NSG 3130 Fundamentals II 2026/2027 | Clinical Judgment, Patient
Safety & Nursing Skills Practice Questions with Rationales
Question 1
A nurse is preparing to administer a unit of packed red blood cells
(PRBCs) to an adult client. Which nursing action is mandatory
immediately prior to initiating the transfusion?
A. Prime the blood administration tubing with 5%Dextrose in Water
(D5 W).
B. Verify client identity and blood product compatibility at the bedside
with a second licensed nurse.
Docsity
C. Warm the blood product in a microwave to prevent hypothermic
shivering.
D. Infuse the entire unit rapidly over 15 minutes to prevent hemolysis.
Correct Answer: B. Verify client identity and blood product
compatibility at the bedside with a second licensed nurse.
Docsity
Detailed Rationale: Blood administration requires strict dual-nurse
verification at the bedside comparing the blood bank tag, client blood
band, and medical record to prevent fatal acute hemolytic transfusion
reactions. PRBCs are primed exclusively with 0.9%Sodium Chloride
(normal saline), never dextrose (which causes hemolysis) or lactated
Ringer's (which contains calcium and can cause clotting).
Question 2
,A nurse enters a client's room and suspects a transfusion reaction
because the client is reporting chills, lower back pain, and dyspnea.
What is the nurse's first immediate action?
A. Slow the transfusion rate and reassess vital signs in 15 minutes.
B. Stop the transfusion immediately, maintain IV access with new tubing
and normal saline, and notify the provider.
C. Administer the prescribed PRN antipyretic and continue monitoring.
D. Discontinue the intravenous line entirely and document the finding.
Correct Answer: B. Stop the transfusion immediately, maintain IV
access with new tubing and normal saline, and notify the provider.
Docsity
Detailed Rationale: The client is exhibiting classic signs of an acute
hemolytic or severe allergic transfusion reaction. The priority safety
action is to stop the transfusion immediately, disconnect the blood
tubing, infuse fresh 0.9%normal saline through new tubing to keep the
vein open, and notify the provider and blood bank.
Question 3
A nurse is verifying enteral tube placement before initiating the first
scheduled tube feeding. Which assessment provides the strongest
evidence of gastric placement and should be performed in addition to
checking external tube markings?
Docsity
A. Auscultating injected air over the epigastrium ("whoosh test")
B. Testing the pH of aspirated gastric fluid using pH indicator paper
,Docsity
C. Observing the client for a cough or gag response during insertion
D. Confirming the client can speak clearly without hoarseness
Correct Answer: B. Testing the pH of aspirated gastric fluid using pH
indicator paper
Detailed Rationale: Testing the pH of fluid aspirated from a newly
placed enteral tube is a reliable bedside indicator of placement. Gastric
fluid is typically acidic (pH ≤ 5.5). Auscultating injected air is unreliable
and no longer recommended as an evidence-based method for
confirming tube placement. Radiographic confirmation (X-ray) remains
the gold standard prior to initial feeding.
Question 4
A nurse is caring for a client with a newly created colostomy. During an
initial postoperative assessment, the nurse notes that the stoma
appears dusky, dry, and cool to the touch. What is the appropriate
nursing interpretation and action?
Docsity
A. This is a normal, expected finding immediately following surgery.
B. Apply warm, moist compresses directly over the stoma to stimulate
circulation.
C. This indicates compromised perfusion and ischemia; notify the
surgeon immediately.
D. Document the finding as mild bruising and recheck in 4 hours.
, Correct Answer: C. This indicates compromised perfusion and ischemia;
notify the surgeon immediately.
Detailed Rationale: A healthy stoma should appear beefy red, moist,
and warm. A dusky, pale, cyanotic, or cool stoma indicates inadequate
blood supply (ischemia or necrosis) and requires immediate surgical
notification to prevent stomal tissue death.
Question 5
A nurse is managing a client receiving total parenteral nutrition (TPN)
via a central venous access device. The current TPN bag is empty, and
the replacement bag has not yet arrived from the pharmacy. Which
intravenous solution should the nurse hang temporarily to prevent
rebound hypoglycemia?
A. 0.9%Sodium Chloride
B. 10%Dextrose in Water (D10 W)
C. Lactated Ringer's solution
D. 0.45%Sodium Chloride
Correct Answer: B. 10%Dextrose in Water (D10 W)
Detailed Rationale: TPN solutions contain high glucose concentrations,
prompting the pancreas to secrete elevated insulin levels. If TPN is
interrupted abruptly, the persistent high insulin level causes rapid
rebound hypoglycemia. Infusing a comparable dextrose solution (D10 W
or D20 Wdepending on institutional protocol) prevents this sharp drop.
Question 6
Safety & Nursing Skills Practice Questions with Rationales
Question 1
A nurse is preparing to administer a unit of packed red blood cells
(PRBCs) to an adult client. Which nursing action is mandatory
immediately prior to initiating the transfusion?
A. Prime the blood administration tubing with 5%Dextrose in Water
(D5 W).
B. Verify client identity and blood product compatibility at the bedside
with a second licensed nurse.
Docsity
C. Warm the blood product in a microwave to prevent hypothermic
shivering.
D. Infuse the entire unit rapidly over 15 minutes to prevent hemolysis.
Correct Answer: B. Verify client identity and blood product
compatibility at the bedside with a second licensed nurse.
Docsity
Detailed Rationale: Blood administration requires strict dual-nurse
verification at the bedside comparing the blood bank tag, client blood
band, and medical record to prevent fatal acute hemolytic transfusion
reactions. PRBCs are primed exclusively with 0.9%Sodium Chloride
(normal saline), never dextrose (which causes hemolysis) or lactated
Ringer's (which contains calcium and can cause clotting).
Question 2
,A nurse enters a client's room and suspects a transfusion reaction
because the client is reporting chills, lower back pain, and dyspnea.
What is the nurse's first immediate action?
A. Slow the transfusion rate and reassess vital signs in 15 minutes.
B. Stop the transfusion immediately, maintain IV access with new tubing
and normal saline, and notify the provider.
C. Administer the prescribed PRN antipyretic and continue monitoring.
D. Discontinue the intravenous line entirely and document the finding.
Correct Answer: B. Stop the transfusion immediately, maintain IV
access with new tubing and normal saline, and notify the provider.
Docsity
Detailed Rationale: The client is exhibiting classic signs of an acute
hemolytic or severe allergic transfusion reaction. The priority safety
action is to stop the transfusion immediately, disconnect the blood
tubing, infuse fresh 0.9%normal saline through new tubing to keep the
vein open, and notify the provider and blood bank.
Question 3
A nurse is verifying enteral tube placement before initiating the first
scheduled tube feeding. Which assessment provides the strongest
evidence of gastric placement and should be performed in addition to
checking external tube markings?
Docsity
A. Auscultating injected air over the epigastrium ("whoosh test")
B. Testing the pH of aspirated gastric fluid using pH indicator paper
,Docsity
C. Observing the client for a cough or gag response during insertion
D. Confirming the client can speak clearly without hoarseness
Correct Answer: B. Testing the pH of aspirated gastric fluid using pH
indicator paper
Detailed Rationale: Testing the pH of fluid aspirated from a newly
placed enteral tube is a reliable bedside indicator of placement. Gastric
fluid is typically acidic (pH ≤ 5.5). Auscultating injected air is unreliable
and no longer recommended as an evidence-based method for
confirming tube placement. Radiographic confirmation (X-ray) remains
the gold standard prior to initial feeding.
Question 4
A nurse is caring for a client with a newly created colostomy. During an
initial postoperative assessment, the nurse notes that the stoma
appears dusky, dry, and cool to the touch. What is the appropriate
nursing interpretation and action?
Docsity
A. This is a normal, expected finding immediately following surgery.
B. Apply warm, moist compresses directly over the stoma to stimulate
circulation.
C. This indicates compromised perfusion and ischemia; notify the
surgeon immediately.
D. Document the finding as mild bruising and recheck in 4 hours.
, Correct Answer: C. This indicates compromised perfusion and ischemia;
notify the surgeon immediately.
Detailed Rationale: A healthy stoma should appear beefy red, moist,
and warm. A dusky, pale, cyanotic, or cool stoma indicates inadequate
blood supply (ischemia or necrosis) and requires immediate surgical
notification to prevent stomal tissue death.
Question 5
A nurse is managing a client receiving total parenteral nutrition (TPN)
via a central venous access device. The current TPN bag is empty, and
the replacement bag has not yet arrived from the pharmacy. Which
intravenous solution should the nurse hang temporarily to prevent
rebound hypoglycemia?
A. 0.9%Sodium Chloride
B. 10%Dextrose in Water (D10 W)
C. Lactated Ringer's solution
D. 0.45%Sodium Chloride
Correct Answer: B. 10%Dextrose in Water (D10 W)
Detailed Rationale: TPN solutions contain high glucose concentrations,
prompting the pancreas to secrete elevated insulin levels. If TPN is
interrupted abruptly, the persistent high insulin level causes rapid
rebound hypoglycemia. Infusing a comparable dextrose solution (D10 W
or D20 Wdepending on institutional protocol) prevents this sharp drop.
Question 6
