NSG 3130 Exam 3 V1 | NSG 3130
Fundamental Concepts & Skills for
Nursing Practice II | Actual Q&A with
Rationale (NSG3130 Exam 3) | Galen
College of Nursing
1. A nurse is caring for a patient who is 24 hours postoperative following abdominal surgery.
Which of the following assessment findings should the nurse prioritize as the most immediate
concern?
A. Reported pain level of 6 on a 1-10 scale.
B. Oxygen saturation of 88% on room air.
C. Absent bowel sounds in all four quadrants.
D. Serosanguinous drainage on the surgical dressing.
Answer: B
Rationale: According to the ABC (Airway, Breathing, Circulation) priority framework, an
oxygen saturation of 88% indicates potential respiratory distress or atelectasis, which is
common after abdominal surgery. While absent bowel sounds and pain are expected
findings in the immediate postoperative period, they do not take precedence over impaired
gas exchange. The nurse must intervene immediately by encouraging deep breathing or
applying supplemental oxygen as prescribed.
,2. When performing tracheostomy care, which action by the student nurse requires
immediate intervention by the clinical instructor?
A. Cleaning the inner cannula with sterile normal saline.
B. Removing the old ties before securing the new ones.
C. Suctioning for 10 seconds during catheter withdrawal.
D. Using a sterile applicator to clean under the faceplate.
Answer: B
Rationale: To prevent accidental decannulation, the nurse must never remove the old
tracheostomy ties until the new ones are securely in place. If the patient coughs while the
ties are off, the tracheostomy tube could be expelled, creating a medical emergency. This
safety protocol is a critical standard of care in tracheostomy management.
3. A patient with chronic obstructive pulmonary disease (COPD) is receiving oxygen at 2 L/min
via nasal cannula. The nurse understands that higher concentrations of oxygen could be
dangerous because:
A. It might lead to oxygen toxicity and lung scarring.
B. High levels of oxygen can suppress the respiratory drive.
C. Higher flow rates will cause severe nasal mucosal drying.
D. It increases the risk of combustion in the hospital room.
Answer: B
, Rationale: In patients with chronic hypercapnia, the body’s primary stimulus for breathing
shifts from high CO2 levels to low oxygen levels (hypoxic drive). Providing excessive
oxygen can raise the PaO2 to a point where this drive is eliminated, leading to
hypoventilation or respiratory arrest. The nurse must carefully monitor the patient’s
respiratory rate and effort when adjusting oxygen levels.
4. During the assessment of a pressure injury on a patient’s sacrum, the nurse notes full-
thickness skin loss with visible subcutaneous fat, but no bone or muscle is exposed. How
should this be staged?
A. Stage 2
B. Stage 4
C. Stage 3
D. Unstageable
Answer: C
Rationale: A Stage 3 pressure injury is characterized by full-thickness tissue loss where
subcutaneous fat may be visible, but bone, tendon, or muscle are not exposed. Stage 2
involves partial-thickness loss of the dermis, while Stage 4 involves exposed bone or
muscle. Slough or eschar may be present but does not obscure the depth of the wound in a
Stage 3 classification.
Fundamental Concepts & Skills for
Nursing Practice II | Actual Q&A with
Rationale (NSG3130 Exam 3) | Galen
College of Nursing
1. A nurse is caring for a patient who is 24 hours postoperative following abdominal surgery.
Which of the following assessment findings should the nurse prioritize as the most immediate
concern?
A. Reported pain level of 6 on a 1-10 scale.
B. Oxygen saturation of 88% on room air.
C. Absent bowel sounds in all four quadrants.
D. Serosanguinous drainage on the surgical dressing.
Answer: B
Rationale: According to the ABC (Airway, Breathing, Circulation) priority framework, an
oxygen saturation of 88% indicates potential respiratory distress or atelectasis, which is
common after abdominal surgery. While absent bowel sounds and pain are expected
findings in the immediate postoperative period, they do not take precedence over impaired
gas exchange. The nurse must intervene immediately by encouraging deep breathing or
applying supplemental oxygen as prescribed.
,2. When performing tracheostomy care, which action by the student nurse requires
immediate intervention by the clinical instructor?
A. Cleaning the inner cannula with sterile normal saline.
B. Removing the old ties before securing the new ones.
C. Suctioning for 10 seconds during catheter withdrawal.
D. Using a sterile applicator to clean under the faceplate.
Answer: B
Rationale: To prevent accidental decannulation, the nurse must never remove the old
tracheostomy ties until the new ones are securely in place. If the patient coughs while the
ties are off, the tracheostomy tube could be expelled, creating a medical emergency. This
safety protocol is a critical standard of care in tracheostomy management.
3. A patient with chronic obstructive pulmonary disease (COPD) is receiving oxygen at 2 L/min
via nasal cannula. The nurse understands that higher concentrations of oxygen could be
dangerous because:
A. It might lead to oxygen toxicity and lung scarring.
B. High levels of oxygen can suppress the respiratory drive.
C. Higher flow rates will cause severe nasal mucosal drying.
D. It increases the risk of combustion in the hospital room.
Answer: B
, Rationale: In patients with chronic hypercapnia, the body’s primary stimulus for breathing
shifts from high CO2 levels to low oxygen levels (hypoxic drive). Providing excessive
oxygen can raise the PaO2 to a point where this drive is eliminated, leading to
hypoventilation or respiratory arrest. The nurse must carefully monitor the patient’s
respiratory rate and effort when adjusting oxygen levels.
4. During the assessment of a pressure injury on a patient’s sacrum, the nurse notes full-
thickness skin loss with visible subcutaneous fat, but no bone or muscle is exposed. How
should this be staged?
A. Stage 2
B. Stage 4
C. Stage 3
D. Unstageable
Answer: C
Rationale: A Stage 3 pressure injury is characterized by full-thickness tissue loss where
subcutaneous fat may be visible, but bone, tendon, or muscle are not exposed. Stage 2
involves partial-thickness loss of the dermis, while Stage 4 involves exposed bone or
muscle. Slough or eschar may be present but does not obscure the depth of the wound in a
Stage 3 classification.
