NSG 3130 Exam 1 2026/2027 | Practice Questions, Correct
Answers & Detailed Rationales | Fundamentals II Review
Question 1
A nurse is preparing to administer an intramuscular (IM) injection to an
adult client who is receiving a 3 mL volume of medication. Which
anatomical site is the safest and most preferred choice for this volume?
• A. Deltoid muscle
• B. Ventrogluteal site
• C. Vastus lateralis site
• D. Dorsogluteal site
Correct Answer: B. Ventrogluteal site
Detailed Rationale: The ventrogluteal site is the preferred and safest
site for IM injections in adults, especially for volumes up to 3 mL. It
provides a deep, large muscle mass away from major nerves (such as
the sciatic nerve) and large blood vessels. The deltoid muscle is
recommended only for small volumes (≤ 1 mL). The dorsogluteal site is
no longer recommended due to proximity to the sciatic nerve and
superior gluteal artery.
Question 2
A healthcare provider orders a 24-hour urine collection for a client to
evaluate renal function. Which instruction must the nurse give the
client regarding the collection process?
• A. Save the first morning urine void on Day 1 as the start of the
specimen collection.
, • B. Discard the first morning urine void on Day 1, then collect all
subsequent urine for 24 hours including the first void of Day 2.
• C. Keep the urine specimen at room temperature throughout the
24-hour period.
• D. Collect only the midstream portion of each voiding throughout
the 24 hours.
Correct Answer: B. Discard the first morning urine void on Day 1, then
collect all subsequent urine for 24 hours including the first void of Day
2.
Detailed Rationale: The 24-hour collection begins after the client voids
and discards the first urine specimen in the morning. This ensures that
the collection starts with an empty bladder containing no residual urine
from the night before. All urine produced over the next 24 hours—
ending with the first morning void on the following day—must be
collected and kept refrigerated or on ice to prevent bacterial growth
and chemical breakdown.
Question 3
A nurse is evaluating a client's risk for pressure injury development
using the Braden Scale. Which score indicates the highest risk for
pressure injury development?
• A. 23
• B. 19
• C. 15
• D. 8
,Correct Answer: D. 8
Detailed Rationale: The Braden Scale assesses 6 subscales (sensory
perception, moisture, activity, mobility, nutrition, friction/shear) with
total scores ranging from 6 to 23. Lower total scores indicate higher risk
(scores ≤ 9indicate severe/very high risk; a score of 23 represents
minimal risk).
Question 4
A client with a Stage 2 pressure injury on the sacrum requires a dressing
change. Which dressing type is most appropriate for a clean, Stage 2
pressure injury with minimal exudate?
• A. Hydrocolloid dressing
• B. Alginate dressing
• C. Wet-to-dry gauze dressing
• D. Enzymatic debriding ointment with dry gauze
Correct Answer: A. Hydrocolloid dressing
Detailed Rationale: Hydrocolloid dressings maintain a moist wound-
healing environment, protect partial-thickness wounds (Stage 2
pressure injuries) from friction and external contamination, and are
appropriate for wounds with light to moderate exudate. Alginate
dressings are designed for heavy exudate. Wet-to-dry dressings cause
mechanical debridement and can damage newly granulating tissue.
Question 5
, A client with chronic obstructive pulmonary disease (COPD) is receiving
oxygen via nasal cannula. Why must the nurse exercise caution when
increasing the oxygen flow rate above 2 L/min for this client?
• A. High oxygen concentrations irritate the nasal mucosa and cause
epistaxis.
• B. High oxygen concentrations can suppress the hypoxic
respiratory drive in hypercapnic clients.
• C. It increases the risk of oxygen toxicity within 30 minutes.
• D. It causes hyperventilation and metabolic alkalosis.
Correct Answer: B. High oxygen concentrations can suppress the
hypoxic respiratory drive in hypercapnic clients.
Detailed Rationale: Clients with severe COPD often have chronically
elevated arterial carbon dioxide levels (PaCO2 ) and rely on low oxygen
levels (PaO2 ) as their primary stimulus (hypoxic drive) to breathe.
Supplying high oxygen levels can increase arterial oxygen levels,
abolishing this drive, which can lead to hypoventilation, respiratory
depression, and severe carbon dioxide narcosis.
Question 6
When measuring a client's blood pressure, the nurse chooses a cuff
where the inflatable bladder width covers 20% of the client's upper arm
circumference. What effect will this cuff size have on the blood pressure
reading?
• A. The reading will be falsely low.
• B. The reading will be falsely high.
Answers & Detailed Rationales | Fundamentals II Review
Question 1
A nurse is preparing to administer an intramuscular (IM) injection to an
adult client who is receiving a 3 mL volume of medication. Which
anatomical site is the safest and most preferred choice for this volume?
• A. Deltoid muscle
• B. Ventrogluteal site
• C. Vastus lateralis site
• D. Dorsogluteal site
Correct Answer: B. Ventrogluteal site
Detailed Rationale: The ventrogluteal site is the preferred and safest
site for IM injections in adults, especially for volumes up to 3 mL. It
provides a deep, large muscle mass away from major nerves (such as
the sciatic nerve) and large blood vessels. The deltoid muscle is
recommended only for small volumes (≤ 1 mL). The dorsogluteal site is
no longer recommended due to proximity to the sciatic nerve and
superior gluteal artery.
Question 2
A healthcare provider orders a 24-hour urine collection for a client to
evaluate renal function. Which instruction must the nurse give the
client regarding the collection process?
• A. Save the first morning urine void on Day 1 as the start of the
specimen collection.
, • B. Discard the first morning urine void on Day 1, then collect all
subsequent urine for 24 hours including the first void of Day 2.
• C. Keep the urine specimen at room temperature throughout the
24-hour period.
• D. Collect only the midstream portion of each voiding throughout
the 24 hours.
Correct Answer: B. Discard the first morning urine void on Day 1, then
collect all subsequent urine for 24 hours including the first void of Day
2.
Detailed Rationale: The 24-hour collection begins after the client voids
and discards the first urine specimen in the morning. This ensures that
the collection starts with an empty bladder containing no residual urine
from the night before. All urine produced over the next 24 hours—
ending with the first morning void on the following day—must be
collected and kept refrigerated or on ice to prevent bacterial growth
and chemical breakdown.
Question 3
A nurse is evaluating a client's risk for pressure injury development
using the Braden Scale. Which score indicates the highest risk for
pressure injury development?
• A. 23
• B. 19
• C. 15
• D. 8
,Correct Answer: D. 8
Detailed Rationale: The Braden Scale assesses 6 subscales (sensory
perception, moisture, activity, mobility, nutrition, friction/shear) with
total scores ranging from 6 to 23. Lower total scores indicate higher risk
(scores ≤ 9indicate severe/very high risk; a score of 23 represents
minimal risk).
Question 4
A client with a Stage 2 pressure injury on the sacrum requires a dressing
change. Which dressing type is most appropriate for a clean, Stage 2
pressure injury with minimal exudate?
• A. Hydrocolloid dressing
• B. Alginate dressing
• C. Wet-to-dry gauze dressing
• D. Enzymatic debriding ointment with dry gauze
Correct Answer: A. Hydrocolloid dressing
Detailed Rationale: Hydrocolloid dressings maintain a moist wound-
healing environment, protect partial-thickness wounds (Stage 2
pressure injuries) from friction and external contamination, and are
appropriate for wounds with light to moderate exudate. Alginate
dressings are designed for heavy exudate. Wet-to-dry dressings cause
mechanical debridement and can damage newly granulating tissue.
Question 5
, A client with chronic obstructive pulmonary disease (COPD) is receiving
oxygen via nasal cannula. Why must the nurse exercise caution when
increasing the oxygen flow rate above 2 L/min for this client?
• A. High oxygen concentrations irritate the nasal mucosa and cause
epistaxis.
• B. High oxygen concentrations can suppress the hypoxic
respiratory drive in hypercapnic clients.
• C. It increases the risk of oxygen toxicity within 30 minutes.
• D. It causes hyperventilation and metabolic alkalosis.
Correct Answer: B. High oxygen concentrations can suppress the
hypoxic respiratory drive in hypercapnic clients.
Detailed Rationale: Clients with severe COPD often have chronically
elevated arterial carbon dioxide levels (PaCO2 ) and rely on low oxygen
levels (PaO2 ) as their primary stimulus (hypoxic drive) to breathe.
Supplying high oxygen levels can increase arterial oxygen levels,
abolishing this drive, which can lead to hypoventilation, respiratory
depression, and severe carbon dioxide narcosis.
Question 6
When measuring a client's blood pressure, the nurse chooses a cuff
where the inflatable bladder width covers 20% of the client's upper arm
circumference. What effect will this cuff size have on the blood pressure
reading?
• A. The reading will be falsely low.
• B. The reading will be falsely high.
