NSG 3130 Exam 2 V1 | NSG 3130 Fundamental
Concepts & Skills for Nursing Practice II | Actual
Q&A with Rationale (NSG3130 Exam 2) | Galen
College of Nursing
1. A nurse is preparing to witness a client signing an informed consent form for an elective
surgery. Which of the following is the nurse’s primary responsibility in this process?
A. To explain the risks and benefits of the procedure to the client
B. To provide alternative treatment options to the client
C. To verify that the client is competent and signing voluntarily
D. To document the client’s medical history before the signature
Correct Answer: C
Explanation: The nurse’s primary role in witnessing informed consent is to confirm the
client is signing the document voluntarily and appears competent to do so. It is the
surgeon’s legal responsibility to explain the risks, benefits, and alternatives of the
procedure. The nurse acts as a witness to the signature and the client’s understanding that
they are signing the form.
2. A postoperative client has developed an evisceration of the abdominal wound. What is the
immediate priority action for the nurse?
A. Attempt to reinsert the protruding organs gently into the cavity
B. Apply a clean, dry pressure dressing to the site
,C. Place the client in a high-Fowler’s position to reduce abdominal pressure
D. Cover the protruding organs with sterile towels moistened with sterile normal saline
Correct Answer: D
Explanation: Evisceration is a medical emergency where internal organs protrude through
a surgical incision. The nurse must cover the organs with sterile, saline-soaked towels to
prevent drying and infection. The nurse should also notify the surgeon immediately and
maintain the client in a low-Fowler’s position with knees flexed to reduce tension on the
wound.
3. When administering an intramuscular (IM) injection using the Z-track method, what is the
primary rationale for this technique?
A. To prevent the medication from leaking back into the subcutaneous tissue
B. To minimize pain by avoiding nerve endings near the skin surface
C. To ensure the medication is deposited into the subcutaneous tissue
D. To increase the speed of medication absorption into the bloodstream
Correct Answer: A
Explanation: The Z-track method involves pulling the skin and subcutaneous tissue to the
side before inserting the needle. This creates a zigzag path that seals the medication within
the muscle layer once the tissue is released. This technique is particularly important for
irritating medications to prevent tissue damage and staining.
, 4. A nurse is assessing a client’s intravenous (IV) site and notes that the area is cool, pale, and
swollen. The client reports a feeling of tightness. Which complication should the nurse
suspect?
A. Phlebitis
B. Infiltration
C. Extravasation
D. Thrombophlebitis
Correct Answer: B
Explanation: Infiltration occurs when non-vesicant IV fluid leaks into the surrounding
subcutaneous tissue, characterized by coolness, pallor, and edema. Phlebitis, by contrast,
involves warmth and redness along the vein. The nurse must stop the infusion immediately
and elevate the extremity to promote fluid reabsorption.
5. Which of the following clinical findings is the earliest indicator of malignant hyperthermia
in a patient undergoing general anesthesia?
A. A rapid rise in body temperature to 105 F
B. Tachycardia and tachypnea
C. Generalized muscle rigidity
D. Hyperkalemia and metabolic acidosis
Correct Answer: B
Concepts & Skills for Nursing Practice II | Actual
Q&A with Rationale (NSG3130 Exam 2) | Galen
College of Nursing
1. A nurse is preparing to witness a client signing an informed consent form for an elective
surgery. Which of the following is the nurse’s primary responsibility in this process?
A. To explain the risks and benefits of the procedure to the client
B. To provide alternative treatment options to the client
C. To verify that the client is competent and signing voluntarily
D. To document the client’s medical history before the signature
Correct Answer: C
Explanation: The nurse’s primary role in witnessing informed consent is to confirm the
client is signing the document voluntarily and appears competent to do so. It is the
surgeon’s legal responsibility to explain the risks, benefits, and alternatives of the
procedure. The nurse acts as a witness to the signature and the client’s understanding that
they are signing the form.
2. A postoperative client has developed an evisceration of the abdominal wound. What is the
immediate priority action for the nurse?
A. Attempt to reinsert the protruding organs gently into the cavity
B. Apply a clean, dry pressure dressing to the site
,C. Place the client in a high-Fowler’s position to reduce abdominal pressure
D. Cover the protruding organs with sterile towels moistened with sterile normal saline
Correct Answer: D
Explanation: Evisceration is a medical emergency where internal organs protrude through
a surgical incision. The nurse must cover the organs with sterile, saline-soaked towels to
prevent drying and infection. The nurse should also notify the surgeon immediately and
maintain the client in a low-Fowler’s position with knees flexed to reduce tension on the
wound.
3. When administering an intramuscular (IM) injection using the Z-track method, what is the
primary rationale for this technique?
A. To prevent the medication from leaking back into the subcutaneous tissue
B. To minimize pain by avoiding nerve endings near the skin surface
C. To ensure the medication is deposited into the subcutaneous tissue
D. To increase the speed of medication absorption into the bloodstream
Correct Answer: A
Explanation: The Z-track method involves pulling the skin and subcutaneous tissue to the
side before inserting the needle. This creates a zigzag path that seals the medication within
the muscle layer once the tissue is released. This technique is particularly important for
irritating medications to prevent tissue damage and staining.
, 4. A nurse is assessing a client’s intravenous (IV) site and notes that the area is cool, pale, and
swollen. The client reports a feeling of tightness. Which complication should the nurse
suspect?
A. Phlebitis
B. Infiltration
C. Extravasation
D. Thrombophlebitis
Correct Answer: B
Explanation: Infiltration occurs when non-vesicant IV fluid leaks into the surrounding
subcutaneous tissue, characterized by coolness, pallor, and edema. Phlebitis, by contrast,
involves warmth and redness along the vein. The nurse must stop the infusion immediately
and elevate the extremity to promote fluid reabsorption.
5. Which of the following clinical findings is the earliest indicator of malignant hyperthermia
in a patient undergoing general anesthesia?
A. A rapid rise in body temperature to 105 F
B. Tachycardia and tachypnea
C. Generalized muscle rigidity
D. Hyperkalemia and metabolic acidosis
Correct Answer: B
