NSG 3130 Final Exam V1 | NSG 3130
Fundamental Concepts & Skills for
Nursing Practice II | Actual Q&A with
Rationale (NSG3130 Final Exam) | Galen
College of Nursing
1. A nurse is preparing to administer a medication to a patient. Which action is the most
critical first step to ensure patient safety according to the ‘rights’ of medication
administration?
A. Check the medication label against the MAR three times.
B. Verify the patient’s identity using two unique identifiers.
C. Explain the purpose and side effects of the drug to the patient.
D. Document the administration immediately after the drug is given.
Answer: B
Rationale: Verifying the patient’s identity using two identifiers, such as name and date of
birth, is the essential first step to prevent medical errors. This practice ensures that the
medication is being administered to the correct individual as intended by the provider’s
order. Failure to perform this check is a leading cause of sentinel events in clinical settings.
2. A patient is scheduled for elective surgery. The nurse notices the surgical consent form is
not signed. What is the nurse’s primary responsibility regarding informed consent?
A. Explain the risks and benefits of the procedure to the patient.
,B. Inform the surgeon that the consent form has not been signed.
C. Obtain the signature and witness that the patient signed it voluntarily.
D. Verify that the patient has a clear understanding of the procedure before signing.
Answer: B
Rationale: The primary responsibility of the nurse is to witness the signature and verify
that a signature was obtained, but the legal duty to explain the procedure lies with the
surgeon. If the consent is missing, the nurse must notify the provider immediately so the
discussion can take place. The nurse ensures the patient is competent to sign but does not
provide the primary education on surgical risks.
3. A nurse is caring for a patient with a potassium level of 6.2 mEq/L. Which cardiac rhythm
change should the nurse monitor for most closely?
A. Flattened T waves
B. Tall, peaked T waves
C. Prominent U waves
D. Shortened PR interval
Answer: B
Rationale: Hyperkalemia, defined as a potassium level above 5.0 mEq/L, significantly
impacts cardiac conduction. Tall, peaked T waves are a classic early sign of high potassium
, levels on an EKG. If left untreated, this can progress to wide QRS complexes and life-
threatening ventricular arrhythmias.
4. Which of the following is a characteristic of a Stage 2 pressure injury?
A. Non-blanchable erythema of intact skin.
B. Full-thickness skin loss with visible adipose tissue.
C. Full-thickness tissue loss with exposed bone or muscle.
D. Partial-thickness loss of dermis presenting as a shallow open ulcer.
Answer: D
Rationale: A Stage 2 pressure injury involves partial-thickness loss of the dermis and
presents as a shallow, open ulcer with a red-pink wound bed without slough. It may also
present as an intact or open/ruptured serum-filled blister. This stage does not involve
visible fat or deeper tissues, which would categorize it as Stage 3 or 4.
5. A nurse is performing a sterile dressing change. Which action would result in a break in
sterile technique?
A. Opening the sterile pack away from the body.
B. Keeping sterile gloved hands above the waist level.
C. Reaching over the sterile field to pick up a gauze pad.
D. Discarding the outer 1-inch border of the sterile field.
Answer: C
Fundamental Concepts & Skills for
Nursing Practice II | Actual Q&A with
Rationale (NSG3130 Final Exam) | Galen
College of Nursing
1. A nurse is preparing to administer a medication to a patient. Which action is the most
critical first step to ensure patient safety according to the ‘rights’ of medication
administration?
A. Check the medication label against the MAR three times.
B. Verify the patient’s identity using two unique identifiers.
C. Explain the purpose and side effects of the drug to the patient.
D. Document the administration immediately after the drug is given.
Answer: B
Rationale: Verifying the patient’s identity using two identifiers, such as name and date of
birth, is the essential first step to prevent medical errors. This practice ensures that the
medication is being administered to the correct individual as intended by the provider’s
order. Failure to perform this check is a leading cause of sentinel events in clinical settings.
2. A patient is scheduled for elective surgery. The nurse notices the surgical consent form is
not signed. What is the nurse’s primary responsibility regarding informed consent?
A. Explain the risks and benefits of the procedure to the patient.
,B. Inform the surgeon that the consent form has not been signed.
C. Obtain the signature and witness that the patient signed it voluntarily.
D. Verify that the patient has a clear understanding of the procedure before signing.
Answer: B
Rationale: The primary responsibility of the nurse is to witness the signature and verify
that a signature was obtained, but the legal duty to explain the procedure lies with the
surgeon. If the consent is missing, the nurse must notify the provider immediately so the
discussion can take place. The nurse ensures the patient is competent to sign but does not
provide the primary education on surgical risks.
3. A nurse is caring for a patient with a potassium level of 6.2 mEq/L. Which cardiac rhythm
change should the nurse monitor for most closely?
A. Flattened T waves
B. Tall, peaked T waves
C. Prominent U waves
D. Shortened PR interval
Answer: B
Rationale: Hyperkalemia, defined as a potassium level above 5.0 mEq/L, significantly
impacts cardiac conduction. Tall, peaked T waves are a classic early sign of high potassium
, levels on an EKG. If left untreated, this can progress to wide QRS complexes and life-
threatening ventricular arrhythmias.
4. Which of the following is a characteristic of a Stage 2 pressure injury?
A. Non-blanchable erythema of intact skin.
B. Full-thickness skin loss with visible adipose tissue.
C. Full-thickness tissue loss with exposed bone or muscle.
D. Partial-thickness loss of dermis presenting as a shallow open ulcer.
Answer: D
Rationale: A Stage 2 pressure injury involves partial-thickness loss of the dermis and
presents as a shallow, open ulcer with a red-pink wound bed without slough. It may also
present as an intact or open/ruptured serum-filled blister. This stage does not involve
visible fat or deeper tissues, which would categorize it as Stage 3 or 4.
5. A nurse is performing a sterile dressing change. Which action would result in a break in
sterile technique?
A. Opening the sterile pack away from the body.
B. Keeping sterile gloved hands above the waist level.
C. Reaching over the sterile field to pick up a gauze pad.
D. Discarding the outer 1-inch border of the sterile field.
Answer: C
