NSG 3130 Exam 1 V2 | NSG 3130
Fundamental Concepts & Skills for
Nursing Practice II | Actual Q&A with
Rationale (NSG3130 Exam 1) | Galen
College of Nursing
1. A nurse is caring for a patient with a suspected fluid volume deficit. Which clinical
manifestation should the nurse expect to observe?
A. Distended neck veins
B. Decreased skin turgor
C. Increased blood pressure
D. Peripheral edema
Answer: B
Rationale: Decreased skin turgor is a classic sign of dehydration or fluid volume deficit
because the skin loses elasticity when the interstitial fluid volume drops. Distended neck
veins and peripheral edema are signs of fluid volume excess, not deficit. Increased blood
pressure is also associated with fluid overload, whereas hypotension is more common in
deficit states.
2. When assessing a patient for a suspected Stage II pressure injury, which description should
the nurse look for?
A. Non-blanchable erythema of intact skin
,B. Full-thickness skin loss with visible adipose tissue
C. Partial-thickness loss of skin with exposed dermis
D. Full-thickness tissue loss with exposed bone
Answer: C
Rationale: A Stage II pressure injury involves partial-thickness loss of skin with exposed
dermis, often appearing as a shallow open ulcer or a ruptured blister. Stage I is defined by
non-blanchable erythema of intact skin. Full-thickness loss with visible fat refers to Stage
III, while exposed bone indicates Stage IV.
3. A nurse is preparing to administer a subcutaneous injection. At which angle should the
nurse insert the needle for a patient with a moderate amount of subcutaneous tissue?
A. 45 to 90 degrees
B. 15 degrees
C. 90 degrees only
D. 10 to 15 degrees
Answer: A
Rationale: Subcutaneous injections are typically administered at a 45- to 90-degree angle
depending on the patient’s body mass and the length of the needle. A 90-degree angle is
used if 2 inches of tissue can be grasped, while 45 degrees is used for thinner patients.
, Intradermal injections are given at a 5- to 15-degree angle, making the other options
incorrect.
4. A patient’s serum potassium level is 2.8 mEq/L. Which cardiac rhythm change should the
nurse monitor for most closely?
A. Peaked T waves
B. Presence of U waves
C. Prolonged PR interval
D. Widened QRS complex
Answer: B
Rationale: Hypokalemia, defined as a potassium level below 3.5 mEq/L, is associated with
the development of U waves and ST segment depression on an ECG. Peaked T waves and a
widened QRS complex are characteristic of hyperkalemia, which is high potassium.
Prolonged PR intervals can occur in various electrolyte disturbances but are not the
hallmark of low potassium like the U wave is.
5. Which intervention is most effective in preventing catheter-associated urinary tract
infections (CAUTIs)?
A. Maintaining a closed drainage system
B. Cleaning the perineal area with antiseptic wipes every 4 hours
C. Irrigating the catheter daily with sterile saline
Fundamental Concepts & Skills for
Nursing Practice II | Actual Q&A with
Rationale (NSG3130 Exam 1) | Galen
College of Nursing
1. A nurse is caring for a patient with a suspected fluid volume deficit. Which clinical
manifestation should the nurse expect to observe?
A. Distended neck veins
B. Decreased skin turgor
C. Increased blood pressure
D. Peripheral edema
Answer: B
Rationale: Decreased skin turgor is a classic sign of dehydration or fluid volume deficit
because the skin loses elasticity when the interstitial fluid volume drops. Distended neck
veins and peripheral edema are signs of fluid volume excess, not deficit. Increased blood
pressure is also associated with fluid overload, whereas hypotension is more common in
deficit states.
2. When assessing a patient for a suspected Stage II pressure injury, which description should
the nurse look for?
A. Non-blanchable erythema of intact skin
,B. Full-thickness skin loss with visible adipose tissue
C. Partial-thickness loss of skin with exposed dermis
D. Full-thickness tissue loss with exposed bone
Answer: C
Rationale: A Stage II pressure injury involves partial-thickness loss of skin with exposed
dermis, often appearing as a shallow open ulcer or a ruptured blister. Stage I is defined by
non-blanchable erythema of intact skin. Full-thickness loss with visible fat refers to Stage
III, while exposed bone indicates Stage IV.
3. A nurse is preparing to administer a subcutaneous injection. At which angle should the
nurse insert the needle for a patient with a moderate amount of subcutaneous tissue?
A. 45 to 90 degrees
B. 15 degrees
C. 90 degrees only
D. 10 to 15 degrees
Answer: A
Rationale: Subcutaneous injections are typically administered at a 45- to 90-degree angle
depending on the patient’s body mass and the length of the needle. A 90-degree angle is
used if 2 inches of tissue can be grasped, while 45 degrees is used for thinner patients.
, Intradermal injections are given at a 5- to 15-degree angle, making the other options
incorrect.
4. A patient’s serum potassium level is 2.8 mEq/L. Which cardiac rhythm change should the
nurse monitor for most closely?
A. Peaked T waves
B. Presence of U waves
C. Prolonged PR interval
D. Widened QRS complex
Answer: B
Rationale: Hypokalemia, defined as a potassium level below 3.5 mEq/L, is associated with
the development of U waves and ST segment depression on an ECG. Peaked T waves and a
widened QRS complex are characteristic of hyperkalemia, which is high potassium.
Prolonged PR intervals can occur in various electrolyte disturbances but are not the
hallmark of low potassium like the U wave is.
5. Which intervention is most effective in preventing catheter-associated urinary tract
infections (CAUTIs)?
A. Maintaining a closed drainage system
B. Cleaning the perineal area with antiseptic wipes every 4 hours
C. Irrigating the catheter daily with sterile saline
