NSG 3100 Fundamental Concepts & Skills I Exam 3 | 75 Questions
And Answers With Rationale | 2026/2027 Updates
Question 1.
A nurse is performing a head-to-toe assessment on a newly admitted patient. When assessing the skin, the nurse notes
tenting when pinching the skin on the back of the hand. This finding indicates:
A. Edema.
B. Dehydration.
C. Hypervolemia.
D. Peripheral vascular disease.
Correct Answer: B
Rationale:
Skin tenting (poor skin turgor) occurs when the skin remains elevated after being pinched and released, indicating
decreased skin elasticity due to dehydration or aging. In older adults, decreased turgor may be normal, but in younger
adults it strongly suggests fluid deficit. Edema (A) causes skin that pits or remains indented. Hypervolemia (C) does not
affect turgor in this way. Peripheral vascular disease (D) affects color, temperature, and pulses, not turgor.
Question 2.
A nurse is caring for a patient who is deaf and uses American Sign Language (ASL). An ASL interpreter is present during
the admission assessment. The nurse should:
A. Speak directly to the interpreter to ensure accurate communication.
B. Speak directly to the patient while facing them, allowing the interpreter to facilitate communication.
C. Ask the patient's family member to interpret to save time.
D. Write all questions on paper to avoid the need for an interpreter.
Correct Answer: B
Rationale:
When working with an interpreter, the nurse should always speak directly to the patient (not the interpreter), maintain eye
contact with the patient, and use first-person language. The interpreter facilitates communication but the therapeutic
relationship is between the nurse and patient. Using family members as interpreters (C) violates patient privacy and may
result in inaccurate translation. Writing notes (D) is inappropriate for a patient whose primary language is ASL.
Question 3.
A nurse is caring for a patient who has just been diagnosed with terminal cancer. The patient asks, 'Am I going to die?'
The nurse's most therapeutic response is:
A. 'Don't think about that right now. Let's focus on your treatment.'
B. 'What are your thoughts and fears about your diagnosis?'
C. 'Yes, but we don't know when. Everyone dies eventually.'
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,D. 'You should talk to your doctor about that question.'
Correct Answer: B
Rationale:
Therapeutic communication involves exploring the patient's feelings and concerns rather than providing false reassurance
(A), blunt answers (C), or deflecting (D). Asking open-ended questions allows the patient to express emotions, fears, and
needs, enabling the nurse to provide appropriate support, resources, and referrals. This approach respects patient
autonomy and promotes emotional coping.
Question 4.
A nurse witnesses a needlestick injury after recapping a used syringe. The nurse's first action is to:
A. Wash the area with soap and water and report the incident immediately.
B. Apply pressure to the wound and cover with a bandage.
C. Wait to see if symptoms develop before reporting.
D. Squeeze the wound to express any contaminated blood.
Correct Answer: A
Rationale:
After a needlestick or sharps injury, the nurse should immediately wash the area with soap and water (do not squeeze,
scrub, or use bleach), then report the incident to occupational health or the designated authority immediately for post-
exposure evaluation and potential prophylaxis. Delaying reporting (C) reduces the effectiveness of post-exposure
prophylaxis. Squeezing (D) may force pathogens deeper into tissues.
Question 5.
A nurse is caring for a patient who is confused and repeatedly tries to remove their IV catheter. The nurse has tried
reorientation and distraction without success. The nurse's next appropriate action is to:
A. Apply wrist restraints to prevent the patient from pulling out the IV.
B. Request a sitter or implement alternative safety measures before considering restraints.
C. Sedate the patient with PRN antipsychotics ordered for agitation.
D. Remove the IV and discontinue all IV medications.
Correct Answer: B
Rationale:
Restraints are a last resort and require a provider's order, frequent monitoring, and documentation of less restrictive
alternatives attempted first. Alternatives include a patient sitter, camouflaging the IV, mittens, lowering the bed, increasing
supervision, and addressing underlying causes of confusion (pain, infection, hypoxia). Sedation (C) without assessment
is inappropriate. Removing necessary IV access (D) compromises patient care.
Question 6.
Page 2
, A nurse is caring for a patient who has a do-not-resuscitate (DNR) order. The patient goes into cardiac arrest. The nurse
should:
A. Initiate CPR immediately while verifying the DNR order.
B. Honour the DNR order and provide comfort measures only.
C. Call a code blue and begin resuscitation unless the family objects.
D. Ask the family what they want the nurse to do before taking action.
Correct Answer: B
Rationale:
A valid, documented DNR order is a legally binding advance directive that reflects the patient's wishes to forgo
resuscitation. The nurse must honour the DNR and focus on comfort measures, supporting the family, and ensuring a
dignified death. Initiating CPR (A) or calling a code (C) violates the patient's autonomy and constitutes battery. The family's
wishes do not override a valid patient directive (D).
Question 7.
A nurse is caring for a patient who is scheduled for surgery. The patient signed the informed consent form yesterday but
now states, 'I don't want the surgery anymore.' The nurse should:
A. Explain that the consent is already signed and cannot be withdrawn.
B. Notify the surgeon immediately and document the patient's decision.
C. Convince the patient that the surgery is necessary for their health.
D. Ask the family to persuade the patient to proceed with the surgery.
Correct Answer: B
Rationale:
Informed consent is an ongoing process, not a one-time signature. Patients have the absolute right to withdraw consent
at any time before a procedure. The nurse must immediately notify the surgeon, support the patient's decision without
judgment, and document the patient's refusal thoroughly. Forcing or coercing a patient (A, C, D) violates ethical principles
of autonomy and informed consent.
Question 8.
A nurse is reviewing a patient's advance directive and notes a living will and a durable power of attorney for healthcare.
The nurse understands that the durable power of attorney for healthcare:
A. Goes into effect only after the patient's death.
B. Designates a specific person to make healthcare decisions when the patient is unable.
C. Is only valid in the state where it was originally created.
D. Cannot be revoked once the patient becomes incapacitated.
Correct Answer: B
Rationale:
Page 3
And Answers With Rationale | 2026/2027 Updates
Question 1.
A nurse is performing a head-to-toe assessment on a newly admitted patient. When assessing the skin, the nurse notes
tenting when pinching the skin on the back of the hand. This finding indicates:
A. Edema.
B. Dehydration.
C. Hypervolemia.
D. Peripheral vascular disease.
Correct Answer: B
Rationale:
Skin tenting (poor skin turgor) occurs when the skin remains elevated after being pinched and released, indicating
decreased skin elasticity due to dehydration or aging. In older adults, decreased turgor may be normal, but in younger
adults it strongly suggests fluid deficit. Edema (A) causes skin that pits or remains indented. Hypervolemia (C) does not
affect turgor in this way. Peripheral vascular disease (D) affects color, temperature, and pulses, not turgor.
Question 2.
A nurse is caring for a patient who is deaf and uses American Sign Language (ASL). An ASL interpreter is present during
the admission assessment. The nurse should:
A. Speak directly to the interpreter to ensure accurate communication.
B. Speak directly to the patient while facing them, allowing the interpreter to facilitate communication.
C. Ask the patient's family member to interpret to save time.
D. Write all questions on paper to avoid the need for an interpreter.
Correct Answer: B
Rationale:
When working with an interpreter, the nurse should always speak directly to the patient (not the interpreter), maintain eye
contact with the patient, and use first-person language. The interpreter facilitates communication but the therapeutic
relationship is between the nurse and patient. Using family members as interpreters (C) violates patient privacy and may
result in inaccurate translation. Writing notes (D) is inappropriate for a patient whose primary language is ASL.
Question 3.
A nurse is caring for a patient who has just been diagnosed with terminal cancer. The patient asks, 'Am I going to die?'
The nurse's most therapeutic response is:
A. 'Don't think about that right now. Let's focus on your treatment.'
B. 'What are your thoughts and fears about your diagnosis?'
C. 'Yes, but we don't know when. Everyone dies eventually.'
Page 1
,D. 'You should talk to your doctor about that question.'
Correct Answer: B
Rationale:
Therapeutic communication involves exploring the patient's feelings and concerns rather than providing false reassurance
(A), blunt answers (C), or deflecting (D). Asking open-ended questions allows the patient to express emotions, fears, and
needs, enabling the nurse to provide appropriate support, resources, and referrals. This approach respects patient
autonomy and promotes emotional coping.
Question 4.
A nurse witnesses a needlestick injury after recapping a used syringe. The nurse's first action is to:
A. Wash the area with soap and water and report the incident immediately.
B. Apply pressure to the wound and cover with a bandage.
C. Wait to see if symptoms develop before reporting.
D. Squeeze the wound to express any contaminated blood.
Correct Answer: A
Rationale:
After a needlestick or sharps injury, the nurse should immediately wash the area with soap and water (do not squeeze,
scrub, or use bleach), then report the incident to occupational health or the designated authority immediately for post-
exposure evaluation and potential prophylaxis. Delaying reporting (C) reduces the effectiveness of post-exposure
prophylaxis. Squeezing (D) may force pathogens deeper into tissues.
Question 5.
A nurse is caring for a patient who is confused and repeatedly tries to remove their IV catheter. The nurse has tried
reorientation and distraction without success. The nurse's next appropriate action is to:
A. Apply wrist restraints to prevent the patient from pulling out the IV.
B. Request a sitter or implement alternative safety measures before considering restraints.
C. Sedate the patient with PRN antipsychotics ordered for agitation.
D. Remove the IV and discontinue all IV medications.
Correct Answer: B
Rationale:
Restraints are a last resort and require a provider's order, frequent monitoring, and documentation of less restrictive
alternatives attempted first. Alternatives include a patient sitter, camouflaging the IV, mittens, lowering the bed, increasing
supervision, and addressing underlying causes of confusion (pain, infection, hypoxia). Sedation (C) without assessment
is inappropriate. Removing necessary IV access (D) compromises patient care.
Question 6.
Page 2
, A nurse is caring for a patient who has a do-not-resuscitate (DNR) order. The patient goes into cardiac arrest. The nurse
should:
A. Initiate CPR immediately while verifying the DNR order.
B. Honour the DNR order and provide comfort measures only.
C. Call a code blue and begin resuscitation unless the family objects.
D. Ask the family what they want the nurse to do before taking action.
Correct Answer: B
Rationale:
A valid, documented DNR order is a legally binding advance directive that reflects the patient's wishes to forgo
resuscitation. The nurse must honour the DNR and focus on comfort measures, supporting the family, and ensuring a
dignified death. Initiating CPR (A) or calling a code (C) violates the patient's autonomy and constitutes battery. The family's
wishes do not override a valid patient directive (D).
Question 7.
A nurse is caring for a patient who is scheduled for surgery. The patient signed the informed consent form yesterday but
now states, 'I don't want the surgery anymore.' The nurse should:
A. Explain that the consent is already signed and cannot be withdrawn.
B. Notify the surgeon immediately and document the patient's decision.
C. Convince the patient that the surgery is necessary for their health.
D. Ask the family to persuade the patient to proceed with the surgery.
Correct Answer: B
Rationale:
Informed consent is an ongoing process, not a one-time signature. Patients have the absolute right to withdraw consent
at any time before a procedure. The nurse must immediately notify the surgeon, support the patient's decision without
judgment, and document the patient's refusal thoroughly. Forcing or coercing a patient (A, C, D) violates ethical principles
of autonomy and informed consent.
Question 8.
A nurse is reviewing a patient's advance directive and notes a living will and a durable power of attorney for healthcare.
The nurse understands that the durable power of attorney for healthcare:
A. Goes into effect only after the patient's death.
B. Designates a specific person to make healthcare decisions when the patient is unable.
C. Is only valid in the state where it was originally created.
D. Cannot be revoked once the patient becomes incapacitated.
Correct Answer: B
Rationale:
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