NURS 101L Fundamentals of Nursing Skills Lab Final Exam 2026 |WCU
1. When preparing to administer an intramuscular injection using the Z-track
method, what is the primary rationale for this specific technique?
A. To reduce the risk of hitting a major blood vessel
B. To ensure the medication is absorbed more rapidly into the bloodstream
C. To decrease the pain associated with the needle penetration
D. To prevent the medication from leaking into the subcutaneous tissue and causing irritation
Answer: D
Rationale: The Z-track method is used to seal medication in the muscle and prevent it from
tracking back into the subcutaneous tissue, which reduces skin irritation and staining.
2. A nurse is preparing a sterile field for a dressing change. Which action would
cause the nurse to discard the field and start over?
A. The nurse opens the first flap of the sterile kit away from their body
B. The nurse drops a sterile gauze pad onto the field from 6 inches above
C. The nurse maintains a 1-inch border around the edge of the sterile field as contaminated
D. The nurse reaches across the sterile field to pick up a pair of forceps
Answer: D
Rationale: Reaching across a sterile field contaminates it because micro-organisms from
the nurse’s sleeve or arm can fall onto the field.
,3. Which assessment finding is the most reliable indicator that an enteral
feeding tube is correctly positioned in the stomach?
A. Auscultation of an air bolus over the epigastric area
B. Observation of the patient for coughing or cyanosis
C. Aspirate pH of 6.0 or higher
D. Radiographic (X-ray) confirmation of the tube tip
Answer: D
Rationale: While pH testing is a common bedside check, radiographic confirmation is the
gold standard for verifying initial tube placement.
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 vagal
stimulation.
5. A patient is receiving an intravenous infusion. The nurse notes the site is cool
to the touch, swollen, and the patient complains of a burning sensation. What is
the priority nursing action?
A. Apply a warm compress to the site immediately
B. Slow the infusion rate and monitor for 30 minutes
C. Flush the line with normal saline to check patency
D. Stop the infusion and remove the IV catheter
Answer: D
, Rationale: These are signs of infiltration. The priority is to stop the infusion and remove
the catheter to prevent further tissue damage.
6. In which order should a nurse remove Personal Protective Equipment (PPE)
after caring for a patient in transmission-based precautions?
A. Gloves, goggles, gown, mask
B. Mask, gown, goggles, gloves
C. Gown, mask, gloves, goggles
D. Goggles, mask, gown, gloves
Answer: A
Rationale: The standard sequence for doffing is gloves (most contaminated), followed by
eye protection, gown, and finally the mask/respirator.
7. When mixing regular insulin and NPH insulin in the same syringe, what is the
correct sequence?
A. Inject air into NPH, inject air into Regular, draw Regular, then draw NPH
B. Draw NPH first, then draw Regular
C. Draw each separately and mix them in a third container
D. Inject air into Regular, inject air into NPH, draw NPH, then draw Regular
Answer: A
Rationale: The correct sequence is air into NPH (cloudy), air into Regular (clear), draw
Regular, then draw NPH. This prevents contaminating the clear insulin with the cloudy
protein.
1. When preparing to administer an intramuscular injection using the Z-track
method, what is the primary rationale for this specific technique?
A. To reduce the risk of hitting a major blood vessel
B. To ensure the medication is absorbed more rapidly into the bloodstream
C. To decrease the pain associated with the needle penetration
D. To prevent the medication from leaking into the subcutaneous tissue and causing irritation
Answer: D
Rationale: The Z-track method is used to seal medication in the muscle and prevent it from
tracking back into the subcutaneous tissue, which reduces skin irritation and staining.
2. A nurse is preparing a sterile field for a dressing change. Which action would
cause the nurse to discard the field and start over?
A. The nurse opens the first flap of the sterile kit away from their body
B. The nurse drops a sterile gauze pad onto the field from 6 inches above
C. The nurse maintains a 1-inch border around the edge of the sterile field as contaminated
D. The nurse reaches across the sterile field to pick up a pair of forceps
Answer: D
Rationale: Reaching across a sterile field contaminates it because micro-organisms from
the nurse’s sleeve or arm can fall onto the field.
,3. Which assessment finding is the most reliable indicator that an enteral
feeding tube is correctly positioned in the stomach?
A. Auscultation of an air bolus over the epigastric area
B. Observation of the patient for coughing or cyanosis
C. Aspirate pH of 6.0 or higher
D. Radiographic (X-ray) confirmation of the tube tip
Answer: D
Rationale: While pH testing is a common bedside check, radiographic confirmation is the
gold standard for verifying initial tube placement.
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 vagal
stimulation.
5. A patient is receiving an intravenous infusion. The nurse notes the site is cool
to the touch, swollen, and the patient complains of a burning sensation. What is
the priority nursing action?
A. Apply a warm compress to the site immediately
B. Slow the infusion rate and monitor for 30 minutes
C. Flush the line with normal saline to check patency
D. Stop the infusion and remove the IV catheter
Answer: D
, Rationale: These are signs of infiltration. The priority is to stop the infusion and remove
the catheter to prevent further tissue damage.
6. In which order should a nurse remove Personal Protective Equipment (PPE)
after caring for a patient in transmission-based precautions?
A. Gloves, goggles, gown, mask
B. Mask, gown, goggles, gloves
C. Gown, mask, gloves, goggles
D. Goggles, mask, gown, gloves
Answer: A
Rationale: The standard sequence for doffing is gloves (most contaminated), followed by
eye protection, gown, and finally the mask/respirator.
7. When mixing regular insulin and NPH insulin in the same syringe, what is the
correct sequence?
A. Inject air into NPH, inject air into Regular, draw Regular, then draw NPH
B. Draw NPH first, then draw Regular
C. Draw each separately and mix them in a third container
D. Inject air into Regular, inject air into NPH, draw NPH, then draw Regular
Answer: A
Rationale: The correct sequence is air into NPH (cloudy), air into Regular (clear), draw
Regular, then draw NPH. This prevents contaminating the clear insulin with the cloudy
protein.
