NSG 3100 Unit 1 & 2 Combined Comprehensive
Questions And Answers With Verified 2026/2027
Updates & Expert Rationales
QUESTION 1
A nurse is caring for a client in restraints. When reviewing the order, what should
the nurse question?
A. The provider states that the staff is to use soft wrist restraints bilaterally
B. The provider states the restraint is good for 12 hours until the patient gets his
psychiatric evaluation
C. The provider says to only use wrist restraints when the patient shows signs of physical
aggression
D. The provider states the purpose of the restraint is to prevent the client from
physically cutting themselves
Correct Answer: B. The provider states the restraint is good for 12 hours until the
patient gets his psychiatric evaluation
Expert Rationale: Restraint orders are time-limited and must be renewed frequently.
The Joint Commission and CMS guidelines require that restraints be used only as a last
resort and that orders have specific time limits. The provider's statement that the
restraint order is good for 12 hours does not align with best practices. The order should
specify the type of restraint, the reason for use, and the duration. It must be renewed
after 4 hours for adults (2 hours for children, 1 hour for ages 9-17). The other options
are components of a valid restraint order that a nurse would not necessarily question.
QUESTION 2
A nurse is caring for a client who is sitting in a chair and asks to return to bed.
Which of the following actions is the nurse's priority at this time?
A. Determine the client's ability to help with the transfer
B. Use a transfer belt to assist
,C. Call for additional staff to assist with the transfer
D. Obtain a walker for the client to use to transfer back to bed
Correct Answer: A. Determine the client's ability to help with the transfer
Expert Rationale: The priority action when preparing to transfer a patient is to first
determine their ability to assist. This assessment informs the safest transfer technique
and what equipment or assistance may be needed. Using a transfer belt, calling for
additional staff, or obtaining a walker are all secondary interventions that depend on the
initial assessment of the client's capabilities. Without knowing the client's strength and
ability to bear weight, the nurse cannot safely proceed with any transfer method.
QUESTION 3
A nurse is educating a new graduate nurse on body mechanics. Which of the
following statements indicates a good use of body mechanics?
A. The nurse suggests that the new grad keep feet close together when preparing to lift
the patient
B. The nurse suggests the new grad always twist their back towards the direction of the
transfer as opposed to away from it
C. The nurse suggests the nurse sleep on a firm mattress as opposed to a soft one
D. The nurse suggests the new grad not attempt to lift anything greater than 50 lbs
without assistance
Correct Answer: D. The nurse suggests the new grad not attempt to lift anything
greater than 50 lbs without assistance
Expert Rationale: Body mechanics principles include maintaining a wide base of
support (feet shoulder-width apart, not close together), avoiding twisting motions, and
not lifting heavy objects alone. General guidelines recommend not lifting anything
greater than 50 lbs without assistance to prevent back injury. Sleeping on a firm
mattress is beneficial for spinal alignment but is not a primary body mechanics principle
for patient care. Proper body mechanics also involve using leg muscles to lift, keeping
the object close to the body, and pivoting instead of twisting.
, QUESTION 4
A nurse is caring for a patient that is unconscious. The nurse knows that in order
to promote drainage of secretions when performing oral care, which position is
best to place them in?
A. Prone Position
B. Lateral Position
C. Reverse Trendelenburg's
D. High Fowler's Position
Correct Answer: B. Lateral Position
Expert Rationale: For an unconscious patient, positioning them in a lateral (side-lying)
position promotes drainage of oral secretions and prevents aspiration. This position
allows gravity to facilitate the flow of secretions out of the mouth and reduces the risk
of aspiration into the lungs. High Fowler's position is useful for breathing but does not
promote drainage as effectively. The prone position is not ideal for oral care in an
unconscious patient. Reverse Trendelenburg's is primarily used to reduce intracranial
pressure.
QUESTION 5
A nurse is educating a client on the effects of immobility. Which of the following,
if stated by the patient, indicates they need additional teaching?
A. "I may develop diarrhea which can lead to skin breakdown"
B. "I may experience stiff joints or contractures"
C. "I may experience more frequent UTIs"
D. "I may experience pooling of respiratory secretions"
Correct Answer: A. "I may develop diarrhea which can lead to skin breakdown"
Expert Rationale: Immobility typically causes constipation, not diarrhea, due to
decreased peristalsis. Diarrhea is not a common effect of immobility. The other
statements are accurate. Immobility leads to joint stiffness and contractures (B),
increased risk of urinary tract infections due to urinary stasis (C), and pooling of
respiratory secretions leading to atelectasis or pneumonia (D). The patient's statement
Questions And Answers With Verified 2026/2027
Updates & Expert Rationales
QUESTION 1
A nurse is caring for a client in restraints. When reviewing the order, what should
the nurse question?
A. The provider states that the staff is to use soft wrist restraints bilaterally
B. The provider states the restraint is good for 12 hours until the patient gets his
psychiatric evaluation
C. The provider says to only use wrist restraints when the patient shows signs of physical
aggression
D. The provider states the purpose of the restraint is to prevent the client from
physically cutting themselves
Correct Answer: B. The provider states the restraint is good for 12 hours until the
patient gets his psychiatric evaluation
Expert Rationale: Restraint orders are time-limited and must be renewed frequently.
The Joint Commission and CMS guidelines require that restraints be used only as a last
resort and that orders have specific time limits. The provider's statement that the
restraint order is good for 12 hours does not align with best practices. The order should
specify the type of restraint, the reason for use, and the duration. It must be renewed
after 4 hours for adults (2 hours for children, 1 hour for ages 9-17). The other options
are components of a valid restraint order that a nurse would not necessarily question.
QUESTION 2
A nurse is caring for a client who is sitting in a chair and asks to return to bed.
Which of the following actions is the nurse's priority at this time?
A. Determine the client's ability to help with the transfer
B. Use a transfer belt to assist
,C. Call for additional staff to assist with the transfer
D. Obtain a walker for the client to use to transfer back to bed
Correct Answer: A. Determine the client's ability to help with the transfer
Expert Rationale: The priority action when preparing to transfer a patient is to first
determine their ability to assist. This assessment informs the safest transfer technique
and what equipment or assistance may be needed. Using a transfer belt, calling for
additional staff, or obtaining a walker are all secondary interventions that depend on the
initial assessment of the client's capabilities. Without knowing the client's strength and
ability to bear weight, the nurse cannot safely proceed with any transfer method.
QUESTION 3
A nurse is educating a new graduate nurse on body mechanics. Which of the
following statements indicates a good use of body mechanics?
A. The nurse suggests that the new grad keep feet close together when preparing to lift
the patient
B. The nurse suggests the new grad always twist their back towards the direction of the
transfer as opposed to away from it
C. The nurse suggests the nurse sleep on a firm mattress as opposed to a soft one
D. The nurse suggests the new grad not attempt to lift anything greater than 50 lbs
without assistance
Correct Answer: D. The nurse suggests the new grad not attempt to lift anything
greater than 50 lbs without assistance
Expert Rationale: Body mechanics principles include maintaining a wide base of
support (feet shoulder-width apart, not close together), avoiding twisting motions, and
not lifting heavy objects alone. General guidelines recommend not lifting anything
greater than 50 lbs without assistance to prevent back injury. Sleeping on a firm
mattress is beneficial for spinal alignment but is not a primary body mechanics principle
for patient care. Proper body mechanics also involve using leg muscles to lift, keeping
the object close to the body, and pivoting instead of twisting.
, QUESTION 4
A nurse is caring for a patient that is unconscious. The nurse knows that in order
to promote drainage of secretions when performing oral care, which position is
best to place them in?
A. Prone Position
B. Lateral Position
C. Reverse Trendelenburg's
D. High Fowler's Position
Correct Answer: B. Lateral Position
Expert Rationale: For an unconscious patient, positioning them in a lateral (side-lying)
position promotes drainage of oral secretions and prevents aspiration. This position
allows gravity to facilitate the flow of secretions out of the mouth and reduces the risk
of aspiration into the lungs. High Fowler's position is useful for breathing but does not
promote drainage as effectively. The prone position is not ideal for oral care in an
unconscious patient. Reverse Trendelenburg's is primarily used to reduce intracranial
pressure.
QUESTION 5
A nurse is educating a client on the effects of immobility. Which of the following,
if stated by the patient, indicates they need additional teaching?
A. "I may develop diarrhea which can lead to skin breakdown"
B. "I may experience stiff joints or contractures"
C. "I may experience more frequent UTIs"
D. "I may experience pooling of respiratory secretions"
Correct Answer: A. "I may develop diarrhea which can lead to skin breakdown"
Expert Rationale: Immobility typically causes constipation, not diarrhea, due to
decreased peristalsis. Diarrhea is not a common effect of immobility. The other
statements are accurate. Immobility leads to joint stiffness and contractures (B),
increased risk of urinary tract infections due to urinary stasis (C), and pooling of
respiratory secretions leading to atelectasis or pneumonia (D). The patient's statement
