NURS 101L Fundamentals of Nursing Skills Lab Week 9 Comprehensive
Quiz 2026 |WCU
1. When assessing a patient’s surgical incision, the nurse notes the presence of
thick, yellow-green drainage. How should this be documented?
A. Purulent drainage
B. Sanguineous drainage
C. Serosanguineous drainage
D. Serous drainage
Answer: A
Rationale: Purulent drainage is thick and indicates infection; it can be yellow, green, or
brown. Serous is clear, sanguineous is bloody, and serosanguineous is a pinkish mix.
2. A nurse is preparing to change a sterile dressing. Which action by the nurse
would violate the principles of surgical asepsis?
A. Opening the outermost flap of the sterile kit away from the body
B. Holding sterile objects above the level of the waist
C. Keeping a 1-inch border around the edge of the sterile field
D. Reaching over the sterile field to pick up a gauze pad
Answer: D
Rationale: Reaching over a sterile field contaminates it because dander or microorganisms
from the nurse’s clothing or skin could fall onto the field.
,3. When performing a wound irrigation, which pressure range is typically
recommended to effectively debride without damaging healthy tissue?
A. 1 to 2 psi
B. 20 to 30 psi
C. 4 to 15 psi
D. 35 to 50 psi
Answer: C
Rationale: A pressure range of 4 to 15 psi is sufficient to remove surface bacteria and
debris without causing tissue trauma.
4. A patient has a pressure injury that involves full-thickness skin loss with
visible subcutaneous fat, but no bone or muscle is exposed. What stage is this?
A. Stage 3
B. Stage 2
C. Stage 1
D. Stage 4
Answer: A
Rationale: Stage 3 involves full-thickness loss where adipose (fat) is visible, but fascia,
muscle, tendon, ligament, or bone are not exposed.
5. Which intramuscular (IM) injection site is preferred for an adult because it is
situated away from major nerves and blood vessels?
A. Dorsogluteal
B. Ventrogluteal
C. Vastus lateralis
D. Deltoid
Answer: B
Rationale: The ventrogluteal site is the safest and preferred site for IM injections in adults
because it lacks major nerves and blood vessels and has a large muscle mass.
, 6. The nurse is administering a sub-Q injection of Heparin. Which of the
following is an essential step in the procedure?
A. Select a site at least 2 inches away from the umbilicus
B. Massage the site after injection to increase absorption
C. Aspirate for blood return before injecting
D. Use a 1.5-inch needle at a 90-degree angle
Answer: A
Rationale: Heparin should be injected in the abdomen at least 2 inches from the umbilicus.
Aspiration and massaging are contraindicated as they can cause hematoma.
7. While inserting a Foley catheter into a female patient, the nurse accidentally
inserts it into the vagina. What is the correct next step?
A. Withdraw the catheter and immediately reinsert it into the meatus
B. Leave the catheter in the vagina and obtain a new sterile kit to attempt insertion
C. Wipe the catheter with alcohol and try again
D. Inflate the balloon to see if it causes pain
Answer: B
Rationale: Leaving the catheter in the vagina acts as a landmark to help avoid repeating
the mistake. A new sterile kit must be used to ensure asepsis.
8. A nurse is administering an enema. The patient complains of sudden
abdominal cramping. What should the nurse do first?
A. Stop the procedure immediately and call the physician
B. Speed up the flow to finish the procedure faster
C. Instruct the patient to hold their breath
D. Lower the enema bag to slow the rate of flow
Answer: D
Rationale: Slowing the flow by lowering the bag usually relieves cramping. If cramping
persists, the procedure should be stopped.
Quiz 2026 |WCU
1. When assessing a patient’s surgical incision, the nurse notes the presence of
thick, yellow-green drainage. How should this be documented?
A. Purulent drainage
B. Sanguineous drainage
C. Serosanguineous drainage
D. Serous drainage
Answer: A
Rationale: Purulent drainage is thick and indicates infection; it can be yellow, green, or
brown. Serous is clear, sanguineous is bloody, and serosanguineous is a pinkish mix.
2. A nurse is preparing to change a sterile dressing. Which action by the nurse
would violate the principles of surgical asepsis?
A. Opening the outermost flap of the sterile kit away from the body
B. Holding sterile objects above the level of the waist
C. Keeping a 1-inch border around the edge of the sterile field
D. Reaching over the sterile field to pick up a gauze pad
Answer: D
Rationale: Reaching over a sterile field contaminates it because dander or microorganisms
from the nurse’s clothing or skin could fall onto the field.
,3. When performing a wound irrigation, which pressure range is typically
recommended to effectively debride without damaging healthy tissue?
A. 1 to 2 psi
B. 20 to 30 psi
C. 4 to 15 psi
D. 35 to 50 psi
Answer: C
Rationale: A pressure range of 4 to 15 psi is sufficient to remove surface bacteria and
debris without causing tissue trauma.
4. A patient has a pressure injury that involves full-thickness skin loss with
visible subcutaneous fat, but no bone or muscle is exposed. What stage is this?
A. Stage 3
B. Stage 2
C. Stage 1
D. Stage 4
Answer: A
Rationale: Stage 3 involves full-thickness loss where adipose (fat) is visible, but fascia,
muscle, tendon, ligament, or bone are not exposed.
5. Which intramuscular (IM) injection site is preferred for an adult because it is
situated away from major nerves and blood vessels?
A. Dorsogluteal
B. Ventrogluteal
C. Vastus lateralis
D. Deltoid
Answer: B
Rationale: The ventrogluteal site is the safest and preferred site for IM injections in adults
because it lacks major nerves and blood vessels and has a large muscle mass.
, 6. The nurse is administering a sub-Q injection of Heparin. Which of the
following is an essential step in the procedure?
A. Select a site at least 2 inches away from the umbilicus
B. Massage the site after injection to increase absorption
C. Aspirate for blood return before injecting
D. Use a 1.5-inch needle at a 90-degree angle
Answer: A
Rationale: Heparin should be injected in the abdomen at least 2 inches from the umbilicus.
Aspiration and massaging are contraindicated as they can cause hematoma.
7. While inserting a Foley catheter into a female patient, the nurse accidentally
inserts it into the vagina. What is the correct next step?
A. Withdraw the catheter and immediately reinsert it into the meatus
B. Leave the catheter in the vagina and obtain a new sterile kit to attempt insertion
C. Wipe the catheter with alcohol and try again
D. Inflate the balloon to see if it causes pain
Answer: B
Rationale: Leaving the catheter in the vagina acts as a landmark to help avoid repeating
the mistake. A new sterile kit must be used to ensure asepsis.
8. A nurse is administering an enema. The patient complains of sudden
abdominal cramping. What should the nurse do first?
A. Stop the procedure immediately and call the physician
B. Speed up the flow to finish the procedure faster
C. Instruct the patient to hold their breath
D. Lower the enema bag to slow the rate of flow
Answer: D
Rationale: Slowing the flow by lowering the bag usually relieves cramping. If cramping
persists, the procedure should be stopped.
