NSG 300 Exam 3 – Foundations of Nursing EXAM with
Questions and Answers/Plus a Rationale Updated 2026
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Table of Contents
1. Nursing Process and Clinical Judgment
2. Patient Safety and Quality Improvement
3. Skin Integrity and Wound Care
4. Fluid, Electrolyte, and Acid-Base Balance
5. Perioperative Nursing Care
1. A patient with a stage 3 pressure injury on the sacrum has a wound bed with 60% granulation
tissue and 40% slough. Which nursing action is most appropriate when planning care to optimize
wound healing?
A. Apply a dry sterile dressing to keep the wound bed free of moisture.
B. Perform mechanical debridement using wet-to-dry dressings to remove slough.
C. Consult with a wound care specialist regarding autolytic or enzymatic debridement.
D. Irrigate the wound with hydrogen peroxide to ensure the bacterial load is minimized.
CORRECT ANSWER : B
Rationale: Mechanical debridement with wet-to-dry dressings is an effective method to remove
slough and necrotic tissue from a wound bed. Option A is incorrect because keeping the wound
dry prevents epithelialization; option C is a valid consideration but secondary to immediate
removal; option D is incorrect because hydrogen peroxide is cytotoxic to healthy granulation
tissue and delays healing.
,2. A client is receiving a hypertonic intravenous solution. As a nurse, you monitor for signs of fluid
volume overload. Which clinical manifestation is most indicative of this complication?
A. Development of a new S3 heart sound and bilateral crackles in the lungs.
B. Increased urine specific gravity and concentrated, dark-colored urine.
C. Flattened neck veins and hypotension when moving from supine to sitting.
D. Decreased serum sodium levels and muscle cramping.
CORRECT ANSWER : A
Rationale: Fluid volume overload leads to increased vascular volume, resulting in cardiac
workload strain (S3) and pulmonary congestion (crackles). Option B indicates dehydration;
option C indicates hypovolemia; option D typically indicates dilutional hyponatremia, which is a
risk but not the most direct physical assessment indicator of immediate pulmonary overload.
3. A patient is scheduled for a bowel resection. During the preoperative assessment, the patient
mentions taking herbal supplements daily. Which supplement requires the nurse to notify the
surgeon immediately due to increased bleeding risk?
A. Melatonin
B. Garlic
C. Echinacea
D. Vitamin C
CORRECT ANSWER : B
Rationale: Garlic, along with ginger and ginkgo biloba, has antiplatelet properties that can
increase the risk of hemorrhage during and after surgery. Melatonin, Echinacea, and Vitamin C
do not typically present a significant, immediate contraindication for intraoperative bleeding
risks compared to garlic.
4. A nurse is evaluating the effectiveness of interventions for a patient with orthostatic hypotension.
Which finding suggests the patient has met the goal for safe mobility?
A. A decrease in systolic blood pressure of 15 mmHg upon standing.
B. An increase in heart rate of 30 beats per minute upon standing.
C. A blood pressure reading of 120/80 mmHg while lying and 114/76 mmHg while standing.
, D. A blood pressure reading of 110/70 mmHg while lying and 90/60 mmHg while standing.
CORRECT ANSWER : C
Rationale: Orthostatic hypotension is defined as a drop in systolic BP of ≥20 mmHg or diastolic
BP of ≥10 mmHg within 3 minutes of standing. Option C shows a stable BP, while options A and
D indicate significant drops, and option B suggests a compensatory tachycardia associated with
symptomatic orthostasis.
5. A nurse is caring for a patient with acute respiratory acidosis. Which arterial blood gas (ABG)
result would the nurse expect to see?
A. pH 7.50, PaCO2 30 mmHg
B. pH 7.48, HCO3 28 mEq/L
C. pH 7.28, PaCO2 50 mmHg
D. pH 7.30, HCO3 18 mEq/L
CORRECT ANSWER : C
Rationale: Respiratory acidosis is characterized by a low pH (<7.35) and an elevated PaCO2
(>45 mmHg). Option A represents respiratory alkalosis; option B represents metabolic
alkalosis; option D represents metabolic acidosis.
6. A client has an order for a continuous IV infusion. Upon assessment, the nurse notes the site is
swollen, cool to the touch, and pale. What is the priority action?
A. Flush the line to determine if it is still patent.
B. Stop the infusion and remove the peripheral catheter.
C. Apply a warm compress to the area to increase circulation.
D. Elevate the extremity and continue the infusion at a slower rate.
CORRECT ANSWER : B
Rationale: The symptoms describe infiltration. The priority is to stop the infusion immediately to
prevent further fluid accumulation in the subcutaneous tissue and remove the catheter. Option A
is dangerous; option C may be appropriate later, but removal is priority; option D is incorrect
as the infusion must be discontinued.
7. A patient is at high risk for falls. Which intervention reflects a proactive approach to fall
prevention based on clinical evidence?
, A. Applying vest restraints to keep the patient in bed during the night.
B. Implementing a scheduled rounding protocol every hour to address the "4 Ps".
C. Keeping all four side rails of the hospital bed in the raised position.
D. Placing the patient in a room far from the nursing station to reduce noise.
CORRECT ANSWER : B
Rationale: Scheduled rounding (addressing Pain, Potty, Position, and Possessions) is an
evidence-based practice to meet patient needs and reduce the impulse to get up unassisted.
Restraints (A) require a medical order and are a last resort; four side rails (C) can be
considered a restraint and increase injury risk; distant room placement (D) decreases
surveillance.
8. Which action by the nurse demonstrates an understanding of surgical asepsis during the setup of
a sterile field?
A. Placing a sterile package on the edge of the sterile field.
B. Reaching over the sterile field to adjust a piece of equipment.
C. Maintaining a 1-inch border around the edges of the sterile drape as non-sterile.
D. Holding sterile objects below the level of the waist.
CORRECT ANSWER : C
Rationale: The edges of a sterile drape (the 1-inch border) are considered contaminated due to
the possibility of contact with non-sterile surfaces. Option A violates the border; option B
introduces contamination from the nurse's uniform; option D violates the principle that sterile
items must remain above the waist.
9. A patient with a nasogastric (NG) tube requires medication administration. What is the most
accurate method for the nurse to verify tube placement before administering the medication?
A. Auscultating for a "whoosh" of air over the epigastrium.
B. Testing the pH of the gastric aspirate.
C. Obtaining an X-ray confirmation of tube tip placement.
D. Measuring the length of the tube exiting the naris.
CORRECT ANSWER : C
Questions and Answers/Plus a Rationale Updated 2026
A+/Instant Download PDF
Table of Contents
1. Nursing Process and Clinical Judgment
2. Patient Safety and Quality Improvement
3. Skin Integrity and Wound Care
4. Fluid, Electrolyte, and Acid-Base Balance
5. Perioperative Nursing Care
1. A patient with a stage 3 pressure injury on the sacrum has a wound bed with 60% granulation
tissue and 40% slough. Which nursing action is most appropriate when planning care to optimize
wound healing?
A. Apply a dry sterile dressing to keep the wound bed free of moisture.
B. Perform mechanical debridement using wet-to-dry dressings to remove slough.
C. Consult with a wound care specialist regarding autolytic or enzymatic debridement.
D. Irrigate the wound with hydrogen peroxide to ensure the bacterial load is minimized.
CORRECT ANSWER : B
Rationale: Mechanical debridement with wet-to-dry dressings is an effective method to remove
slough and necrotic tissue from a wound bed. Option A is incorrect because keeping the wound
dry prevents epithelialization; option C is a valid consideration but secondary to immediate
removal; option D is incorrect because hydrogen peroxide is cytotoxic to healthy granulation
tissue and delays healing.
,2. A client is receiving a hypertonic intravenous solution. As a nurse, you monitor for signs of fluid
volume overload. Which clinical manifestation is most indicative of this complication?
A. Development of a new S3 heart sound and bilateral crackles in the lungs.
B. Increased urine specific gravity and concentrated, dark-colored urine.
C. Flattened neck veins and hypotension when moving from supine to sitting.
D. Decreased serum sodium levels and muscle cramping.
CORRECT ANSWER : A
Rationale: Fluid volume overload leads to increased vascular volume, resulting in cardiac
workload strain (S3) and pulmonary congestion (crackles). Option B indicates dehydration;
option C indicates hypovolemia; option D typically indicates dilutional hyponatremia, which is a
risk but not the most direct physical assessment indicator of immediate pulmonary overload.
3. A patient is scheduled for a bowel resection. During the preoperative assessment, the patient
mentions taking herbal supplements daily. Which supplement requires the nurse to notify the
surgeon immediately due to increased bleeding risk?
A. Melatonin
B. Garlic
C. Echinacea
D. Vitamin C
CORRECT ANSWER : B
Rationale: Garlic, along with ginger and ginkgo biloba, has antiplatelet properties that can
increase the risk of hemorrhage during and after surgery. Melatonin, Echinacea, and Vitamin C
do not typically present a significant, immediate contraindication for intraoperative bleeding
risks compared to garlic.
4. A nurse is evaluating the effectiveness of interventions for a patient with orthostatic hypotension.
Which finding suggests the patient has met the goal for safe mobility?
A. A decrease in systolic blood pressure of 15 mmHg upon standing.
B. An increase in heart rate of 30 beats per minute upon standing.
C. A blood pressure reading of 120/80 mmHg while lying and 114/76 mmHg while standing.
, D. A blood pressure reading of 110/70 mmHg while lying and 90/60 mmHg while standing.
CORRECT ANSWER : C
Rationale: Orthostatic hypotension is defined as a drop in systolic BP of ≥20 mmHg or diastolic
BP of ≥10 mmHg within 3 minutes of standing. Option C shows a stable BP, while options A and
D indicate significant drops, and option B suggests a compensatory tachycardia associated with
symptomatic orthostasis.
5. A nurse is caring for a patient with acute respiratory acidosis. Which arterial blood gas (ABG)
result would the nurse expect to see?
A. pH 7.50, PaCO2 30 mmHg
B. pH 7.48, HCO3 28 mEq/L
C. pH 7.28, PaCO2 50 mmHg
D. pH 7.30, HCO3 18 mEq/L
CORRECT ANSWER : C
Rationale: Respiratory acidosis is characterized by a low pH (<7.35) and an elevated PaCO2
(>45 mmHg). Option A represents respiratory alkalosis; option B represents metabolic
alkalosis; option D represents metabolic acidosis.
6. A client has an order for a continuous IV infusion. Upon assessment, the nurse notes the site is
swollen, cool to the touch, and pale. What is the priority action?
A. Flush the line to determine if it is still patent.
B. Stop the infusion and remove the peripheral catheter.
C. Apply a warm compress to the area to increase circulation.
D. Elevate the extremity and continue the infusion at a slower rate.
CORRECT ANSWER : B
Rationale: The symptoms describe infiltration. The priority is to stop the infusion immediately to
prevent further fluid accumulation in the subcutaneous tissue and remove the catheter. Option A
is dangerous; option C may be appropriate later, but removal is priority; option D is incorrect
as the infusion must be discontinued.
7. A patient is at high risk for falls. Which intervention reflects a proactive approach to fall
prevention based on clinical evidence?
, A. Applying vest restraints to keep the patient in bed during the night.
B. Implementing a scheduled rounding protocol every hour to address the "4 Ps".
C. Keeping all four side rails of the hospital bed in the raised position.
D. Placing the patient in a room far from the nursing station to reduce noise.
CORRECT ANSWER : B
Rationale: Scheduled rounding (addressing Pain, Potty, Position, and Possessions) is an
evidence-based practice to meet patient needs and reduce the impulse to get up unassisted.
Restraints (A) require a medical order and are a last resort; four side rails (C) can be
considered a restraint and increase injury risk; distant room placement (D) decreases
surveillance.
8. Which action by the nurse demonstrates an understanding of surgical asepsis during the setup of
a sterile field?
A. Placing a sterile package on the edge of the sterile field.
B. Reaching over the sterile field to adjust a piece of equipment.
C. Maintaining a 1-inch border around the edges of the sterile drape as non-sterile.
D. Holding sterile objects below the level of the waist.
CORRECT ANSWER : C
Rationale: The edges of a sterile drape (the 1-inch border) are considered contaminated due to
the possibility of contact with non-sterile surfaces. Option A violates the border; option B
introduces contamination from the nurse's uniform; option D violates the principle that sterile
items must remain above the waist.
9. A patient with a nasogastric (NG) tube requires medication administration. What is the most
accurate method for the nurse to verify tube placement before administering the medication?
A. Auscultating for a "whoosh" of air over the epigastrium.
B. Testing the pH of the gastric aspirate.
C. Obtaining an X-ray confirmation of tube tip placement.
D. Measuring the length of the tube exiting the naris.
CORRECT ANSWER : C
