NSG 3100 EXAM 1 COMPREHENSIVE EXAM QUESTIONS
COMPLETE WITH 100% VERIFIED SOLUTIONS
Question 1
A nurse is preparing to administer oral medications to a patient. What is the
standard method for identifying the patient prior to medication administration?
A) Ask the patient their name and date of birth
B) Check the room number and bed label
C) Verify the patient's identification band using two identifiers
D) Confirm the patient's name with a family member
E) Match the medication to the patient's chart
Correct Answer: C
Rationale: The Joint Commission requires two patient identifiers before any
procedure or medication administration. The identification band contains the
patient's legal name, date of birth, and medical record number. Room numbers
and bed labels are unreliable as patients may be transferred. Family members are
not always accurate sources of identification.
Question 2
Which assessment finding indicates that a patient is experiencing hypoxia?
A) Respiratory rate of 14 breaths per minute
B) Pink mucous membranes
C) Oxygen saturation of 88% on room air
D) Clear breath sounds bilaterally
E) Normal skin color
,Correct Answer: C
Rationale: Normal oxygen saturation is 95-100%. A reading of 88% indicates
hypoxemia, which can lead to tissue hypoxia. Pink mucous membranes, clear
breath sounds, and respiratory rate of 14 are normal findings. Hypoxia may
present with cyanosis, confusion, tachycardia, and tachypnea.
Question 3
What is the correct sequence for donning personal protective equipment?
A) Gown, mask, goggles, gloves
B) Mask, gown, goggles, gloves
C) Gloves, gown, mask, goggles
D) Goggles, mask, gown, gloves
E) Gown, gloves, mask, goggles
Correct Answer: A
Rationale: The correct order for donning PPE is gown first, followed by mask or
respirator, then goggles or face shield, and finally gloves. This sequence ensures
that the gown covers the torso and the gloves are placed last to cover the cuffs of
the gown, providing maximum protection.
Question 4
A nurse is assessing a patient's peripheral pulses. Which pulse site is most
commonly used to assess heart rate in an adult?
A) Brachial pulse
B) Femoral pulse
C) Radial pulse
D) Popliteal pulse
E) Dorsalis pedis pulse
Correct Answer: C
,Rationale: The radial pulse is the most accessible and commonly used site for
assessing heart rate in adults. It is located on the thumb side of the wrist. Brachial
pulse is used for blood pressure measurement and in infants. Femoral and
popliteal pulses are used when radial pulses are difficult to palpate. Dorsalis pedis
is used for assessing lower extremity circulation.
Question 5
When measuring blood pressure, which Korotkoff sound indicates the systolic
pressure?
A) First sound heard
B) Sound becomes muffled
C) Sound disappears completely
D) Sound becomes sharp and tapping
E) Sound becomes swishing
Correct Answer: A
Rationale: The first appearance of clear, tapping sounds (Korotkoff phase I)
indicates the systolic pressure. The sounds become louder (phase II), then crisp
and distinct (phase III), followed by muffling (phase IV), and finally disappear
(phase V), which indicates diastolic pressure in adults.
Question 6
A patient's temperature is 38.5°C (101.3°F). Which route of temperature
measurement would provide the most accurate core temperature?
A) Oral
B) Axillary
C) Tympanic
D) Rectal
E) Temporal artery
, Correct Answer: D
Rationale: Rectal temperature is considered the closest to core body temperature
and is the most accurate when a precise measurement is needed. Axillary is the
least accurate and reflects skin temperature. Oral temperatures can be affected by
eating, drinking, or mouth breathing. Tympanic and temporal artery
measurements are convenient but can be affected by environmental factors.
Question 7
Which patient is at highest risk for developing a pressure injury?
A) A patient who ambulates with a walker
B) A patient who is incontinent and bedridden
C) A patient who eats a high-protein diet
D) A patient who is obese but mobile
E) A patient who uses a wheelchair independently
Correct Answer: B
Rationale: Incontinence combined with immobility significantly increases pressure
injury risk. Moisture from urine or feces can macerate skin, making it more
susceptible to breakdown. The Braden Scale identifies sensory perception,
moisture, activity, mobility, nutrition, and friction/shear as risk factors. Immobility
is a primary risk factor as it prevents pressure relief.
Question 8
What is the normal range for adult respiratory rate?
A) 8-12 breaths per minute
B) 12-20 breaths per minute
C) 16-24 breaths per minute
D) 20-28 breaths per minute
E) 24-32 breaths per minute
COMPLETE WITH 100% VERIFIED SOLUTIONS
Question 1
A nurse is preparing to administer oral medications to a patient. What is the
standard method for identifying the patient prior to medication administration?
A) Ask the patient their name and date of birth
B) Check the room number and bed label
C) Verify the patient's identification band using two identifiers
D) Confirm the patient's name with a family member
E) Match the medication to the patient's chart
Correct Answer: C
Rationale: The Joint Commission requires two patient identifiers before any
procedure or medication administration. The identification band contains the
patient's legal name, date of birth, and medical record number. Room numbers
and bed labels are unreliable as patients may be transferred. Family members are
not always accurate sources of identification.
Question 2
Which assessment finding indicates that a patient is experiencing hypoxia?
A) Respiratory rate of 14 breaths per minute
B) Pink mucous membranes
C) Oxygen saturation of 88% on room air
D) Clear breath sounds bilaterally
E) Normal skin color
,Correct Answer: C
Rationale: Normal oxygen saturation is 95-100%. A reading of 88% indicates
hypoxemia, which can lead to tissue hypoxia. Pink mucous membranes, clear
breath sounds, and respiratory rate of 14 are normal findings. Hypoxia may
present with cyanosis, confusion, tachycardia, and tachypnea.
Question 3
What is the correct sequence for donning personal protective equipment?
A) Gown, mask, goggles, gloves
B) Mask, gown, goggles, gloves
C) Gloves, gown, mask, goggles
D) Goggles, mask, gown, gloves
E) Gown, gloves, mask, goggles
Correct Answer: A
Rationale: The correct order for donning PPE is gown first, followed by mask or
respirator, then goggles or face shield, and finally gloves. This sequence ensures
that the gown covers the torso and the gloves are placed last to cover the cuffs of
the gown, providing maximum protection.
Question 4
A nurse is assessing a patient's peripheral pulses. Which pulse site is most
commonly used to assess heart rate in an adult?
A) Brachial pulse
B) Femoral pulse
C) Radial pulse
D) Popliteal pulse
E) Dorsalis pedis pulse
Correct Answer: C
,Rationale: The radial pulse is the most accessible and commonly used site for
assessing heart rate in adults. It is located on the thumb side of the wrist. Brachial
pulse is used for blood pressure measurement and in infants. Femoral and
popliteal pulses are used when radial pulses are difficult to palpate. Dorsalis pedis
is used for assessing lower extremity circulation.
Question 5
When measuring blood pressure, which Korotkoff sound indicates the systolic
pressure?
A) First sound heard
B) Sound becomes muffled
C) Sound disappears completely
D) Sound becomes sharp and tapping
E) Sound becomes swishing
Correct Answer: A
Rationale: The first appearance of clear, tapping sounds (Korotkoff phase I)
indicates the systolic pressure. The sounds become louder (phase II), then crisp
and distinct (phase III), followed by muffling (phase IV), and finally disappear
(phase V), which indicates diastolic pressure in adults.
Question 6
A patient's temperature is 38.5°C (101.3°F). Which route of temperature
measurement would provide the most accurate core temperature?
A) Oral
B) Axillary
C) Tympanic
D) Rectal
E) Temporal artery
, Correct Answer: D
Rationale: Rectal temperature is considered the closest to core body temperature
and is the most accurate when a precise measurement is needed. Axillary is the
least accurate and reflects skin temperature. Oral temperatures can be affected by
eating, drinking, or mouth breathing. Tympanic and temporal artery
measurements are convenient but can be affected by environmental factors.
Question 7
Which patient is at highest risk for developing a pressure injury?
A) A patient who ambulates with a walker
B) A patient who is incontinent and bedridden
C) A patient who eats a high-protein diet
D) A patient who is obese but mobile
E) A patient who uses a wheelchair independently
Correct Answer: B
Rationale: Incontinence combined with immobility significantly increases pressure
injury risk. Moisture from urine or feces can macerate skin, making it more
susceptible to breakdown. The Braden Scale identifies sensory perception,
moisture, activity, mobility, nutrition, and friction/shear as risk factors. Immobility
is a primary risk factor as it prevents pressure relief.
Question 8
What is the normal range for adult respiratory rate?
A) 8-12 breaths per minute
B) 12-20 breaths per minute
C) 16-24 breaths per minute
D) 20-28 breaths per minute
E) 24-32 breaths per minute
