NRSG 100 Exam 3 V3 | NRSG 100 Fundamentals of
Nursing | Actual Q&A with Rationale (NRSG100
Exam 3) | Ivy Tech
1. A nurse is assessing a patient’s pressure injury and notes partial-thickness loss of dermis
presenting as a shallow open ulcer with a red-pink wound bed, without slough. How should
the nurse stage this injury?
A. Stage 1
B. Unstageable
C. Stage 3
D. Stage 2
Correct Answer: D
Explanation: 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. It may also present as an
intact or open/ruptured serum-filled blister. This stage does not include slough or bruising,
which would indicate deeper tissue damage.
2. Which action is most important for the nurse to take when preparing a patient for a
surgical procedure requiring informed consent?
A. Explain the risks and benefits of the surgery to the patient.
B. Describe the alternative treatments available to the patient.
,C. Witness the patient’s signature on the consent form.
D. Ensure the patient understands the surgical technique used.
Correct Answer: C
Explanation: The nurse’s primary role in the informed consent process is to witness the
patient’s signature, ensuring it is voluntary and that the patient appears competent. It is the
surgeon’s legal responsibility to explain the procedure, risks, benefits, and alternatives. If
the nurse notes the patient does not understand the procedure, the surgeon must be
notified to provide further clarification before the signature is obtained.
3. A postoperative patient is being taught how to use an incentive spirometer. Which
instruction should the nurse include?
A. Exhale forcefully into the device to raise the piston.
B. Inhale slowly and deeply to maintain the ball at the marked level.
C. Use the device once every 4 hours while awake.
D. Hold your breath for 15 seconds after reaching the goal volume.
Correct Answer: B
Explanation: Incentive spirometry encourages deep breathing by providing visual
feedback, and the patient should inhale slowly and deeply. This action helps to inflate the
alveoli and prevent atelectasis, a common postoperative complication. The typical
recommendation is for the patient to perform this exercise 5 to 10 times every hour while
awake.
,4. When performing a sterile dressing change, the nurse inadvertently touches the sterile
field with a clean glove. What is the appropriate next step?
A. Continue the procedure but avoid that specific area of the field.
B. Apply a sterile drape over the contaminated area.
C. Discard the supplies and start over with a new sterile field.
D. Wipe the contaminated area with an alcohol swab.
Correct Answer: C
Explanation: According to surgical asepsis principles, if a sterile object touches a non-
sterile object, it is considered contaminated. Once the sterile field is contaminated, the
nurse must start the process over to ensure patient safety and prevent infection.
Attempting to ‘patch’ the field or ignore the break in technique increases the risk of
healthcare-associated infections.
5. A nurse is caring for a patient who is 2 days postoperative following abdominal surgery.
The patient reports a ‘popping’ sensation after coughing, and the nurse observes the wound
edges have separated with internal organs protruding. What is the priority nursing action?
A. Apply a tight abdominal binder to the site.
B. Push the organs back into the abdominal cavity gently.
C. Administer pain medication and place the patient in Trendelenburg.
D. Cover the area with sterile dressings soaked in sterile normal saline.
, Correct Answer: D
Explanation: Evisceration is a medical emergency where abdominal organs protrude
through a dehisced wound. The nurse must cover the protruding organs with sterile,
saline-soaked towels to prevent tissue drying and infection. Following this, the nurse
should immediately notify the surgeon and prepare the patient for emergency surgery.
6. Which laboratory value should the nurse prioritize monitoring for a patient receiving Total
Parenteral Nutrition (TPN)?
A. Serum sodium
B. Hemoglobin
C. Blood glucose level
D. Serum creatinine
Correct Answer: C
Explanation: TPN solutions contain high concentrations of dextrose, which places the
patient at a significant risk for hyperglycemia. Frequent blood glucose monitoring (usually
every 6 hours) is standard practice to ensure the patient’s metabolic state remains stable. If
TPN is discontinued abruptly, the nurse must also monitor for rebound hypoglycemia.
7. A nurse is providing discharge instructions to a patient with a new colostomy. Which
statement by the patient indicates a need for further teaching?
A. I should empty my pouch when it is one-third full.
B. I should cut the wafer to be 1/8 inch larger than the stoma.
Nursing | Actual Q&A with Rationale (NRSG100
Exam 3) | Ivy Tech
1. A nurse is assessing a patient’s pressure injury and notes partial-thickness loss of dermis
presenting as a shallow open ulcer with a red-pink wound bed, without slough. How should
the nurse stage this injury?
A. Stage 1
B. Unstageable
C. Stage 3
D. Stage 2
Correct Answer: D
Explanation: 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. It may also present as an
intact or open/ruptured serum-filled blister. This stage does not include slough or bruising,
which would indicate deeper tissue damage.
2. Which action is most important for the nurse to take when preparing a patient for a
surgical procedure requiring informed consent?
A. Explain the risks and benefits of the surgery to the patient.
B. Describe the alternative treatments available to the patient.
,C. Witness the patient’s signature on the consent form.
D. Ensure the patient understands the surgical technique used.
Correct Answer: C
Explanation: The nurse’s primary role in the informed consent process is to witness the
patient’s signature, ensuring it is voluntary and that the patient appears competent. It is the
surgeon’s legal responsibility to explain the procedure, risks, benefits, and alternatives. If
the nurse notes the patient does not understand the procedure, the surgeon must be
notified to provide further clarification before the signature is obtained.
3. A postoperative patient is being taught how to use an incentive spirometer. Which
instruction should the nurse include?
A. Exhale forcefully into the device to raise the piston.
B. Inhale slowly and deeply to maintain the ball at the marked level.
C. Use the device once every 4 hours while awake.
D. Hold your breath for 15 seconds after reaching the goal volume.
Correct Answer: B
Explanation: Incentive spirometry encourages deep breathing by providing visual
feedback, and the patient should inhale slowly and deeply. This action helps to inflate the
alveoli and prevent atelectasis, a common postoperative complication. The typical
recommendation is for the patient to perform this exercise 5 to 10 times every hour while
awake.
,4. When performing a sterile dressing change, the nurse inadvertently touches the sterile
field with a clean glove. What is the appropriate next step?
A. Continue the procedure but avoid that specific area of the field.
B. Apply a sterile drape over the contaminated area.
C. Discard the supplies and start over with a new sterile field.
D. Wipe the contaminated area with an alcohol swab.
Correct Answer: C
Explanation: According to surgical asepsis principles, if a sterile object touches a non-
sterile object, it is considered contaminated. Once the sterile field is contaminated, the
nurse must start the process over to ensure patient safety and prevent infection.
Attempting to ‘patch’ the field or ignore the break in technique increases the risk of
healthcare-associated infections.
5. A nurse is caring for a patient who is 2 days postoperative following abdominal surgery.
The patient reports a ‘popping’ sensation after coughing, and the nurse observes the wound
edges have separated with internal organs protruding. What is the priority nursing action?
A. Apply a tight abdominal binder to the site.
B. Push the organs back into the abdominal cavity gently.
C. Administer pain medication and place the patient in Trendelenburg.
D. Cover the area with sterile dressings soaked in sterile normal saline.
, Correct Answer: D
Explanation: Evisceration is a medical emergency where abdominal organs protrude
through a dehisced wound. The nurse must cover the protruding organs with sterile,
saline-soaked towels to prevent tissue drying and infection. Following this, the nurse
should immediately notify the surgeon and prepare the patient for emergency surgery.
6. Which laboratory value should the nurse prioritize monitoring for a patient receiving Total
Parenteral Nutrition (TPN)?
A. Serum sodium
B. Hemoglobin
C. Blood glucose level
D. Serum creatinine
Correct Answer: C
Explanation: TPN solutions contain high concentrations of dextrose, which places the
patient at a significant risk for hyperglycemia. Frequent blood glucose monitoring (usually
every 6 hours) is standard practice to ensure the patient’s metabolic state remains stable. If
TPN is discontinued abruptly, the nurse must also monitor for rebound hypoglycemia.
7. A nurse is providing discharge instructions to a patient with a new colostomy. Which
statement by the patient indicates a need for further teaching?
A. I should empty my pouch when it is one-third full.
B. I should cut the wafer to be 1/8 inch larger than the stoma.
