NSG 3130 EXAM 2: FUNDAMENTAL
CONCEPTS & SKILLS FOR NURSING
PRACTICE II
1. A nurse observes that a patient’s peripheral IV site is cool, pale, and swollen. The infusion
has slowed significantly. Which action should the nurse take first?
A. Apply a warm compress to the site
B. Flush the IV line with normal saline
C. Stop the infusion and remove the catheter
D. Lower the IV bag below the level of the site
Answer: C
Conceptual Explanation: These are classic signs of infiltration. The primary intervention
is to stop the infusion and remove the catheter to prevent further tissue damage.
2. When preparing to mix Regular and NPH insulin in a single syringe, which step is correct to
prevent contamination?
A. Draw the NPH insulin into the syringe first
B. Inject air into the Regular vial after the NPH vial
,C. Draw the Regular insulin into the syringe first
D. Shake the NPH vial vigorously before drawing
Answer: C
Conceptual Explanation: The nurse should draw ‘clear’ (Regular) before ‘cloudy’ (NPH) to
prevent contaminating the short-acting insulin with the long-acting protein.
3. A patient’s surgical wound has eviscerated. What is the immediate priority for the nurse?
A. Attempt to push the organs back into the abdominal cavity
B. Place the patient in a High-Fowler’s position
C. Apply a tight abdominal binder to provide support
D. Cover the protruding organs with sterile gauze soaked in sterile normal saline
Answer: D
Conceptual Explanation: Evisceration is a medical emergency. Organs must be kept moist
with sterile saline until surgery can be performed. Pushing them back is contraindicated.
4. During the insertion of a Foley catheter in a female patient, the nurse accidentally inserts
the catheter into the vagina. What should the nurse do next?
A. Leave the catheter in the vagina and obtain a new sterile kit to attempt reinsertion
B. Remove it and immediately reinsert it into the meatus
C. Wipe the catheter with alcohol and try again
, D. Ask the patient to cough and redirect the catheter upward
Answer: A
Conceptual Explanation: Leaving the misplaced catheter in the vagina acts as a landmark
to avoid re-entering the vagina. A new sterile kit must be used to maintain asepsis.
5. At what maximum height should a nurse hang a large-volume cleansing enema bag above
the patient’s anus?
A. 18 inches (45 cm)
B. 24 inches (60 cm)
C. 6 inches (15 cm)
D. 18 inches (45 cm)
A. 12 inches (30 cm)
Answer: D
Conceptual Explanation: Hanging the bag higher than 18 inches increases the pressure
too much, which can cause rapid distension and cramping.
6. A healthcare provider orders wrist restraints for a confused patient who is pulling at their
ventilator tubing. How often must the nurse obtain a renewed written order for these
restraints?
A. Every 48 hours
B. Every 7 days
CONCEPTS & SKILLS FOR NURSING
PRACTICE II
1. A nurse observes that a patient’s peripheral IV site is cool, pale, and swollen. The infusion
has slowed significantly. Which action should the nurse take first?
A. Apply a warm compress to the site
B. Flush the IV line with normal saline
C. Stop the infusion and remove the catheter
D. Lower the IV bag below the level of the site
Answer: C
Conceptual Explanation: These are classic signs of infiltration. The primary intervention
is to stop the infusion and remove the catheter to prevent further tissue damage.
2. When preparing to mix Regular and NPH insulin in a single syringe, which step is correct to
prevent contamination?
A. Draw the NPH insulin into the syringe first
B. Inject air into the Regular vial after the NPH vial
,C. Draw the Regular insulin into the syringe first
D. Shake the NPH vial vigorously before drawing
Answer: C
Conceptual Explanation: The nurse should draw ‘clear’ (Regular) before ‘cloudy’ (NPH) to
prevent contaminating the short-acting insulin with the long-acting protein.
3. A patient’s surgical wound has eviscerated. What is the immediate priority for the nurse?
A. Attempt to push the organs back into the abdominal cavity
B. Place the patient in a High-Fowler’s position
C. Apply a tight abdominal binder to provide support
D. Cover the protruding organs with sterile gauze soaked in sterile normal saline
Answer: D
Conceptual Explanation: Evisceration is a medical emergency. Organs must be kept moist
with sterile saline until surgery can be performed. Pushing them back is contraindicated.
4. During the insertion of a Foley catheter in a female patient, the nurse accidentally inserts
the catheter into the vagina. What should the nurse do next?
A. Leave the catheter in the vagina and obtain a new sterile kit to attempt reinsertion
B. Remove it and immediately reinsert it into the meatus
C. Wipe the catheter with alcohol and try again
, D. Ask the patient to cough and redirect the catheter upward
Answer: A
Conceptual Explanation: Leaving the misplaced catheter in the vagina acts as a landmark
to avoid re-entering the vagina. A new sterile kit must be used to maintain asepsis.
5. At what maximum height should a nurse hang a large-volume cleansing enema bag above
the patient’s anus?
A. 18 inches (45 cm)
B. 24 inches (60 cm)
C. 6 inches (15 cm)
D. 18 inches (45 cm)
A. 12 inches (30 cm)
Answer: D
Conceptual Explanation: Hanging the bag higher than 18 inches increases the pressure
too much, which can cause rapid distension and cramping.
6. A healthcare provider orders wrist restraints for a confused patient who is pulling at their
ventilator tubing. How often must the nurse obtain a renewed written order for these
restraints?
A. Every 48 hours
B. Every 7 days
