,NSG 3130 / NSG3130 Exam 1 Fundamental Concepts &
Skills for Nursing Practice II
QUESTION 1
A nurse is preparing to administer a cleansing enema to an adult patient.
The nurse should insert the rectal tube approximately how far?
A) 1 to 2 inches (2.5 to 5 cm).
B) 2 to 3 inches (5 to 7.5 cm).
C) 3 to 4 inches (7.5 to 10 cm).
D) 4 to 5 inches (10 to 12.5 cm).
*ANSWER: C) 3 to 4 inches (7.5 to 10 cm). *
*RATIONALE: The rectal tube should be inserted 3 to 4 inches (7.5 to 10 cm)
for an adult patient during enema administration. This ensures the tube
passes beyond the external and internal sphincters into the rectum. Inserting
too shallow (A, B) may cause the solution to leak out, while inserting too deep
(D) may damage the bowel mucosa.
QUESTION 2
A nurse is caring for a patient who is diagnosed with a urinary tract
infection (UTI). Which of the following symptoms is most commonly seen in
older adult patients with a UTI?
A) Dysuria.
B) Frequency.
C) Confusion.
D) Hematuria.
,*ANSWER: C) Confusion. *
*RATIONALE: Older adult patients often present with atypical symptoms of a
UTI, such as confusion, lethargy, or a change in behavior, rather than classic
symptoms like dysuria (A), frequency (B), or hematuria (D). The nurse should
be alert for these subtle changes in mental status, which may be the only sign
of infection in this population.
QUESTION 3
A nurse is assessing a patient's peripheral pulse and notes that the pulse is
weak and thready. The nurse should document this finding as which of the
following?
A) 1+.
B) 2+.
C) 3+.
D) 4+.
*ANSWER: A) 1+. *
*RATIONALE: Pulse strength is rated on a scale of 0 to 4+. A 1+ pulse is
weak and thready, indicating diminished perfusion. 2+ (B) is a normal, easily
palpable pulse. 3+ (C) is a full, bounding pulse. 4+ (D) is a strong, bounding
pulse.
QUESTION 4
A nurse is preparing to administer a medication via the subcutaneous route.
Which of the following needles is most appropriate for this injection?
, A) 18-gauge, 1.5-inch needle.
B) 21-gauge, 1-inch needle.
C) 25-gauge, 5/8-inch needle.
D) 27-gauge, 1/2-inch needle.
*ANSWER: D) 27-gauge, 1/2-inch needle. *
*RATIONALE: Subcutaneous injections are given into the fatty tissue layer,
so a short needle (3/8 to 5/8 inch) with a small gauge (25-27 gauge) is
appropriate. A 27-gauge, 1/2-inch needle (D) is ideal. An 18-gauge (A) is
used for large-bore IVs. A 21-gauge (B) is used for IM injections. A 25-gauge,
5/8-inch (C) could also be used, but the 27-gauge is preferred for smaller
volume injections.
QUESTION 5
A nurse is caring for a patient who is receiving oxygen at 2 L/min via nasal
cannula. Which of the following is the most accurate method to monitor
the patient's oxygenation status?
A) Pulse oximetry.
B) Arterial blood gas (ABG).
C) Respiratory rate.
D) Skin color assessment.
*ANSWER: B) Arterial blood gas (ABG). *
*RATIONALE: Arterial blood gas (ABG) analysis is the most accurate method
to assess oxygenation and acid-base status. Pulse oximetry (A) is a non-
invasive estimate but can be affected by poor perfusion, motion, or nail
polish. Respiratory rate (C) and skin color assessment (D) are less reliable
indicators of oxygenation.
Skills for Nursing Practice II
QUESTION 1
A nurse is preparing to administer a cleansing enema to an adult patient.
The nurse should insert the rectal tube approximately how far?
A) 1 to 2 inches (2.5 to 5 cm).
B) 2 to 3 inches (5 to 7.5 cm).
C) 3 to 4 inches (7.5 to 10 cm).
D) 4 to 5 inches (10 to 12.5 cm).
*ANSWER: C) 3 to 4 inches (7.5 to 10 cm). *
*RATIONALE: The rectal tube should be inserted 3 to 4 inches (7.5 to 10 cm)
for an adult patient during enema administration. This ensures the tube
passes beyond the external and internal sphincters into the rectum. Inserting
too shallow (A, B) may cause the solution to leak out, while inserting too deep
(D) may damage the bowel mucosa.
QUESTION 2
A nurse is caring for a patient who is diagnosed with a urinary tract
infection (UTI). Which of the following symptoms is most commonly seen in
older adult patients with a UTI?
A) Dysuria.
B) Frequency.
C) Confusion.
D) Hematuria.
,*ANSWER: C) Confusion. *
*RATIONALE: Older adult patients often present with atypical symptoms of a
UTI, such as confusion, lethargy, or a change in behavior, rather than classic
symptoms like dysuria (A), frequency (B), or hematuria (D). The nurse should
be alert for these subtle changes in mental status, which may be the only sign
of infection in this population.
QUESTION 3
A nurse is assessing a patient's peripheral pulse and notes that the pulse is
weak and thready. The nurse should document this finding as which of the
following?
A) 1+.
B) 2+.
C) 3+.
D) 4+.
*ANSWER: A) 1+. *
*RATIONALE: Pulse strength is rated on a scale of 0 to 4+. A 1+ pulse is
weak and thready, indicating diminished perfusion. 2+ (B) is a normal, easily
palpable pulse. 3+ (C) is a full, bounding pulse. 4+ (D) is a strong, bounding
pulse.
QUESTION 4
A nurse is preparing to administer a medication via the subcutaneous route.
Which of the following needles is most appropriate for this injection?
, A) 18-gauge, 1.5-inch needle.
B) 21-gauge, 1-inch needle.
C) 25-gauge, 5/8-inch needle.
D) 27-gauge, 1/2-inch needle.
*ANSWER: D) 27-gauge, 1/2-inch needle. *
*RATIONALE: Subcutaneous injections are given into the fatty tissue layer,
so a short needle (3/8 to 5/8 inch) with a small gauge (25-27 gauge) is
appropriate. A 27-gauge, 1/2-inch needle (D) is ideal. An 18-gauge (A) is
used for large-bore IVs. A 21-gauge (B) is used for IM injections. A 25-gauge,
5/8-inch (C) could also be used, but the 27-gauge is preferred for smaller
volume injections.
QUESTION 5
A nurse is caring for a patient who is receiving oxygen at 2 L/min via nasal
cannula. Which of the following is the most accurate method to monitor
the patient's oxygenation status?
A) Pulse oximetry.
B) Arterial blood gas (ABG).
C) Respiratory rate.
D) Skin color assessment.
*ANSWER: B) Arterial blood gas (ABG). *
*RATIONALE: Arterial blood gas (ABG) analysis is the most accurate method
to assess oxygenation and acid-base status. Pulse oximetry (A) is a non-
invasive estimate but can be affected by poor perfusion, motion, or nail
polish. Respiratory rate (C) and skin color assessment (D) are less reliable
indicators of oxygenation.
