NSG 300 Exam 3 | Foundations of Nursing | Grand Canyon University (GCU) |
Practice Questions, Answers & Rationales | 3 versions
Prepare for NSG 300 Exam 3 with this comprehensive Foundations of Nursing
study guide featuring original practice questions, accurate answers, and detailed
rationales. Covers core nursing concepts, patient safety, infection prevention,
wound care, pain management, and evidence-based nursing practice. Perfect for
focused review, self-assessment, and exam preparation
1. A nurse is preparing to administer an intramuscular (IM) injection to an adult
patient who has an average body frame. Which needle gauge and length
combination should the nurse select to ensure the medication is deposited safely
into the ventrogluteal muscle?
A) 25-gauge, 5/8-inch needle
B) 22-gauge, 1.5-inch needle
C) 18-gauge, 1-inch needle
D) 27-gauge, 0.5-inch needle
Answer: B) 22-gauge, 1.5-inch needle
Rationale: To reach the deep muscle tissue of the ventrogluteal site in an average-sized
adult, a needle length of 1.5 inches is standard. A 21-to-23 gauge needle is appropriate
for most standard-viscosity IM medications, minimizing patient discomfort while
ensuring proper delivery. A 5/8-inch needle would only reach the subcutaneous layer.
2. A nurse is reviewing a new medication prescription that reads: "Morphine
Sulfate 2 mg IV every 4 hours PRN for severe pain." The nurse notes that this
prescription is complete because it includes which critical parameter?
A) The patient's exact weight
B) A specific clinical indication for administration
C) The manufacturer's brand name
D) The location of the pharmacy
Answer: B) A specific clinical indication for administration
,Rationale: For any "PRN" (as needed) medication order to be legally complete and safe,
it must include a specific clinical justification or indication (e.g., "for severe pain"). This
ensures the nurse knows exactly when it is clinically appropriate to exercise judgment
and administer the drug.
3. While conducting a preoperative assessment, a patient tells the nurse, "I take a
warfain pill every night because I used to have blood clots in my lungs." Why is
this information a critical priority for the surgical team?
A) Anticoagulants increase the risk of malignant hyperthermia
B) Anticoagulants alter the binding affinity of neuromuscular blockers
C) Anticoagulants significantly increase the risk of life-threatening intraoperative
hemorrhage
D) Anticoagulants prevent the patient from waking up from general anesthesia
Answer: C) Anticoagulants significantly increase the risk of life-threatening
intraoperative hemorrhage
Rationale: Warfarin is a potent anticoagulant that disrupts the coagulation cascade.
Continuing this medication up to the time of surgery poses a severe risk of uncontrolled
intraoperative and postoperative bleeding. The surgeon typically requires it to be
discontinued several days preoperatively.
4. A patient who is 12 hours postoperative from an open cholecystectomy
describes a sharp, aching pain located directly along their abdominal incision line
that worsens with movement. The nurse should classify this pain as:
A) Visceral nociceptive pain
B) Somatic nociceptive pain
C) Neuropathic pain
D) Psychogenic pain
Answer: B) Somatic nociceptive pain
Rationale: Somatic pain originates from tissue structural damage to the skin,
subcutaneous tissues, bone, joints, or muscles. Incisional pain is a classic example of
deep somatic nociceptive pain, typically characterized as sharp, aching, localized, and
aggravated by movement.
5. A nurse checks on a patient who is receiving continuous intravenous
hydromorphone via a PCA pump. The nurse finds the patient sleeping heavily,
difficult to arouse verbally, and notes a respiratory rate of 8 breaths per minute.
What is the nurse's first action?
,A) Turn up the room lights and shake the patient's arm vigorously
B) Stop the PCA pump infusion immediately and prepare to administer Naloxone
C) Document that the patient's pain is adequately controlled
D) Increase the oxygen flow rate on the nasal cannula to 6 L/min
Answer: B) Stop the PCA pump infusion immediately and prepare to administer
Naloxone
Rationale: A respiratory rate below 10 breaths per minute combined with a decreased
level of consciousness indicates severe opioid-induced respiratory depression. The
immediate priority is to stop further medication delivery and administer the opioid
antagonist Naloxone (Narcan) to reverse the respiratory depression.
6. While repositioning an immobile patient, the nurse assesses the sacral area
and finds an intact patch of skin with localized, non-blanchable redness. The
tissue feels warm and slightly boggy. How should the nurse stage this pressure
injury?
A) Stage 1 pressure injury
B) Stage 2 pressure injury
C) Stage 3 pressure injury
D) Unstageable pressure injury
Answer: A) Stage 1 pressure injury
Rationale: A Stage 1 pressure injury features intact skin with localized, non-blanchable
erythema (the redness does not fade to white when pressed). Changes in sensation,
temperature (warmth or coolness), or tissue consistency (boggy or firm) often
accompany this stage.
7. A nurse notes that a patient’s surgical abdominal dressing has a significant
amount of pale pink, watery, thin drainage soaking through the outer gauze
layers. The nurse should document this exudate as:
A) Serous drainage
B) Sanguineous drainage
C) Serosanguineous drainage
D) Purulent drainage
Answer: C) Serosanguineous drainage
Rationale: Serosanguineous drainage is a mixture of clear serum and red blood cells. It
appears thin, watery, and pale pink or tinged with red. It is a normal finding in surgical
wounds during the first few postoperative days. Serous is clear, sanguineous is bloody,
and purulent is pus.
, 8. To ensure compliance with Joint Commission safety goals during medication
administration, which action must the nurse perform to correctly identify the
patient?
A) Look at the name card taped to the wall over the patient’s bed
B) Verify the patient's identity by asking their visitor or family member
C) Ask the patient to verbally state their full name and date of birth, and check their ID
wristband
D) Cross-reference the patient's room number with the computer screen log
Answer: C) Ask the patient to verbally state their full name and date of birth, and
check their ID wristband
Rationale: National Patient Safety Goals mandate using at least two independent
patient identifiers prior to any medication administration or procedure. Asking the patient
to state their name and birthdate while comparing it directly to the ID band and the MAR
fulfills this safety requirement. Room numbers and door tags are never acceptable
identifiers.
9. A nurse is preparing to administer an intradermal injection for an allergy skin
test. At what angle should the nurse insert the needle into the skin?
A) 90 degrees
B) 45 degrees
C) 30 degrees
D) 5 to 15 degrees
Answer: D) 5 to 15 degrees
Rationale: Intradermal injections must be deposited into the highly vascular dermis layer
right underneath the epidermis. This requires an almost flat insertion angle of 5 to 15
degrees with the needle bevel facing upwards. Steeper angles will bypass the dermis
and enter subcutaneous fat.
10. During a dressing change on a deep sacral wound, the nurse notes that the
base of the wound is filled with bright red, moist, granular tissue that bleeds
slightly when cleansed. The nurse recognizes this as:
A) Slough tissue
B) Eschar tissue
C) Granulation tissue
D) Purulent tissue
Practice Questions, Answers & Rationales | 3 versions
Prepare for NSG 300 Exam 3 with this comprehensive Foundations of Nursing
study guide featuring original practice questions, accurate answers, and detailed
rationales. Covers core nursing concepts, patient safety, infection prevention,
wound care, pain management, and evidence-based nursing practice. Perfect for
focused review, self-assessment, and exam preparation
1. A nurse is preparing to administer an intramuscular (IM) injection to an adult
patient who has an average body frame. Which needle gauge and length
combination should the nurse select to ensure the medication is deposited safely
into the ventrogluteal muscle?
A) 25-gauge, 5/8-inch needle
B) 22-gauge, 1.5-inch needle
C) 18-gauge, 1-inch needle
D) 27-gauge, 0.5-inch needle
Answer: B) 22-gauge, 1.5-inch needle
Rationale: To reach the deep muscle tissue of the ventrogluteal site in an average-sized
adult, a needle length of 1.5 inches is standard. A 21-to-23 gauge needle is appropriate
for most standard-viscosity IM medications, minimizing patient discomfort while
ensuring proper delivery. A 5/8-inch needle would only reach the subcutaneous layer.
2. A nurse is reviewing a new medication prescription that reads: "Morphine
Sulfate 2 mg IV every 4 hours PRN for severe pain." The nurse notes that this
prescription is complete because it includes which critical parameter?
A) The patient's exact weight
B) A specific clinical indication for administration
C) The manufacturer's brand name
D) The location of the pharmacy
Answer: B) A specific clinical indication for administration
,Rationale: For any "PRN" (as needed) medication order to be legally complete and safe,
it must include a specific clinical justification or indication (e.g., "for severe pain"). This
ensures the nurse knows exactly when it is clinically appropriate to exercise judgment
and administer the drug.
3. While conducting a preoperative assessment, a patient tells the nurse, "I take a
warfain pill every night because I used to have blood clots in my lungs." Why is
this information a critical priority for the surgical team?
A) Anticoagulants increase the risk of malignant hyperthermia
B) Anticoagulants alter the binding affinity of neuromuscular blockers
C) Anticoagulants significantly increase the risk of life-threatening intraoperative
hemorrhage
D) Anticoagulants prevent the patient from waking up from general anesthesia
Answer: C) Anticoagulants significantly increase the risk of life-threatening
intraoperative hemorrhage
Rationale: Warfarin is a potent anticoagulant that disrupts the coagulation cascade.
Continuing this medication up to the time of surgery poses a severe risk of uncontrolled
intraoperative and postoperative bleeding. The surgeon typically requires it to be
discontinued several days preoperatively.
4. A patient who is 12 hours postoperative from an open cholecystectomy
describes a sharp, aching pain located directly along their abdominal incision line
that worsens with movement. The nurse should classify this pain as:
A) Visceral nociceptive pain
B) Somatic nociceptive pain
C) Neuropathic pain
D) Psychogenic pain
Answer: B) Somatic nociceptive pain
Rationale: Somatic pain originates from tissue structural damage to the skin,
subcutaneous tissues, bone, joints, or muscles. Incisional pain is a classic example of
deep somatic nociceptive pain, typically characterized as sharp, aching, localized, and
aggravated by movement.
5. A nurse checks on a patient who is receiving continuous intravenous
hydromorphone via a PCA pump. The nurse finds the patient sleeping heavily,
difficult to arouse verbally, and notes a respiratory rate of 8 breaths per minute.
What is the nurse's first action?
,A) Turn up the room lights and shake the patient's arm vigorously
B) Stop the PCA pump infusion immediately and prepare to administer Naloxone
C) Document that the patient's pain is adequately controlled
D) Increase the oxygen flow rate on the nasal cannula to 6 L/min
Answer: B) Stop the PCA pump infusion immediately and prepare to administer
Naloxone
Rationale: A respiratory rate below 10 breaths per minute combined with a decreased
level of consciousness indicates severe opioid-induced respiratory depression. The
immediate priority is to stop further medication delivery and administer the opioid
antagonist Naloxone (Narcan) to reverse the respiratory depression.
6. While repositioning an immobile patient, the nurse assesses the sacral area
and finds an intact patch of skin with localized, non-blanchable redness. The
tissue feels warm and slightly boggy. How should the nurse stage this pressure
injury?
A) Stage 1 pressure injury
B) Stage 2 pressure injury
C) Stage 3 pressure injury
D) Unstageable pressure injury
Answer: A) Stage 1 pressure injury
Rationale: A Stage 1 pressure injury features intact skin with localized, non-blanchable
erythema (the redness does not fade to white when pressed). Changes in sensation,
temperature (warmth or coolness), or tissue consistency (boggy or firm) often
accompany this stage.
7. A nurse notes that a patient’s surgical abdominal dressing has a significant
amount of pale pink, watery, thin drainage soaking through the outer gauze
layers. The nurse should document this exudate as:
A) Serous drainage
B) Sanguineous drainage
C) Serosanguineous drainage
D) Purulent drainage
Answer: C) Serosanguineous drainage
Rationale: Serosanguineous drainage is a mixture of clear serum and red blood cells. It
appears thin, watery, and pale pink or tinged with red. It is a normal finding in surgical
wounds during the first few postoperative days. Serous is clear, sanguineous is bloody,
and purulent is pus.
, 8. To ensure compliance with Joint Commission safety goals during medication
administration, which action must the nurse perform to correctly identify the
patient?
A) Look at the name card taped to the wall over the patient’s bed
B) Verify the patient's identity by asking their visitor or family member
C) Ask the patient to verbally state their full name and date of birth, and check their ID
wristband
D) Cross-reference the patient's room number with the computer screen log
Answer: C) Ask the patient to verbally state their full name and date of birth, and
check their ID wristband
Rationale: National Patient Safety Goals mandate using at least two independent
patient identifiers prior to any medication administration or procedure. Asking the patient
to state their name and birthdate while comparing it directly to the ID band and the MAR
fulfills this safety requirement. Room numbers and door tags are never acceptable
identifiers.
9. A nurse is preparing to administer an intradermal injection for an allergy skin
test. At what angle should the nurse insert the needle into the skin?
A) 90 degrees
B) 45 degrees
C) 30 degrees
D) 5 to 15 degrees
Answer: D) 5 to 15 degrees
Rationale: Intradermal injections must be deposited into the highly vascular dermis layer
right underneath the epidermis. This requires an almost flat insertion angle of 5 to 15
degrees with the needle bevel facing upwards. Steeper angles will bypass the dermis
and enter subcutaneous fat.
10. During a dressing change on a deep sacral wound, the nurse notes that the
base of the wound is filled with bright red, moist, granular tissue that bleeds
slightly when cleansed. The nurse recognizes this as:
A) Slough tissue
B) Eschar tissue
C) Granulation tissue
D) Purulent tissue
