NRSG 100 Exam 4 V3 | NRSG 100
Fundamentals of Nursing | Actual Q&A
with Rationale (NRSG100 Exam 4) | Ivy
Tech
1. A nurse is caring for a client who is experiencing dyspnea and is using accessory muscles to
breathe. Which of the following should be the nurse’s priority action?
A. Place the client in a high-Fowler’s position
B. Auscultate the client’s lung sounds
C. Place the client in a high-Fowler’s position
D. Administer oxygen via nasal cannula
Correct Answer: C
The high-Fowler’s position allows for maximum chest expansion and facilitates better gas
exchange for clients in respiratory distress. This immediate nursing intervention helps
decrease the work of breathing before other assessments or treatments are completed.
Implementing this position is a standard non-pharmacological priority for acute dyspnea.
2. When performing tracheostomy care, which action by the nurse is essential to maintain
sterile technique?
A. Suctioning the client for 30 seconds continuously
B. Cleaning the stoma with tap water
,C. Opening sterile supplies and maintaining a 1-inch border around the sterile field
D. Removing the old ties before securing the new ones
Correct Answer: C
Maintaining a sterile field is critical when performing tracheostomy care to prevent the
introduction of pathogens into the lower respiratory tract. The 1-inch border is considered
contaminated and should not be touched by sterile gloves. Proper aseptic technique is a
fundamental competency tested in the Ivy Tech NRSG 100 curriculum.
3. A client is diagnosed with hypokalemia. Which of the following assessment findings should
the nurse anticipate?
A. Hyperactive bowel sounds
B. Muscle weakness and cardiac arrhythmias
C. Positive Trousseau’s sign
D. Increased blood pressure
Correct Answer: B
Hypokalemia significantly affects neuromuscular function and cardiac electrical
conduction. Muscle weakness and life-threatening arrhythmias are classic signs of low
serum potassium levels. Monitoring for these changes is a vital safety measure during the
acute phase of electrolyte imbalance.
, 4. The nurse is assessing a pressure injury and notes a full-thickness skin loss with visible
subcutaneous fat, but no bone or muscle exposed. How should the nurse stage this injury?
A. Stage 2
B. Stage 3
C. Stage 4
D. Unstageable
Correct Answer: B
Stage 3 pressure injuries involve full-thickness skin loss where adipose tissue is visible in
the ulcer. The absence of exposed bone, tendon, or muscle distinguishes it from a Stage 4
injury. Accurate staging is necessary for appropriate wound care documentation and
treatment selection.
5. A nurse is preparing to administer a cleansing enema to a client. Which position is most
appropriate for this procedure?
A. Right lateral Sims’ position
B. Left lateral Sims’ position
C. Supine position
D. Dorsal recumbent position
Correct Answer: B
Fundamentals of Nursing | Actual Q&A
with Rationale (NRSG100 Exam 4) | Ivy
Tech
1. A nurse is caring for a client who is experiencing dyspnea and is using accessory muscles to
breathe. Which of the following should be the nurse’s priority action?
A. Place the client in a high-Fowler’s position
B. Auscultate the client’s lung sounds
C. Place the client in a high-Fowler’s position
D. Administer oxygen via nasal cannula
Correct Answer: C
The high-Fowler’s position allows for maximum chest expansion and facilitates better gas
exchange for clients in respiratory distress. This immediate nursing intervention helps
decrease the work of breathing before other assessments or treatments are completed.
Implementing this position is a standard non-pharmacological priority for acute dyspnea.
2. When performing tracheostomy care, which action by the nurse is essential to maintain
sterile technique?
A. Suctioning the client for 30 seconds continuously
B. Cleaning the stoma with tap water
,C. Opening sterile supplies and maintaining a 1-inch border around the sterile field
D. Removing the old ties before securing the new ones
Correct Answer: C
Maintaining a sterile field is critical when performing tracheostomy care to prevent the
introduction of pathogens into the lower respiratory tract. The 1-inch border is considered
contaminated and should not be touched by sterile gloves. Proper aseptic technique is a
fundamental competency tested in the Ivy Tech NRSG 100 curriculum.
3. A client is diagnosed with hypokalemia. Which of the following assessment findings should
the nurse anticipate?
A. Hyperactive bowel sounds
B. Muscle weakness and cardiac arrhythmias
C. Positive Trousseau’s sign
D. Increased blood pressure
Correct Answer: B
Hypokalemia significantly affects neuromuscular function and cardiac electrical
conduction. Muscle weakness and life-threatening arrhythmias are classic signs of low
serum potassium levels. Monitoring for these changes is a vital safety measure during the
acute phase of electrolyte imbalance.
, 4. The nurse is assessing a pressure injury and notes a full-thickness skin loss with visible
subcutaneous fat, but no bone or muscle exposed. How should the nurse stage this injury?
A. Stage 2
B. Stage 3
C. Stage 4
D. Unstageable
Correct Answer: B
Stage 3 pressure injuries involve full-thickness skin loss where adipose tissue is visible in
the ulcer. The absence of exposed bone, tendon, or muscle distinguishes it from a Stage 4
injury. Accurate staging is necessary for appropriate wound care documentation and
treatment selection.
5. A nurse is preparing to administer a cleansing enema to a client. Which position is most
appropriate for this procedure?
A. Right lateral Sims’ position
B. Left lateral Sims’ position
C. Supine position
D. Dorsal recumbent position
Correct Answer: B
