NURS 101L | Fundamentals of Nursing Skills Lab | Actual Exam 4 2026
|WCU
1. When preparing to administer an intramuscular (IM) injection using the Z-
track method, what is the primary purpose of this technique?
A. To reduce the risk of needle-stick injuries to the nurse
B. To ensure the medication remains in the muscle and prevents leakage into subcutaneous tissue
C. To increase the speed of medication absorption into the bloodstream
D. To decrease the amount of pain felt by the patient during the needle insertion
Answer: B
Rationale: The Z-track method creates a zigzag path that seals the medication in the
muscle tissue, preventing it from leaking back into the subcutaneous layer, which reduces
irritation and staining.
2. A nurse is preparing a sterile field for a dressing change. Which action would
contaminate the sterile field?
A. Opening the sterile drape away from the body first
B. Reaching over the sterile field to pick up a gauze pad
C. Keeping the sterile objects above the level of the waist
D. Dropping sterile items onto the center of the field from 6 inches above
Answer: B
Rationale: Reaching over a sterile field violates the principles of surgical asepsis because
microorganisms can drop from the nurse’s arm or clothing onto the field.
,3. A patient requires an indwelling urinary catheter. After the nurse cleanses the
labia minora and before inserting the catheter, the labia accidentally slip from
the nurse’s non-dominant hand and close. What should the nurse do next?
A. Continue with the insertion immediately before more bacteria enter
B. Wipe the meatus once with the remaining antiseptic swab and insert
C. Discard the current sterile kit and start the entire procedure over with new supplies
D. Reclean the area with the remaining sterile antiseptic swabs provided in the kit
Answer: D
Rationale: If the labia close after cleaning, the area is considered contaminated. The nurse
must re-cleanse the area with sterile supplies. If the kit lacks more swabs, a new kit is
needed, but typically the remaining swabs in the kit are used first.
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. 10 seconds
C. 20 seconds
D. 30 seconds
Answer: B
Rationale: Suctioning should be limited to 10-15 seconds to prevent hypoxia and mucosal
damage. Longer durations significantly increase the risk of oxygen desaturation.
5. The nurse is assessing a patient’s radial pulse and notes it is irregular. What is
the most appropriate nursing action?
A. Document the pulse as ‘irregular’ and move to the next vital sign
B. Wait 5 minutes and re-assess the radial pulse for 30 seconds
C. Assess the apical pulse for a full 60 seconds
D. Apply a pulse oximeter to verify the heart rate
Answer: C
, Rationale: When a peripheral pulse is irregular, the apical pulse should be counted for a
full minute to ensure accuracy and to detect any pulse deficits.
6. Which of the following is a key safety intervention when transferring a
patient from a bed to a wheelchair?
A. Instructing the patient to place their arms around the nurse’s neck
B. Locking the wheels of both the bed and the wheelchair
C. Keeping the bed at its highest position during the transfer
D. Using a narrow base of support with feet together
Answer: B
Rationale: Locking the wheels prevents the equipment from moving, which is critical for
preventing falls during transfers.
7. The nurse is caring for a patient with a Stage 3 pressure injury. Which
characteristic is consistent with this stage?
A. Non-blanchable erythema of intact skin
B. Full-thickness skin loss involving damage to subcutaneous tissue
C. Partial-thickness loss of dermis appearing as a shallow open ulcer
D. Full-thickness tissue loss with exposed bone or tendon
Answer: B
Rationale: Stage 3 involves full-thickness skin loss where subcutaneous fat may be visible,
but bone, tendon, or muscle are not exposed. Stage 4 involves exposed bone/muscle.
8. Before initiating a tube feeding through a nasogastric (NG) tube, what is the
gold standard for verifying correct tube placement?
A. Aspirating gastric contents and checking the pH
B. Obtaining a chest or abdominal X-ray
C. Auscultating a ‘whoosh’ sound over the epigastrium while injecting air
D. Checking the measurement markings on the tube at the naris
Answer: B
|WCU
1. When preparing to administer an intramuscular (IM) injection using the Z-
track method, what is the primary purpose of this technique?
A. To reduce the risk of needle-stick injuries to the nurse
B. To ensure the medication remains in the muscle and prevents leakage into subcutaneous tissue
C. To increase the speed of medication absorption into the bloodstream
D. To decrease the amount of pain felt by the patient during the needle insertion
Answer: B
Rationale: The Z-track method creates a zigzag path that seals the medication in the
muscle tissue, preventing it from leaking back into the subcutaneous layer, which reduces
irritation and staining.
2. A nurse is preparing a sterile field for a dressing change. Which action would
contaminate the sterile field?
A. Opening the sterile drape away from the body first
B. Reaching over the sterile field to pick up a gauze pad
C. Keeping the sterile objects above the level of the waist
D. Dropping sterile items onto the center of the field from 6 inches above
Answer: B
Rationale: Reaching over a sterile field violates the principles of surgical asepsis because
microorganisms can drop from the nurse’s arm or clothing onto the field.
,3. A patient requires an indwelling urinary catheter. After the nurse cleanses the
labia minora and before inserting the catheter, the labia accidentally slip from
the nurse’s non-dominant hand and close. What should the nurse do next?
A. Continue with the insertion immediately before more bacteria enter
B. Wipe the meatus once with the remaining antiseptic swab and insert
C. Discard the current sterile kit and start the entire procedure over with new supplies
D. Reclean the area with the remaining sterile antiseptic swabs provided in the kit
Answer: D
Rationale: If the labia close after cleaning, the area is considered contaminated. The nurse
must re-cleanse the area with sterile supplies. If the kit lacks more swabs, a new kit is
needed, but typically the remaining swabs in the kit are used first.
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. 10 seconds
C. 20 seconds
D. 30 seconds
Answer: B
Rationale: Suctioning should be limited to 10-15 seconds to prevent hypoxia and mucosal
damage. Longer durations significantly increase the risk of oxygen desaturation.
5. The nurse is assessing a patient’s radial pulse and notes it is irregular. What is
the most appropriate nursing action?
A. Document the pulse as ‘irregular’ and move to the next vital sign
B. Wait 5 minutes and re-assess the radial pulse for 30 seconds
C. Assess the apical pulse for a full 60 seconds
D. Apply a pulse oximeter to verify the heart rate
Answer: C
, Rationale: When a peripheral pulse is irregular, the apical pulse should be counted for a
full minute to ensure accuracy and to detect any pulse deficits.
6. Which of the following is a key safety intervention when transferring a
patient from a bed to a wheelchair?
A. Instructing the patient to place their arms around the nurse’s neck
B. Locking the wheels of both the bed and the wheelchair
C. Keeping the bed at its highest position during the transfer
D. Using a narrow base of support with feet together
Answer: B
Rationale: Locking the wheels prevents the equipment from moving, which is critical for
preventing falls during transfers.
7. The nurse is caring for a patient with a Stage 3 pressure injury. Which
characteristic is consistent with this stage?
A. Non-blanchable erythema of intact skin
B. Full-thickness skin loss involving damage to subcutaneous tissue
C. Partial-thickness loss of dermis appearing as a shallow open ulcer
D. Full-thickness tissue loss with exposed bone or tendon
Answer: B
Rationale: Stage 3 involves full-thickness skin loss where subcutaneous fat may be visible,
but bone, tendon, or muscle are not exposed. Stage 4 involves exposed bone/muscle.
8. Before initiating a tube feeding through a nasogastric (NG) tube, what is the
gold standard for verifying correct tube placement?
A. Aspirating gastric contents and checking the pH
B. Obtaining a chest or abdominal X-ray
C. Auscultating a ‘whoosh’ sound over the epigastrium while injecting air
D. Checking the measurement markings on the tube at the naris
Answer: B
