NSG 3100 Exam 4 | Fundamentals of
Nursing
TEST BANK & SUCCESS GUIDE (2026/2027) - GALEN COLLEGE
(1) A nurse is preparing to administer an intramuscular (IM) injection to an infant.
Which site is the most appropriate?
A. Deltoid
B. Dorsogluteal
C. Ventrogluteal
D. Vastus lateralis
CORRECT ANSWER: D
Clinical Rationale: The vastus lateralis (anterolateral thigh) is the preferred site for IM
injections in infants because it is the most developed muscle at that age and lacks major
nerves or blood vessels.
(2) A nurse is checking the 'Six Rights' of medication administration. Which of the
following is included in these rights?
A. Right Physician
B. Right Room
C. Right Documentation
D. Right Diagnosis
CORRECT ANSWER: C
Clinical Rationale: The six rights are: Right Patient, Right Medication, Right Dose, Right
Route, Right Time, and Right Documentation.
,(3) A nurse notes that a client's peripheral IV site is cool to the touch, swollen, and the
infusion has slowed. Which complication should the nurse suspect?
A. Phlebitis
B. Infiltration
C. Extravasation
D. Air Embolism
CORRECT ANSWER: B
Clinical Rationale: Infiltration is the leakage of non-vesicant IV fluid into the tissue, causing
coolness, pallor, and swelling. Phlebitis would be warm and red.
(4) During the pre-operative assessment, a client tells the nurse they have a severe
allergy to kiwi and bananas. This information is critical because it may indicate a
potential allergy to:
A. Penicillin
B. Latex
C. Iodine
D. Propofol
CORRECT ANSWER: B
Clinical Rationale: There is a known cross-sensitivity between certain fruits (kiwi, banana,
avocado) and latex due to similar protein structures.
,(5) The nurse is providing discharge instructions to a client after a surgical procedure.
What is the most effective way to confirm the client understands the instructions?
A. Asking 'Do you have any questions?'
B. Providing a printed brochure.
C. Asking the client to perform a 'teach-back'.
D. Having the client sign the instruction sheet.
CORRECT ANSWER: C
Clinical Rationale: The 'teach-back' method is the gold standard for verifying
understanding and ensures the client can correctly explain or demonstrate the information
provided.
(6) A nurse is assessing a pressure injury and notes a full-thickness skin loss with visible
subcutaneous fat, but bone and muscle are not exposed. How should this be staged?
A. Stage I
B. Stage II
C. Stage III
D. Stage IV
CORRECT ANSWER: C
Clinical Rationale: Stage III involves full-thickness tissue loss where fat may be visible, but
bone, tendon, or muscle are NOT exposed. Stage IV involves exposed bone or muscle.
, (7) A nurse is caring for a client with an indwelling urinary catheter. Which intervention
is most important for preventing a Catheter-Associated Urinary Tract Infection (CAUTI)?
A. Cleaning the urinary meatus with antiseptic daily.
B. Keeping the drainage bag below the level of the bladder.
C. Irrigating the catheter every 8 hours.
D. Changing the catheter every 7 days.
CORRECT ANSWER: B
Clinical Rationale: Maintaining a closed system and keeping the bag below the bladder
prevents the backflow of urine (which may be contaminated) into the bladder, significantly
reducing infection risk.
(8) A nurse is assessing a client with a new colostomy. The stoma appears beefy-red and
moist. What is the nurse's best action?
A. Notify the surgeon immediately.
B. Apply a dry, sterile dressing.
C. Document the finding as normal.
D. Clean the stoma with alcohol.
CORRECT ANSWER: C
Clinical Rationale: A healthy stoma should be moist and beefy-red (similar to the inside of
the cheek). If it is pale, dusky, or black, it indicates a lack of blood flow and is an emergency.
Nursing
TEST BANK & SUCCESS GUIDE (2026/2027) - GALEN COLLEGE
(1) A nurse is preparing to administer an intramuscular (IM) injection to an infant.
Which site is the most appropriate?
A. Deltoid
B. Dorsogluteal
C. Ventrogluteal
D. Vastus lateralis
CORRECT ANSWER: D
Clinical Rationale: The vastus lateralis (anterolateral thigh) is the preferred site for IM
injections in infants because it is the most developed muscle at that age and lacks major
nerves or blood vessels.
(2) A nurse is checking the 'Six Rights' of medication administration. Which of the
following is included in these rights?
A. Right Physician
B. Right Room
C. Right Documentation
D. Right Diagnosis
CORRECT ANSWER: C
Clinical Rationale: The six rights are: Right Patient, Right Medication, Right Dose, Right
Route, Right Time, and Right Documentation.
,(3) A nurse notes that a client's peripheral IV site is cool to the touch, swollen, and the
infusion has slowed. Which complication should the nurse suspect?
A. Phlebitis
B. Infiltration
C. Extravasation
D. Air Embolism
CORRECT ANSWER: B
Clinical Rationale: Infiltration is the leakage of non-vesicant IV fluid into the tissue, causing
coolness, pallor, and swelling. Phlebitis would be warm and red.
(4) During the pre-operative assessment, a client tells the nurse they have a severe
allergy to kiwi and bananas. This information is critical because it may indicate a
potential allergy to:
A. Penicillin
B. Latex
C. Iodine
D. Propofol
CORRECT ANSWER: B
Clinical Rationale: There is a known cross-sensitivity between certain fruits (kiwi, banana,
avocado) and latex due to similar protein structures.
,(5) The nurse is providing discharge instructions to a client after a surgical procedure.
What is the most effective way to confirm the client understands the instructions?
A. Asking 'Do you have any questions?'
B. Providing a printed brochure.
C. Asking the client to perform a 'teach-back'.
D. Having the client sign the instruction sheet.
CORRECT ANSWER: C
Clinical Rationale: The 'teach-back' method is the gold standard for verifying
understanding and ensures the client can correctly explain or demonstrate the information
provided.
(6) A nurse is assessing a pressure injury and notes a full-thickness skin loss with visible
subcutaneous fat, but bone and muscle are not exposed. How should this be staged?
A. Stage I
B. Stage II
C. Stage III
D. Stage IV
CORRECT ANSWER: C
Clinical Rationale: Stage III involves full-thickness tissue loss where fat may be visible, but
bone, tendon, or muscle are NOT exposed. Stage IV involves exposed bone or muscle.
, (7) A nurse is caring for a client with an indwelling urinary catheter. Which intervention
is most important for preventing a Catheter-Associated Urinary Tract Infection (CAUTI)?
A. Cleaning the urinary meatus with antiseptic daily.
B. Keeping the drainage bag below the level of the bladder.
C. Irrigating the catheter every 8 hours.
D. Changing the catheter every 7 days.
CORRECT ANSWER: B
Clinical Rationale: Maintaining a closed system and keeping the bag below the bladder
prevents the backflow of urine (which may be contaminated) into the bladder, significantly
reducing infection risk.
(8) A nurse is assessing a client with a new colostomy. The stoma appears beefy-red and
moist. What is the nurse's best action?
A. Notify the surgeon immediately.
B. Apply a dry, sterile dressing.
C. Document the finding as normal.
D. Clean the stoma with alcohol.
CORRECT ANSWER: C
Clinical Rationale: A healthy stoma should be moist and beefy-red (similar to the inside of
the cheek). If it is pale, dusky, or black, it indicates a lack of blood flow and is an emergency.
