NSG 3100 EXAM 2 LATEST 2023-2024 ACTUAL EXAM
ALL 100 QUESTIONS AND CORRECT DETAILED
ANSWERS WITH RATIONALES|ALREADY GRADED A+
When applying a wrist restraint, the nurse knows that:
A- The padded side is away from the skin
B- It should be removed at least once every shift
C- The straps should be secured w/ a knot
D- Two fingers' width should fit between the skin and the restraint - ANSWER-D- Two fingers' width
should fit between the skin and the restraint
A patient has a 6-inch laceration on his right forearm. An infection develops at the site. Which of the
following is a sign of a local inflammatory response observed by the nurse?
A- Blanching of the skin
B- Edema at the site
C- Decrease in temperature
D- Bruising at the site - ANSWER-B- Edema at the site
The nurse employs surgical aseptic technique when:
A- Disposing syringes in a puncture-proof container
B- Placing soiled linens in a moisture-resistant bag
C- Washing hands before changing a dressing
D- Inserting an intravenous catheter - ANSWER-D- Inserting an intravenous catheter
A patient with active tuberculosis is admitted to the medical center. The nurse recognizes that
admission of this patient to the unit will require the implementation by the staff of:
A- Droplet precautions
B- Airborne precautions
C- Contact precautions
D- Protective precautions - ANSWER-B- Airborne precautions
,A patient requires a sterile dressing change for a mid-abdominal surgical incision. An appropriate
intervention for the nurse to implement in maintaining sterile asepsis is to:
A- Put sterile gloves on before opening sterile packages
B- Place the cap of the sterile solution well within the sterile field
C- Place sterile items on the edge of the sterile drape
D- Discard packages that may have been in contact w/ the area below waist level - ANSWER-D- Discard
packages that may have been in contact w/ the area below waist level
The unit manager observes the new staff nurse perform the following actions for a patient with isolation
precautions. Which of the following actions should the unit manager address and correct with the new
nurse?
A- Keeping a thermometer, stethoscope and BP cuff in the patient's room.
B- Documenting the precautions required in the patient's record
C- Using a particulate respirator mask for the patient who has tuberculosis
D- Coming out of the room in the PPE to quickly get another dressing - ANSWER-D- Coming out of the
room in the PPE to quickly get another dressing
Pressure injuries form primarily as a result of:
A- Nitrogen buildup in the underlying tissues
B- Prolonged illness or disease
C- Tissue ischemia
D- Poor hygiene - ANSWER-C- Tissue ischemia
The nurse prepares to irrigate the patient's wound. The primary reason for this procedure is to:
A- Create scar formation
B- Remove debris from the wound
C- Improve circulation from the wound
D- Decrease irritation from wound drainage - ANSWER-B- Remove debris from the wound
, On inspection of the patient's wound, the nurse notes that it appears infected and has a large amount of
exudate. An appropriate dressing for the nurse to select on the basis of the wound assessment is:
A- Foam
B- Hydrogel
C- Hydrocolloid
D- Transparent film - ANSWER-A- Foam
The nurse is concerned that the patient's midsternal wound is at risk for dehiscence. Which of the
following is the best intervention to prevent this complication?
A- Administering antibiotics to prevent infection
B- Using appropriate sterile technique when changing the dressing
C- Keeping sterile towels and extra dressing supplies near the patient's bed
D- Having the patient splint the incision site when coughing - ANSWER-D- Having the patient splint the
incision site when coughing
After an injury, the patient has thick, yellow drainage coming from the wound. The nurse describes this
drainage as:
A- Milky
B- Serous
C- Purulent
D- Serosanguinous - ANSWER-C- Purulent
The nurse has applied a pulse oximeter to the finger of a patient who is hypothermic. The pulse
oximeter does not provide a good reading. What action by the nurse is best?
A- Move the oximeter probe to another finger
B- Remove any fingernail polish present on the fingernail
C- Assess the fingers for good circulation
D- Document that the reading cannot be obtained - ANSWER-C- Assess the fingers for good circulation
A nurse performs orthostatic blood pressure readings on a patient w/ the following results: lying 148/76
mmHg, standing 110/60 mmHg. Which action by the nurse is best?
ALL 100 QUESTIONS AND CORRECT DETAILED
ANSWERS WITH RATIONALES|ALREADY GRADED A+
When applying a wrist restraint, the nurse knows that:
A- The padded side is away from the skin
B- It should be removed at least once every shift
C- The straps should be secured w/ a knot
D- Two fingers' width should fit between the skin and the restraint - ANSWER-D- Two fingers' width
should fit between the skin and the restraint
A patient has a 6-inch laceration on his right forearm. An infection develops at the site. Which of the
following is a sign of a local inflammatory response observed by the nurse?
A- Blanching of the skin
B- Edema at the site
C- Decrease in temperature
D- Bruising at the site - ANSWER-B- Edema at the site
The nurse employs surgical aseptic technique when:
A- Disposing syringes in a puncture-proof container
B- Placing soiled linens in a moisture-resistant bag
C- Washing hands before changing a dressing
D- Inserting an intravenous catheter - ANSWER-D- Inserting an intravenous catheter
A patient with active tuberculosis is admitted to the medical center. The nurse recognizes that
admission of this patient to the unit will require the implementation by the staff of:
A- Droplet precautions
B- Airborne precautions
C- Contact precautions
D- Protective precautions - ANSWER-B- Airborne precautions
,A patient requires a sterile dressing change for a mid-abdominal surgical incision. An appropriate
intervention for the nurse to implement in maintaining sterile asepsis is to:
A- Put sterile gloves on before opening sterile packages
B- Place the cap of the sterile solution well within the sterile field
C- Place sterile items on the edge of the sterile drape
D- Discard packages that may have been in contact w/ the area below waist level - ANSWER-D- Discard
packages that may have been in contact w/ the area below waist level
The unit manager observes the new staff nurse perform the following actions for a patient with isolation
precautions. Which of the following actions should the unit manager address and correct with the new
nurse?
A- Keeping a thermometer, stethoscope and BP cuff in the patient's room.
B- Documenting the precautions required in the patient's record
C- Using a particulate respirator mask for the patient who has tuberculosis
D- Coming out of the room in the PPE to quickly get another dressing - ANSWER-D- Coming out of the
room in the PPE to quickly get another dressing
Pressure injuries form primarily as a result of:
A- Nitrogen buildup in the underlying tissues
B- Prolonged illness or disease
C- Tissue ischemia
D- Poor hygiene - ANSWER-C- Tissue ischemia
The nurse prepares to irrigate the patient's wound. The primary reason for this procedure is to:
A- Create scar formation
B- Remove debris from the wound
C- Improve circulation from the wound
D- Decrease irritation from wound drainage - ANSWER-B- Remove debris from the wound
, On inspection of the patient's wound, the nurse notes that it appears infected and has a large amount of
exudate. An appropriate dressing for the nurse to select on the basis of the wound assessment is:
A- Foam
B- Hydrogel
C- Hydrocolloid
D- Transparent film - ANSWER-A- Foam
The nurse is concerned that the patient's midsternal wound is at risk for dehiscence. Which of the
following is the best intervention to prevent this complication?
A- Administering antibiotics to prevent infection
B- Using appropriate sterile technique when changing the dressing
C- Keeping sterile towels and extra dressing supplies near the patient's bed
D- Having the patient splint the incision site when coughing - ANSWER-D- Having the patient splint the
incision site when coughing
After an injury, the patient has thick, yellow drainage coming from the wound. The nurse describes this
drainage as:
A- Milky
B- Serous
C- Purulent
D- Serosanguinous - ANSWER-C- Purulent
The nurse has applied a pulse oximeter to the finger of a patient who is hypothermic. The pulse
oximeter does not provide a good reading. What action by the nurse is best?
A- Move the oximeter probe to another finger
B- Remove any fingernail polish present on the fingernail
C- Assess the fingers for good circulation
D- Document that the reading cannot be obtained - ANSWER-C- Assess the fingers for good circulation
A nurse performs orthostatic blood pressure readings on a patient w/ the following results: lying 148/76
mmHg, standing 110/60 mmHg. Which action by the nurse is best?
