NURS 104L FUNDAMENTALS OF
NURSING SKILLS LAB - FINAL REVIEW
2026
1. A nurse is preparing a sterile field for a dressing change. Which action would contaminate
the sterile field?
A. Placing a sterile gauze pad 0.5 inches from the edge of the sterile drape.
B. Opening the first flap of the sterile kit away from the body.
C. Holding sterile forceps above the waist level at all times.
D. Pouring sterile saline into a container without splashing.
Answer: A
Conceptual Explanation: A 1-inch border around the edge of a sterile field is considered
contaminated. Any item placed within that 1-inch margin is no longer sterile.
2. While inflating the balloon of a foley catheter, the patient reports sudden, sharp pain.
What is the priority nursing action?
A. Finish inflating the balloon quickly to secure it in the bladder.
B. Tell the patient to take deep breaths and continue inflating.
,C. Remove the catheter immediately and notify the provider.
D. Aspirate the fluid and advance the catheter 1-2 more inches.
Answer: D
Conceptual Explanation: Pain during balloon inflation often indicates the balloon is in the
urethra rather than the bladder. The nurse should deflate, advance further, and then re-
attempt inflation.
3. Which clinical finding is the most reliable indicator of correct nasogastric (NG) tube
placement before the first feeding?
A. X-ray visualization of the tube tip in the stomach.
B. Auscultation of an air bolus in the epigastric area.
C. The patient’s ability to speak clearly without coughing.
D. Aspirated gastric fluid with a pH of 4.0.
Answer: A
Conceptual Explanation: While pH testing is used for bedside verification, Radiographic
(X-ray) confirmation is the gold standard and most reliable method to confirm placement
before initiating feedings.
4. During the administration of a large-volume cleansing enema, the patient reports severe
abdominal cramping. What should the nurse do next?
A. Stop the procedure and remove the rectal tube.
, B. Increase the height of the bag to finish the procedure faster.
C. Lower the enema container to slow the rate of flow.
D. Ask the patient to hold their breath and bear down.
Answer: C
Conceptual Explanation: Cramping is common during enemas. Lowering the bag reduces
the pressure and flow rate, which usually alleviates cramping while allowing the procedure
to continue.
5. A nurse is administering a ventrogluteal intramuscular injection. Which landmarks should
be used to locate the site?
A. The acromion process and the axillary line.
B. The greater trochanter, anterior superior iliac spine, and iliac crest.
C. The vastus lateralis muscle and the knee joint.
D. The posterior superior iliac spine and the gluteal fold.
Answer: B
Conceptual Explanation: The ventrogluteal site is located by placing the palm over the
greater trochanter, the index finger on the anterior superior iliac spine, and spreading the
middle finger toward the iliac crest.
NURSING SKILLS LAB - FINAL REVIEW
2026
1. A nurse is preparing a sterile field for a dressing change. Which action would contaminate
the sterile field?
A. Placing a sterile gauze pad 0.5 inches from the edge of the sterile drape.
B. Opening the first flap of the sterile kit away from the body.
C. Holding sterile forceps above the waist level at all times.
D. Pouring sterile saline into a container without splashing.
Answer: A
Conceptual Explanation: A 1-inch border around the edge of a sterile field is considered
contaminated. Any item placed within that 1-inch margin is no longer sterile.
2. While inflating the balloon of a foley catheter, the patient reports sudden, sharp pain.
What is the priority nursing action?
A. Finish inflating the balloon quickly to secure it in the bladder.
B. Tell the patient to take deep breaths and continue inflating.
,C. Remove the catheter immediately and notify the provider.
D. Aspirate the fluid and advance the catheter 1-2 more inches.
Answer: D
Conceptual Explanation: Pain during balloon inflation often indicates the balloon is in the
urethra rather than the bladder. The nurse should deflate, advance further, and then re-
attempt inflation.
3. Which clinical finding is the most reliable indicator of correct nasogastric (NG) tube
placement before the first feeding?
A. X-ray visualization of the tube tip in the stomach.
B. Auscultation of an air bolus in the epigastric area.
C. The patient’s ability to speak clearly without coughing.
D. Aspirated gastric fluid with a pH of 4.0.
Answer: A
Conceptual Explanation: While pH testing is used for bedside verification, Radiographic
(X-ray) confirmation is the gold standard and most reliable method to confirm placement
before initiating feedings.
4. During the administration of a large-volume cleansing enema, the patient reports severe
abdominal cramping. What should the nurse do next?
A. Stop the procedure and remove the rectal tube.
, B. Increase the height of the bag to finish the procedure faster.
C. Lower the enema container to slow the rate of flow.
D. Ask the patient to hold their breath and bear down.
Answer: C
Conceptual Explanation: Cramping is common during enemas. Lowering the bag reduces
the pressure and flow rate, which usually alleviates cramping while allowing the procedure
to continue.
5. A nurse is administering a ventrogluteal intramuscular injection. Which landmarks should
be used to locate the site?
A. The acromion process and the axillary line.
B. The greater trochanter, anterior superior iliac spine, and iliac crest.
C. The vastus lateralis muscle and the knee joint.
D. The posterior superior iliac spine and the gluteal fold.
Answer: B
Conceptual Explanation: The ventrogluteal site is located by placing the palm over the
greater trochanter, the index finger on the anterior superior iliac spine, and spreading the
middle finger toward the iliac crest.
