NURS 101L | Fundamentals of Nursing Skills Lab | Actual Exam 3 2026
|WCU
1. When preparing to administer an intramuscular (IM) injection to a 6-month-
old infant, which site is the most appropriate choice?
A. Dorsogluteal
B. Deltoid
C. Vastus lateralis
D. Ventrogluteal
Answer: C
Rationale: The vastus lateralis is the preferred site for IM injections in infants because it is
the most developed muscle at that age and lacks major nerves or blood vessels.
2. Which action by the nurse maintains surgical asepsis when preparing a sterile
field?
A. Reaching across the sterile field to pick up an instrument.
B. Opening the outermost flap of a sterile kit away from the body.
C. Keeping the sterile field below waist level.
D. Placing a sterile gauze pad within the 1-inch border of the sterile field.
Answer: B
Rationale: Opening the flap away from the body prevents the nurse from reaching over the
sterile field. Reaching over, placing items on the 1-inch border, or keeping the field below
the waist violates sterile technique.
,3. A patient requires an indwelling urinary catheter. What is the primary reason
the nurse should maintain the drainage bag below the level of the bladder?
A. To prevent the bag from being seen by visitors.
B. To facilitate gravity drainage and prevent backflow of urine.
C. To reduce the risk of the catheter being pulled out.
D. To allow for more accurate measurement of output.
Answer: B
Rationale: Keeping the bag below the bladder level prevents urinary reflux, which
significantly increases the risk of catheter-associated urinary tract infections (CAUTI).
4. A nurse is suctioning a patient’s tracheostomy. What is the maximum
duration for each suction pass?
A. 10 to 15 seconds
B. 5 seconds
C. 20 to 30 seconds
D. As long as secretions are visible
Answer: A
Rationale: Suctioning should be limited to 10-15 seconds to prevent hypoxia and vagal
stimulation, which can lead to bradycardia.
5. Which finding is considered a priority when assessing a patient with a newly
applied plaster cast on the lower leg?
A. Capillary refill in the toes is 5 seconds.
B. The patient reports mild itching under the cast.
C. The cast is still damp to the touch.
D. The patient’s temperature is 99.0 F (37.2 C).
Answer: A
, Rationale: A capillary refill of 5 seconds indicates impaired neurovascular status
(compartment syndrome risk), which is a medical emergency. Dampness is expected, and
mild itching is common.
6. When transferring a patient from a bed to a wheelchair, where should the
nurse position the wheelchair?
A. On the patient’s weaker side at a 45-degree angle.
B. On the patient’s stronger side at a 45-degree angle.
C. At the foot of the bed facing away from the patient.
D. Directly in front of the patient while they stand.
Answer: B
Rationale: Placing the wheelchair on the stronger side allows the patient to use their
stronger leg to pivot and support their weight safely.
7. A nurse is preparing to administer 0.5 mL of a medication subcutaneously to
an obese patient. Which needle angle is most appropriate?
A. 90 degrees
B. 45 degrees
C. 15 degrees
D. 180 degrees
Answer: A
Rationale: For obese patients, a 90-degree angle is used for subcutaneous injections to
ensure the medication reaches the adipose tissue. For thin patients, a 45-degree angle is
preferred.
|WCU
1. When preparing to administer an intramuscular (IM) injection to a 6-month-
old infant, which site is the most appropriate choice?
A. Dorsogluteal
B. Deltoid
C. Vastus lateralis
D. Ventrogluteal
Answer: C
Rationale: The vastus lateralis is the preferred site for IM injections in infants because it is
the most developed muscle at that age and lacks major nerves or blood vessels.
2. Which action by the nurse maintains surgical asepsis when preparing a sterile
field?
A. Reaching across the sterile field to pick up an instrument.
B. Opening the outermost flap of a sterile kit away from the body.
C. Keeping the sterile field below waist level.
D. Placing a sterile gauze pad within the 1-inch border of the sterile field.
Answer: B
Rationale: Opening the flap away from the body prevents the nurse from reaching over the
sterile field. Reaching over, placing items on the 1-inch border, or keeping the field below
the waist violates sterile technique.
,3. A patient requires an indwelling urinary catheter. What is the primary reason
the nurse should maintain the drainage bag below the level of the bladder?
A. To prevent the bag from being seen by visitors.
B. To facilitate gravity drainage and prevent backflow of urine.
C. To reduce the risk of the catheter being pulled out.
D. To allow for more accurate measurement of output.
Answer: B
Rationale: Keeping the bag below the bladder level prevents urinary reflux, which
significantly increases the risk of catheter-associated urinary tract infections (CAUTI).
4. A nurse is suctioning a patient’s tracheostomy. What is the maximum
duration for each suction pass?
A. 10 to 15 seconds
B. 5 seconds
C. 20 to 30 seconds
D. As long as secretions are visible
Answer: A
Rationale: Suctioning should be limited to 10-15 seconds to prevent hypoxia and vagal
stimulation, which can lead to bradycardia.
5. Which finding is considered a priority when assessing a patient with a newly
applied plaster cast on the lower leg?
A. Capillary refill in the toes is 5 seconds.
B. The patient reports mild itching under the cast.
C. The cast is still damp to the touch.
D. The patient’s temperature is 99.0 F (37.2 C).
Answer: A
, Rationale: A capillary refill of 5 seconds indicates impaired neurovascular status
(compartment syndrome risk), which is a medical emergency. Dampness is expected, and
mild itching is common.
6. When transferring a patient from a bed to a wheelchair, where should the
nurse position the wheelchair?
A. On the patient’s weaker side at a 45-degree angle.
B. On the patient’s stronger side at a 45-degree angle.
C. At the foot of the bed facing away from the patient.
D. Directly in front of the patient while they stand.
Answer: B
Rationale: Placing the wheelchair on the stronger side allows the patient to use their
stronger leg to pivot and support their weight safely.
7. A nurse is preparing to administer 0.5 mL of a medication subcutaneously to
an obese patient. Which needle angle is most appropriate?
A. 90 degrees
B. 45 degrees
C. 15 degrees
D. 180 degrees
Answer: A
Rationale: For obese patients, a 90-degree angle is used for subcutaneous injections to
ensure the medication reaches the adipose tissue. For thin patients, a 45-degree angle is
preferred.
