2026 NSG 3130 EXAM 2|ACTUAL 130QS&AS WITH
RATIONALES|A+GRADE|GALEN COLLEGE
The nurse is caring for a 6-year-old patient in the emergency department who
just had a full left leg cast placed for a fracture. As the nurse is reviewing the
discharge instructions with the patient's mother, she states, "You don't have to go
over those—I'll read them at home." What should the nurse do?
a. Contact the physician immediately.
b. Consider the possibility of health literacy limitations and assess further.
c. Stop the teaching, because the mother obviously has taken care of casts before.
d. Explain to the mother that reading the instructions with her is required.
ANSWER :->>> b. Consider the possibility of health literacy
limitations and assess further.
Rationale :->>A patient's mother may have limited reading skills or health
literacy and should be further assessed. Contacting the physician in this situation
would not be appropriate because ensuring that the patient and family understand
discharge instructions is the responsibility of the nurse. Assuming that the
mother has taken care of casts in the past may be inaccurate. Stating that reading
the instructions with the nurse is a requirement does not ensure that the patient
or mother comprehends the instructions.
A 58-year-old man is admitted for a small-bowel obstruction late Saturday night.
The admitting orders include the need to place a nasogastric (NG) tube to low
intermittent suction. During the assessment, the nurse determines that the
patient does not speak English. Which action should the nurse take first before
placing the NG tube?
,a. Use two additional staff members when placing the tube so the patient can be
restrained if needed.
b. Request an interpreter per facility protocol.
c. Do not place the NG tube because the physician would not want to frighten the
patient.
d. Document the inability to place the NG tube due to lack of ability to
communicate.
ANSWER :->>> b. Request an interpreter per facility protocol.
Rationale :->>An interpreter employed by the hospital would be the best
choice so that someone in the room can communicate and provide comfort for the
patient. Taking additional staff into the room may increase the patient's anxiety,
thereby decreasing his ability to comprehend the instructions. Although the
physician would not want to frighten the patient, the physician ordered the
nasogastric (NG) tube for the benefit of the patient; therefore, it needs to be
placed. Documenting the inability to place the NG tube due to lack of means of
communication is not acceptable and does not ensure that the patient gets the
needed treatment.
Which nursing diagnoses are used in developing a patient teaching plan? (Select
all that apply.)
a. Moral Distress
ANSWER :->>> b. Lack of Knowledge
c. Difficulty Coping
d. Teaching about Disease
,e. Anxiety
b
Rationale :->>Lack of Knowledge and Literacy Problem are appropriate
nursing diagnoses for use in developing a patient teaching plan. Moral Distress is
a nursing diagnosis for those facing ethical decisions. Difficulty Coping is not a
nursing diagnosis used in developing a teaching plan, but if a patient is not coping
effectively, it may affect the ability to learn. A nursing diagnosis of Anxiety may
affect the patient's ability to learn but is not directly related to developing a
teaching plan. Teaching about Disease is not a nursing diagnosis. It is an
intervention performed by the nurse.
Which nursing diagnosis is appropriate if a patient expresses an interest in
learning?
a. Ready to Learn
b. Lack of Knowledge
c. Effective Information Processing
d. Health-Seeking Behaviors
ANSWER :->>> a. Ready to Learn
Rationale :->>A patient's expression of an interest in learning would indicate
correct use of the nursing diagnosis, Ready to Learn. Lack of Knowledge would
indicate the patient has a deficiency of knowledge on a particular subject.
Effective Information Processing is the patient's ability to acquire useful
information. Health-Seeking Behaviors is active seeking by a person of ways to
alter habits to enhance health.
, A 61-year-old man is undergoing an emergency cardiac catheterization. The
nurse gives his wife the registration paperwork to complete. Which observed
actions may indicate a health literacy issue? (Select all that apply.)
a. Putting on glasses before beginning the paperwork.
b. Asking someone in the waiting area to read the forms to her.
c. Waiting until her daughter arrives to begin the paperwork so
that her daughter can complete the forms.
d. Setting the clipboard aside and staring tearfully out the window.
e. Returning the forms only partially filled out, with missing or
inaccurate information.
ANSWER :->>> b, c, e
Rationale :->>Asking someone else to read the form, waiting for help with the
forms, and partially or inaccurately filling out forms are behaviors indicative of
potential health literacy issues. Needing glasses does not correlate directly with
health literacy. A tearful spouse requires additional assessment to see whether
health literacy is a problem. The wife may be overwhelmed and feel unable to
complete the forms, or she may need to collect her thoughts in the midst of a
stressful time.
Teaching a patient to use an incentive spirometer by demonstration, with a
return demonstration by the patient, is an example of teaching based on which
domain of learning?
a. Psychomotor
RATIONALES|A+GRADE|GALEN COLLEGE
The nurse is caring for a 6-year-old patient in the emergency department who
just had a full left leg cast placed for a fracture. As the nurse is reviewing the
discharge instructions with the patient's mother, she states, "You don't have to go
over those—I'll read them at home." What should the nurse do?
a. Contact the physician immediately.
b. Consider the possibility of health literacy limitations and assess further.
c. Stop the teaching, because the mother obviously has taken care of casts before.
d. Explain to the mother that reading the instructions with her is required.
ANSWER :->>> b. Consider the possibility of health literacy
limitations and assess further.
Rationale :->>A patient's mother may have limited reading skills or health
literacy and should be further assessed. Contacting the physician in this situation
would not be appropriate because ensuring that the patient and family understand
discharge instructions is the responsibility of the nurse. Assuming that the
mother has taken care of casts in the past may be inaccurate. Stating that reading
the instructions with the nurse is a requirement does not ensure that the patient
or mother comprehends the instructions.
A 58-year-old man is admitted for a small-bowel obstruction late Saturday night.
The admitting orders include the need to place a nasogastric (NG) tube to low
intermittent suction. During the assessment, the nurse determines that the
patient does not speak English. Which action should the nurse take first before
placing the NG tube?
,a. Use two additional staff members when placing the tube so the patient can be
restrained if needed.
b. Request an interpreter per facility protocol.
c. Do not place the NG tube because the physician would not want to frighten the
patient.
d. Document the inability to place the NG tube due to lack of ability to
communicate.
ANSWER :->>> b. Request an interpreter per facility protocol.
Rationale :->>An interpreter employed by the hospital would be the best
choice so that someone in the room can communicate and provide comfort for the
patient. Taking additional staff into the room may increase the patient's anxiety,
thereby decreasing his ability to comprehend the instructions. Although the
physician would not want to frighten the patient, the physician ordered the
nasogastric (NG) tube for the benefit of the patient; therefore, it needs to be
placed. Documenting the inability to place the NG tube due to lack of means of
communication is not acceptable and does not ensure that the patient gets the
needed treatment.
Which nursing diagnoses are used in developing a patient teaching plan? (Select
all that apply.)
a. Moral Distress
ANSWER :->>> b. Lack of Knowledge
c. Difficulty Coping
d. Teaching about Disease
,e. Anxiety
b
Rationale :->>Lack of Knowledge and Literacy Problem are appropriate
nursing diagnoses for use in developing a patient teaching plan. Moral Distress is
a nursing diagnosis for those facing ethical decisions. Difficulty Coping is not a
nursing diagnosis used in developing a teaching plan, but if a patient is not coping
effectively, it may affect the ability to learn. A nursing diagnosis of Anxiety may
affect the patient's ability to learn but is not directly related to developing a
teaching plan. Teaching about Disease is not a nursing diagnosis. It is an
intervention performed by the nurse.
Which nursing diagnosis is appropriate if a patient expresses an interest in
learning?
a. Ready to Learn
b. Lack of Knowledge
c. Effective Information Processing
d. Health-Seeking Behaviors
ANSWER :->>> a. Ready to Learn
Rationale :->>A patient's expression of an interest in learning would indicate
correct use of the nursing diagnosis, Ready to Learn. Lack of Knowledge would
indicate the patient has a deficiency of knowledge on a particular subject.
Effective Information Processing is the patient's ability to acquire useful
information. Health-Seeking Behaviors is active seeking by a person of ways to
alter habits to enhance health.
, A 61-year-old man is undergoing an emergency cardiac catheterization. The
nurse gives his wife the registration paperwork to complete. Which observed
actions may indicate a health literacy issue? (Select all that apply.)
a. Putting on glasses before beginning the paperwork.
b. Asking someone in the waiting area to read the forms to her.
c. Waiting until her daughter arrives to begin the paperwork so
that her daughter can complete the forms.
d. Setting the clipboard aside and staring tearfully out the window.
e. Returning the forms only partially filled out, with missing or
inaccurate information.
ANSWER :->>> b, c, e
Rationale :->>Asking someone else to read the form, waiting for help with the
forms, and partially or inaccurately filling out forms are behaviors indicative of
potential health literacy issues. Needing glasses does not correlate directly with
health literacy. A tearful spouse requires additional assessment to see whether
health literacy is a problem. The wife may be overwhelmed and feel unable to
complete the forms, or she may need to collect her thoughts in the midst of a
stressful time.
Teaching a patient to use an incentive spirometer by demonstration, with a
return demonstration by the patient, is an example of teaching based on which
domain of learning?
a. Psychomotor
