NURS 101L Fundamentals of Nursing Skills Lab - Module Exam 3
(Week 9) 2026 |WCU
1. A nurse is preparing to administer an intramuscular injection to an adult
client. Which site is the preferred choice to minimize the risk of nerve or
vascular injury?
A. Dorsogluteal
B. Vastus lateralis
C. Ventrogluteal
D. Deltoid
Answer: C
Rationale: The ventrogluteal site is the preferred site for IM injections in adults because it
is away from major nerves and blood vessels and can accommodate larger volumes of
medication.
2. While performing tracheostomy care, the nurse notes that the tracheostomy
ties are soiled. Which action should the nurse take to ensure patient safety
while changing the ties?
A. Ask an assistant to hold the tracheostomy tube in place during the change.
B. Remove the old ties before applying the new ones.
C. Cut the old ties first to provide better access to the neck.
D. Tie the new ties with a tight double knot to prevent slipping.
Answer: A
Rationale: To prevent accidental dislodgement of the tracheostomy tube, a second person
should hold the tube in place, or the new ties should be secured before removing the old
ones.
,3. The nurse is monitoring an intravenous (IV) site and observes redness,
warmth, and a palpable cord along the vein. These findings are consistent with
which complication?
A. Infiltration
B. Extravasation
C. Hematoma
D. Phlebitis
Answer: D
Rationale: Phlebitis is characterized by pain, increased skin temperature, and redness
along the path of the vein, often with a palpable cord.
4. When administering a cleansing enema, the nurse should position the client
in which of the following positions?
A. Left lateral Sims’ position
B. Dorsal recumbent position
C. Right lateral Sims’ position
D. Prone position
Answer: A
Rationale: The left lateral Sims’ position allows the enema solution to flow by gravity into
the sigmoid colon and rectum, following the natural curve of the colon.
5. A nurse is assessing a pressure injury and finds a shallow, open ulcer with a
red-pink wound bed without slough. How should this wound be staged?
A. Stage 2
B. Stage 1
C. Stage 3
D. Stage 4
Answer: A
, Rationale: Stage 2 pressure injuries involve partial-thickness loss of dermis presenting as
a shallow open ulcer with a red-pink wound bed, without slough or bruising.
6. Which of the following is the most reliable method to verify the placement of
a nasogastric (NG) tube immediately after insertion?
A. Auscultating air injected into the stomach
B. Measuring the pH of aspirated gastric contents
C. Radiographic (X-ray) examination
D. Observing for respiratory distress
Answer: C
Rationale: Radiographic examination is the gold standard and most reliable method for
confirming NG tube placement before the initial use for feeding or medications.
7. When performing a sterile dressing change, the nurse drops a sterile gauze
pad onto the edge of the sterile field. What is the appropriate action?
A. Consider the gauze contaminated and discard it.
B. Pick it up with sterile forceps and move it to the center.
C. Use it anyway since it only touched the edge.
D. Spray it with sterile saline and use it.
Answer: A
Rationale: The 1-inch border of a sterile field is considered contaminated. Any item that
touches this border must be discarded to maintain asepsis.
8. The nurse is preparing to mix Regular insulin and NPH insulin in the same
syringe. Which step should the nurse perform first?
A. Withdraw the Regular insulin
B. Inject air into the Regular vial
C. Withdraw the NPH insulin
D. Inject air into the NPH vial
Answer: D
(Week 9) 2026 |WCU
1. A nurse is preparing to administer an intramuscular injection to an adult
client. Which site is the preferred choice to minimize the risk of nerve or
vascular injury?
A. Dorsogluteal
B. Vastus lateralis
C. Ventrogluteal
D. Deltoid
Answer: C
Rationale: The ventrogluteal site is the preferred site for IM injections in adults because it
is away from major nerves and blood vessels and can accommodate larger volumes of
medication.
2. While performing tracheostomy care, the nurse notes that the tracheostomy
ties are soiled. Which action should the nurse take to ensure patient safety
while changing the ties?
A. Ask an assistant to hold the tracheostomy tube in place during the change.
B. Remove the old ties before applying the new ones.
C. Cut the old ties first to provide better access to the neck.
D. Tie the new ties with a tight double knot to prevent slipping.
Answer: A
Rationale: To prevent accidental dislodgement of the tracheostomy tube, a second person
should hold the tube in place, or the new ties should be secured before removing the old
ones.
,3. The nurse is monitoring an intravenous (IV) site and observes redness,
warmth, and a palpable cord along the vein. These findings are consistent with
which complication?
A. Infiltration
B. Extravasation
C. Hematoma
D. Phlebitis
Answer: D
Rationale: Phlebitis is characterized by pain, increased skin temperature, and redness
along the path of the vein, often with a palpable cord.
4. When administering a cleansing enema, the nurse should position the client
in which of the following positions?
A. Left lateral Sims’ position
B. Dorsal recumbent position
C. Right lateral Sims’ position
D. Prone position
Answer: A
Rationale: The left lateral Sims’ position allows the enema solution to flow by gravity into
the sigmoid colon and rectum, following the natural curve of the colon.
5. A nurse is assessing a pressure injury and finds a shallow, open ulcer with a
red-pink wound bed without slough. How should this wound be staged?
A. Stage 2
B. Stage 1
C. Stage 3
D. Stage 4
Answer: A
, Rationale: Stage 2 pressure injuries involve partial-thickness loss of dermis presenting as
a shallow open ulcer with a red-pink wound bed, without slough or bruising.
6. Which of the following is the most reliable method to verify the placement of
a nasogastric (NG) tube immediately after insertion?
A. Auscultating air injected into the stomach
B. Measuring the pH of aspirated gastric contents
C. Radiographic (X-ray) examination
D. Observing for respiratory distress
Answer: C
Rationale: Radiographic examination is the gold standard and most reliable method for
confirming NG tube placement before the initial use for feeding or medications.
7. When performing a sterile dressing change, the nurse drops a sterile gauze
pad onto the edge of the sterile field. What is the appropriate action?
A. Consider the gauze contaminated and discard it.
B. Pick it up with sterile forceps and move it to the center.
C. Use it anyway since it only touched the edge.
D. Spray it with sterile saline and use it.
Answer: A
Rationale: The 1-inch border of a sterile field is considered contaminated. Any item that
touches this border must be discarded to maintain asepsis.
8. The nurse is preparing to mix Regular insulin and NPH insulin in the same
syringe. Which step should the nurse perform first?
A. Withdraw the Regular insulin
B. Inject air into the Regular vial
C. Withdraw the NPH insulin
D. Inject air into the NPH vial
Answer: D
