions primarily require the use of gloves and a gown to prevent
the spread of pathogens through direct contact.
7. When assessing an apical pulse, where should the nurse place the
stethoscope?
A. Fifth intercostal space, midclavicular line
B. Second intercostal space, left sternal border
C. Second intercostal space, right sternal border
D. Fourth intercostal space, midaxillary line
Answer: A
Rationale: The apical pulse (PMI) is located at the fifth intercostal space at the left
midclavicular line.
8. A nurse is caring for a patient with a Stage 2 pressure injury. What is the
characteristic of this stage?
A. Non-blanchable erythema of intact skin
B. Full-thickness skin loss with visible adipose tissue
C. Full-thickness skin and tissue loss with exposed bone
D. Partial-thickness skin loss with exposed dermis
Answer: D
Rationale: Stage 2 pressure injuries involve partial-thickness loss of skin with exposed
dermis, often presenting as a blister or shallow open ulcer.
