NURS 121L-B Introduction to Medical-Surgical Nursing Practicum -
Module Exam 2 2026 |WCU
1. A nurse is caring for a patient with Clostridium difficile (C. diff). Which
infection control precaution should the nurse implement?
A. Standard precautions only
B. Contact precautions
C. Droplet precautions
D. Airborne precautions
Answer: B
Rationale: C. diff is transmitted via direct contact with contaminated surfaces or stool;
therefore, contact precautions (gown and gloves) and handwashing with soap and water
are required.
2. When performing an abdominal assessment, in which order should the nurse
perform the physical examination techniques?
A. Inspection, Palpation, Percussion, Auscultation
B. Auscultation, Inspection, Palpation, Percussion
C. Palpation, Percussion, Auscultation, Inspection
D. Inspection, Auscultation, Percussion, Palpation
Answer: D
Rationale: For the abdomen, auscultation is performed before palpation and percussion to
avoid altering bowel sounds.
,3. A patient has a Braden Scale score of 12. How should the nurse interpret this
finding?
A. Low risk for pressure injury
B. Moderate risk for pressure injury
C. High risk for pressure injury
D. Very high risk for pressure injury
Answer: C
Rationale: A Braden Scale score of 12 indicates a high risk for pressure injury; scores
typically range from 6 to 23, where lower scores indicate higher risk.
4. The nurse is preparing to administer an intramuscular injection to an obese
patient. Which needle length is most appropriate?
A. 5/8 inch
B. 1 inch
C. 0.5 inch
D. 1.5 to 2 inches
Answer: D
Rationale: Obese patients require longer needles (1.5 to 2 inches) to ensure the
medication reaches the muscle tissue rather than staying in the subcutaneous layer.
5. A patient’s blood pressure is 150/94 mmHg. Which classification of
hypertension does this represent according to current guidelines?
A. Stage 2 Hypertension
B. Stage 1 Hypertension
C. Elevated
D. Hypertensive Crisis
Answer: A
Rationale: Stage 2 Hypertension is defined as a systolic BP of 140 mmHg or higher or a
diastolic BP of 90 mmHg or higher.
, 6. Which action is a priority for the nurse when a patient experiences a tonic-
clonic seizure?
A. Insert a padded tongue blade into the mouth
B. Turn the patient to a side-lying position
C. Restrain the patient’s limbs to prevent injury
D. Administer oral fluids immediately
Answer: B
Rationale: Turning the patient to a side-lying position helps maintain a patent airway and
prevents aspiration during or after a seizure.
7. A nurse finds a patient on the floor. After assessing the patient’s safety and
vital signs, what should be the nurse’s next action?
A. Call the family to report the fall
B. Complete an incident report and place it in the medical record
C. Document the incident report number in the nursing notes
D. Notify the primary healthcare provider
Answer: D
Rationale: The healthcare provider must be notified of a change in status or an injury.
Incident reports are internal documents and should never be placed in or referenced in the
medical record.
8. Which vital sign change is a late sign of hypoxia?
A. Cyanosis
B. Restlessness
C. Tachycardia
D. Tachypnea
Answer: A
Rationale: Cyanosis is a late sign of hypoxia, whereas restlessness and tachycardia are
early signs.
Module Exam 2 2026 |WCU
1. A nurse is caring for a patient with Clostridium difficile (C. diff). Which
infection control precaution should the nurse implement?
A. Standard precautions only
B. Contact precautions
C. Droplet precautions
D. Airborne precautions
Answer: B
Rationale: C. diff is transmitted via direct contact with contaminated surfaces or stool;
therefore, contact precautions (gown and gloves) and handwashing with soap and water
are required.
2. When performing an abdominal assessment, in which order should the nurse
perform the physical examination techniques?
A. Inspection, Palpation, Percussion, Auscultation
B. Auscultation, Inspection, Palpation, Percussion
C. Palpation, Percussion, Auscultation, Inspection
D. Inspection, Auscultation, Percussion, Palpation
Answer: D
Rationale: For the abdomen, auscultation is performed before palpation and percussion to
avoid altering bowel sounds.
,3. A patient has a Braden Scale score of 12. How should the nurse interpret this
finding?
A. Low risk for pressure injury
B. Moderate risk for pressure injury
C. High risk for pressure injury
D. Very high risk for pressure injury
Answer: C
Rationale: A Braden Scale score of 12 indicates a high risk for pressure injury; scores
typically range from 6 to 23, where lower scores indicate higher risk.
4. The nurse is preparing to administer an intramuscular injection to an obese
patient. Which needle length is most appropriate?
A. 5/8 inch
B. 1 inch
C. 0.5 inch
D. 1.5 to 2 inches
Answer: D
Rationale: Obese patients require longer needles (1.5 to 2 inches) to ensure the
medication reaches the muscle tissue rather than staying in the subcutaneous layer.
5. A patient’s blood pressure is 150/94 mmHg. Which classification of
hypertension does this represent according to current guidelines?
A. Stage 2 Hypertension
B. Stage 1 Hypertension
C. Elevated
D. Hypertensive Crisis
Answer: A
Rationale: Stage 2 Hypertension is defined as a systolic BP of 140 mmHg or higher or a
diastolic BP of 90 mmHg or higher.
, 6. Which action is a priority for the nurse when a patient experiences a tonic-
clonic seizure?
A. Insert a padded tongue blade into the mouth
B. Turn the patient to a side-lying position
C. Restrain the patient’s limbs to prevent injury
D. Administer oral fluids immediately
Answer: B
Rationale: Turning the patient to a side-lying position helps maintain a patent airway and
prevents aspiration during or after a seizure.
7. A nurse finds a patient on the floor. After assessing the patient’s safety and
vital signs, what should be the nurse’s next action?
A. Call the family to report the fall
B. Complete an incident report and place it in the medical record
C. Document the incident report number in the nursing notes
D. Notify the primary healthcare provider
Answer: D
Rationale: The healthcare provider must be notified of a change in status or an injury.
Incident reports are internal documents and should never be placed in or referenced in the
medical record.
8. Which vital sign change is a late sign of hypoxia?
A. Cyanosis
B. Restlessness
C. Tachycardia
D. Tachypnea
Answer: A
Rationale: Cyanosis is a late sign of hypoxia, whereas restlessness and tachycardia are
early signs.
