NURS 101L | Fundamentals of Nursing Skills Lab | Exam 3 Study Guide
2026 |WCU
1. When preparing to perform a sterile wound dressing change, the nurse
inadvertently touches the outer 1-inch border of the sterile field with a sterile
glove. Which action should the nurse take next?
A. Avoid using the area near the border and proceed with the dressing change.
B. Replace the sterile gloves and continue the procedure.
C. Consider the field contaminated and prepare a new sterile field with new supplies.
D. Continue with the procedure as the border is considered part of the sterile field.
Answer: A
Rationale: The 1-inch border of a sterile field is considered contaminated. Touching it with
a sterile glove does not contaminate the entire field unless the nurse then touches the
sterile items inside the field. The nurse should simply avoid that specific border area or
replace the glove if they intend to touch the sterile items again.
2. A nurse is administering a sub-q injection of Heparin. Which of the following
techniques is most appropriate to prevent hematoma formation?
A. Aspirate for blood return before injecting the medication.
B. Inject the medication over 30 seconds and avoid rubbing the site.
C. Apply firm pressure to the site for 30 to 60 seconds after injection.
D. Massage the site vigorously after the needle is withdrawn.
Answer: B
Rationale: When administering Heparin, the nurse should not aspirate or massage the site
as these actions increase the risk of bruising and hematoma. Injecting slowly and applying
gentle pressure is recommended.
,3. A patient has a Stage 3 pressure injury on the sacrum. Which description best
matches this stage?
A. Full-thickness skin loss involving damage to subcutaneous tissue that may extend to the fascia.
B. Non-blanchable erythema of intact skin.
C. Partial-thickness loss of dermis presenting as a shallow open ulcer.
D. Full-thickness tissue loss with exposed bone, tendon, or muscle.
Answer: A
Rationale: Stage 3 involves full-thickness tissue loss where subcutaneous fat may be
visible, but bone, tendon, or muscle are not exposed. Stage 4 involves exposed
bone/muscle.
4. When performing tracheostomy suctioning, what is the maximum amount of
time the nurse should apply suction during a single pass?
A. 5 seconds
B. 30 seconds
C. 20 to 25 seconds
D. 10 to 15 seconds
Answer: D
Rationale: Suctioning should be limited to 10-15 seconds to prevent hypoxia and mucosal
trauma. It is also important to hyper-oxygenate the patient before the procedure.
5. The nurse is preparing to mix NPH and Regular insulin in the same syringe.
Which is the correct sequence of drawing up the insulin?
A. Draw up the NPH first, then the Regular insulin.
B. The order does not matter as long as the total dose is correct.
C. Draw them up in separate syringes and then combine them.
D. Draw up the Regular insulin first, then the NPH.
Answer: D
, Rationale: The correct sequence is ‘Clear to Cloudy’ (Regular to NPH). This prevents
contaminating the short-acting (clear) insulin vial with the long-acting (cloudy) insulin.
6. Which assessment finding would most likely indicate that a patient’s
peripheral IV site has developed phlebitis?
A. The site is cool to the touch and swollen.
B. The skin at the site is blanched and leaking fluid.
C. There is a palpable venous cord and redness along the vein path.
D. The dressing is damp and the IV pump is alarming ‘occlusion’.
Answer: C
Rationale: Phlebitis is characterized by warmth, redness, pain, and sometimes a palpable
cord along the vein. Coolness and swelling are more indicative of infiltration.
7. A nurse is inserting a foley catheter into a female patient. After seeing urine
flash in the tubing, what is the next appropriate step?
A. Advance the catheter another 1 to 2 inches (2.5 to 5 cm).
B. Immediately inflate the balloon with the prefilled syringe.
C. Pull back slightly to ensure the catheter is snug against the bladder neck.
D. Remove the guide wire if one was used.
Answer: A
Rationale: Once urine is visualized, the nurse should advance the catheter another 1-2
inches to ensure the balloon is fully inside the bladder before inflation to avoid urethral
trauma.
2026 |WCU
1. When preparing to perform a sterile wound dressing change, the nurse
inadvertently touches the outer 1-inch border of the sterile field with a sterile
glove. Which action should the nurse take next?
A. Avoid using the area near the border and proceed with the dressing change.
B. Replace the sterile gloves and continue the procedure.
C. Consider the field contaminated and prepare a new sterile field with new supplies.
D. Continue with the procedure as the border is considered part of the sterile field.
Answer: A
Rationale: The 1-inch border of a sterile field is considered contaminated. Touching it with
a sterile glove does not contaminate the entire field unless the nurse then touches the
sterile items inside the field. The nurse should simply avoid that specific border area or
replace the glove if they intend to touch the sterile items again.
2. A nurse is administering a sub-q injection of Heparin. Which of the following
techniques is most appropriate to prevent hematoma formation?
A. Aspirate for blood return before injecting the medication.
B. Inject the medication over 30 seconds and avoid rubbing the site.
C. Apply firm pressure to the site for 30 to 60 seconds after injection.
D. Massage the site vigorously after the needle is withdrawn.
Answer: B
Rationale: When administering Heparin, the nurse should not aspirate or massage the site
as these actions increase the risk of bruising and hematoma. Injecting slowly and applying
gentle pressure is recommended.
,3. A patient has a Stage 3 pressure injury on the sacrum. Which description best
matches this stage?
A. Full-thickness skin loss involving damage to subcutaneous tissue that may extend to the fascia.
B. Non-blanchable erythema of intact skin.
C. Partial-thickness loss of dermis presenting as a shallow open ulcer.
D. Full-thickness tissue loss with exposed bone, tendon, or muscle.
Answer: A
Rationale: Stage 3 involves full-thickness tissue loss where subcutaneous fat may be
visible, but bone, tendon, or muscle are not exposed. Stage 4 involves exposed
bone/muscle.
4. When performing tracheostomy suctioning, what is the maximum amount of
time the nurse should apply suction during a single pass?
A. 5 seconds
B. 30 seconds
C. 20 to 25 seconds
D. 10 to 15 seconds
Answer: D
Rationale: Suctioning should be limited to 10-15 seconds to prevent hypoxia and mucosal
trauma. It is also important to hyper-oxygenate the patient before the procedure.
5. The nurse is preparing to mix NPH and Regular insulin in the same syringe.
Which is the correct sequence of drawing up the insulin?
A. Draw up the NPH first, then the Regular insulin.
B. The order does not matter as long as the total dose is correct.
C. Draw them up in separate syringes and then combine them.
D. Draw up the Regular insulin first, then the NPH.
Answer: D
, Rationale: The correct sequence is ‘Clear to Cloudy’ (Regular to NPH). This prevents
contaminating the short-acting (clear) insulin vial with the long-acting (cloudy) insulin.
6. Which assessment finding would most likely indicate that a patient’s
peripheral IV site has developed phlebitis?
A. The site is cool to the touch and swollen.
B. The skin at the site is blanched and leaking fluid.
C. There is a palpable venous cord and redness along the vein path.
D. The dressing is damp and the IV pump is alarming ‘occlusion’.
Answer: C
Rationale: Phlebitis is characterized by warmth, redness, pain, and sometimes a palpable
cord along the vein. Coolness and swelling are more indicative of infiltration.
7. A nurse is inserting a foley catheter into a female patient. After seeing urine
flash in the tubing, what is the next appropriate step?
A. Advance the catheter another 1 to 2 inches (2.5 to 5 cm).
B. Immediately inflate the balloon with the prefilled syringe.
C. Pull back slightly to ensure the catheter is snug against the bladder neck.
D. Remove the guide wire if one was used.
Answer: A
Rationale: Once urine is visualized, the nurse should advance the catheter another 1-2
inches to ensure the balloon is fully inside the bladder before inflation to avoid urethral
trauma.
