STUVIA | ORIGINAL EXAM STUDY BANK
A+ VERIFIED
NSG 3130 - EXAM 1
Fundamental Concepts & Skills for Nursing Practice
II
Galen College of Nursing | BSN Program
200 Multiple Choice
QUESTIONS FORMAT VERSION
WHAT THIS COVERS
Vital Signs & Assessment Infection Control & Safety
Temperature, pulse, respiration, blood pressure, pulse oximetry, Hand hygiene, PPE, standard and transmission-based precautions,
pain assessment and abnormal finding interpretation. sterile technique and needlestick response.
Medication Administration IV Therapy & Electrolytes
Rights of medication, dosage calculation, routes (PO, IM, subQ, ID, Peripheral and central lines, infiltration and phlebitis, fluid and
IV), high-alert drugs and reconciliation. electrolyte imbalances and replacement.
Wound, Ostomy & Skin Perioperative & Mobility
PressureTHIS
ABOUT injury staging, wound assessment and dressing selection,
ASSESSMENT Pre-op preparation, post-op PACU care, transfer and ambulation,
colostomy and urostomy care, skin integrity. traction, immobility complications and fall prevention.
This assessment evaluates a BSN students mastery of intermediate nursing fundamentals required for safe clinical practice.
Items span vital sign interpretation, infection control, medication and IV therapy, wound and ostomy care, perioperative
management, mobility, sensory and sleep alterations, pain management, ethics, cultural competence, and end-of-life care. Each
item presents a clinical scenario requiring selection of the single best nursing response supported by a rationale grounded in
evidence-based practice and current standards. The bank is original content authored for study use; it does not reproduce any
official Galen College examination or any publisher test bank.
NSG 3130 - EXAM 1 | VERSION 2026-2027 | 200 ITEMS ANSWER KEY + RATIONALE | A+ VERIFIED
STUVIA ACTUAL EXAM
,NSG 3130 - EXAM 1 NSG3130 Fundamentals II
EXAM QUESTIONS - MULTIPLE CHOICE
1. A nurse is preparing to take an oral temperature on an adult patient who just finished drinking a cup of hot coffee. Which
action is most appropriate?
A. Take the temperature immediately and document the time of the coffee.
B. Wait 15 to 30 minutes to allow the oral mucosa to return to baseline, then take the temperature.
C. Take a rectal temperature instead, regardless of patient condition.
D. Take an axillary temperature because it is unaffected by oral intake.
Correct Answer: B
Rationale: Hot or cold beverages alter oral temperature readings for 15 to 30 minutes after consumption. The nurse should wait to ensure an
accurate reading. Axillary readings are less accurate and affected by ambient temperature. Rectal temperatures are contraindicated in
certain conditions like recent rectal surgery or neutropenia.
2. A nurse obtains a blood pressure reading of 148/96 mmHg on a 60-year-old patient with no prior hypertension history. The
nurse should first:
A. Document the finding and notify the provider after the shift.
B. Recheck the blood pressure in the opposite arm after the patient rests for 5 minutes.
C. Administer a PRN antihypertensive immediately.
D. Place the patient in Trendelenburg position.
Correct Answer: B
Rationale: An elevated blood pressure reading should be confirmed by rechecking in the opposite arm after the patient rests quietly for at
least 5 minutes. This rules out anxiety, equipment malfunction, or positional causes. Trendelenburg is contraindicated in hypertension. PRN
medications require a provider order.
3. A nurse is assessing an apical pulse on an adult patient. The stethoscope should be placed at the:
A. Second intercostal space, right sternal border.
B. Fifth intercostal space, midclavicular line.
C. Third intercostal space, left sternal border.
D. First intercostal space, midclavicular line.
Correct Answer: B
Rationale: The apical pulse is auscultated at the fifth intercostal space at the midclavicular line (the point of maximum impulse). This
location overlies the apex of the heart and provides the most accurate heart rate. Apical pulse is taken for 1 full minute when assessing
irregular rhythms or in pediatric patients.
4. A nurse is caring for a patient with a respiratory rate of 8 breaths per minute after receiving opioid analgesia. The priority
nursing action is to:
A. Continue to monitor the patient; this is an expected side effect of opioids.
B. Administer naloxone per protocol and notify the provider.
C. Increase the opioid dose to control pain.
D. Document the finding and recheck in 1 hour.
Correct Answer: B
Rationale: A respiratory rate of 8 breaths per minute indicates opioid-induced respiratory depression, which can progress to apnea and
death. Naloxone (Narcan) is the opioid antagonist and should be administered per protocol while notifying the provider. Continued
monitoring without intervention is unsafe.
STUVIA ACTUAL EXAM | ORIGINAL STUDY CONTENT Page 2
,5. When measuring blood pressure, the bladder of the blood pressure cuff should encircle at least what percentage of the
upper arm circumference?
A. 40 percent.
B. 60 percent.
C. 80 percent.
D. 100 percent.
Correct Answer: C
Rationale: The cuff bladder should encircle at least 80 percent of the arm circumference to obtain an accurate reading. A cuff that is too
small yields falsely high readings; one that is too large yields falsely low readings. The bladder width should be approximately 40 percent
of the arm circumference.
6. A nurse is measuring a patient's oxygen saturation using pulse oximetry and obtains a reading of 88 percent on room air.
The patient has dark nail polish. The nurse should:
A. Document the reading as accurate.
B. Remove the nail polish or use an alternate site such as an earlobe or toe, then recheck.
C. Switch to a forehead sensor only if the patient is on oxygen.
D. Increase the oxygen flow without rechecking.
Correct Answer: B
Rationale: Dark nail polish can interfere with pulse oximetry readings. The nurse should remove the polish or use an alternate site such as
the earlobe, toe, or forehead. A reading of 88 percent indicates hypoxemia and requires follow-up, but an accurate reading is needed first
before interventions.
7. A nurse is caring for a patient whose pulse oximetry reading is 90 percent on 2 liters of oxygen via nasal cannula. The
patient has a history of COPD. The nurse understands that:
A. The reading is inaccurate and should be ignored.
B. An SpO2 of 88 to 92 percent is generally acceptable for patients with COPD due to their reliance on hypoxic drive.
C. The patient should be placed on 100 percent oxygen via non-rebreather.
D. The reading is too high; reduce the oxygen.
Correct Answer: B
Rationale: For most patients with COPD, an SpO2 of 88 to 92 percent is the target range. Higher oxygen levels can suppress the hypoxic
drive and lead to CO2 retention. Excessive oxygen can worsen hypercapnia. Blood gases are needed to fully evaluate respiratory status.
8. A nurse is caring for a patient with a fever of 102 degrees Fahrenheit. The patient is diaphoretic and reports chills. The
priority nursing intervention is to:
A. Apply a cooling blanket immediately.
B. Encourage oral fluid intake, monitor vital signs, and administer antipyretics as ordered.
C. Restrict fluids to prevent fluid overload.
D. Bathe the patient in ice water.
Correct Answer: B
Rationale: Fever increases metabolic rate and fluid losses through sweating. The nurse should encourage oral fluids, administer
antipyretics per order, monitor vital signs, and use tepid sponging if needed. Ice water baths cause shivering, which increases core
temperature. Cooling blankets are used for hyperthermia, not simple fever.
, 9. A nurse is assessing an adult patient's radial pulse and notes an irregular rhythm. The appropriate action is to:
A. Document the rate only.
B. Auscultate an apical pulse for 1 full minute and compare to the radial pulse to identify any pulse deficit.
C. Recheck the radial pulse in 4 hours.
D. Apply oxygen at 2 liters via nasal cannula.
Correct Answer: B
Rationale: An irregular radial pulse requires auscultation of the apical pulse for a full 60 seconds. Comparing the apical and radial rates
identifies a pulse deficit, indicating that not all heartbeats are perfusing to the periphery. Pulse deficits are common in atrial fibrillation
and warrant provider notification.
10. A nurse is teaching a patient about home blood pressure monitoring. The nurse should instruct the patient to:
A. Measure blood pressure immediately after exercising.
B. Sit quietly for 5 minutes with feet flat on the floor and arm supported at heart level before measuring.
C. Use any size cuff that fits over the arm.
D. Take the reading after drinking caffeinated coffee.
Correct Answer: B
Rationale: Accurate home blood pressure monitoring requires the patient to sit quietly for 5 minutes with feet flat on the floor, back
supported, and arm at heart level. Caffeine, exercise, and smoking can transiently elevate readings. An appropriately sized cuff is
essential for accuracy.
11. A nurse is caring for a patient on contact precautions for Clostridioides difficile infection. The minimum personal
protective equipment required for entry to the room is:
A. Surgical mask only.
B. Gown and gloves.
C. N95 respirator and eye protection.
D. Goggles only.
Correct Answer: B
Rationale: C. difficile spores are transmitted via the fecal-oral route and require contact precautions with gown and gloves.
Soap-and-water handwashing (not alcohol-based hand rubs) is required because alcohol does not kill spores. N95 respirators are for
airborne precautions.
12. A nurse is performing hand hygiene before patient contact. The patient has no known multidrug-resistant organism.
Which type of hand hygiene is appropriate?
A. Alcohol-based hand rub for at least 15 seconds if hands are not visibly soiled.
B. Surgical scrub with chlorhexidine for 5 minutes.
C. Soap and water for 30 seconds only.
D. No hand hygiene needed for routine contact.
Correct Answer: A
Rationale: Alcohol-based hand rub is the preferred method for routine hand hygiene when hands are not visibly soiled. It is fast, effective
against most pathogens, and better tolerated by staff. Soap and water is required for visible soiling, C. difficile, norovirus, or Bacillus
anthracis.
A+ VERIFIED
NSG 3130 - EXAM 1
Fundamental Concepts & Skills for Nursing Practice
II
Galen College of Nursing | BSN Program
200 Multiple Choice
QUESTIONS FORMAT VERSION
WHAT THIS COVERS
Vital Signs & Assessment Infection Control & Safety
Temperature, pulse, respiration, blood pressure, pulse oximetry, Hand hygiene, PPE, standard and transmission-based precautions,
pain assessment and abnormal finding interpretation. sterile technique and needlestick response.
Medication Administration IV Therapy & Electrolytes
Rights of medication, dosage calculation, routes (PO, IM, subQ, ID, Peripheral and central lines, infiltration and phlebitis, fluid and
IV), high-alert drugs and reconciliation. electrolyte imbalances and replacement.
Wound, Ostomy & Skin Perioperative & Mobility
PressureTHIS
ABOUT injury staging, wound assessment and dressing selection,
ASSESSMENT Pre-op preparation, post-op PACU care, transfer and ambulation,
colostomy and urostomy care, skin integrity. traction, immobility complications and fall prevention.
This assessment evaluates a BSN students mastery of intermediate nursing fundamentals required for safe clinical practice.
Items span vital sign interpretation, infection control, medication and IV therapy, wound and ostomy care, perioperative
management, mobility, sensory and sleep alterations, pain management, ethics, cultural competence, and end-of-life care. Each
item presents a clinical scenario requiring selection of the single best nursing response supported by a rationale grounded in
evidence-based practice and current standards. The bank is original content authored for study use; it does not reproduce any
official Galen College examination or any publisher test bank.
NSG 3130 - EXAM 1 | VERSION 2026-2027 | 200 ITEMS ANSWER KEY + RATIONALE | A+ VERIFIED
STUVIA ACTUAL EXAM
,NSG 3130 - EXAM 1 NSG3130 Fundamentals II
EXAM QUESTIONS - MULTIPLE CHOICE
1. A nurse is preparing to take an oral temperature on an adult patient who just finished drinking a cup of hot coffee. Which
action is most appropriate?
A. Take the temperature immediately and document the time of the coffee.
B. Wait 15 to 30 minutes to allow the oral mucosa to return to baseline, then take the temperature.
C. Take a rectal temperature instead, regardless of patient condition.
D. Take an axillary temperature because it is unaffected by oral intake.
Correct Answer: B
Rationale: Hot or cold beverages alter oral temperature readings for 15 to 30 minutes after consumption. The nurse should wait to ensure an
accurate reading. Axillary readings are less accurate and affected by ambient temperature. Rectal temperatures are contraindicated in
certain conditions like recent rectal surgery or neutropenia.
2. A nurse obtains a blood pressure reading of 148/96 mmHg on a 60-year-old patient with no prior hypertension history. The
nurse should first:
A. Document the finding and notify the provider after the shift.
B. Recheck the blood pressure in the opposite arm after the patient rests for 5 minutes.
C. Administer a PRN antihypertensive immediately.
D. Place the patient in Trendelenburg position.
Correct Answer: B
Rationale: An elevated blood pressure reading should be confirmed by rechecking in the opposite arm after the patient rests quietly for at
least 5 minutes. This rules out anxiety, equipment malfunction, or positional causes. Trendelenburg is contraindicated in hypertension. PRN
medications require a provider order.
3. A nurse is assessing an apical pulse on an adult patient. The stethoscope should be placed at the:
A. Second intercostal space, right sternal border.
B. Fifth intercostal space, midclavicular line.
C. Third intercostal space, left sternal border.
D. First intercostal space, midclavicular line.
Correct Answer: B
Rationale: The apical pulse is auscultated at the fifth intercostal space at the midclavicular line (the point of maximum impulse). This
location overlies the apex of the heart and provides the most accurate heart rate. Apical pulse is taken for 1 full minute when assessing
irregular rhythms or in pediatric patients.
4. A nurse is caring for a patient with a respiratory rate of 8 breaths per minute after receiving opioid analgesia. The priority
nursing action is to:
A. Continue to monitor the patient; this is an expected side effect of opioids.
B. Administer naloxone per protocol and notify the provider.
C. Increase the opioid dose to control pain.
D. Document the finding and recheck in 1 hour.
Correct Answer: B
Rationale: A respiratory rate of 8 breaths per minute indicates opioid-induced respiratory depression, which can progress to apnea and
death. Naloxone (Narcan) is the opioid antagonist and should be administered per protocol while notifying the provider. Continued
monitoring without intervention is unsafe.
STUVIA ACTUAL EXAM | ORIGINAL STUDY CONTENT Page 2
,5. When measuring blood pressure, the bladder of the blood pressure cuff should encircle at least what percentage of the
upper arm circumference?
A. 40 percent.
B. 60 percent.
C. 80 percent.
D. 100 percent.
Correct Answer: C
Rationale: The cuff bladder should encircle at least 80 percent of the arm circumference to obtain an accurate reading. A cuff that is too
small yields falsely high readings; one that is too large yields falsely low readings. The bladder width should be approximately 40 percent
of the arm circumference.
6. A nurse is measuring a patient's oxygen saturation using pulse oximetry and obtains a reading of 88 percent on room air.
The patient has dark nail polish. The nurse should:
A. Document the reading as accurate.
B. Remove the nail polish or use an alternate site such as an earlobe or toe, then recheck.
C. Switch to a forehead sensor only if the patient is on oxygen.
D. Increase the oxygen flow without rechecking.
Correct Answer: B
Rationale: Dark nail polish can interfere with pulse oximetry readings. The nurse should remove the polish or use an alternate site such as
the earlobe, toe, or forehead. A reading of 88 percent indicates hypoxemia and requires follow-up, but an accurate reading is needed first
before interventions.
7. A nurse is caring for a patient whose pulse oximetry reading is 90 percent on 2 liters of oxygen via nasal cannula. The
patient has a history of COPD. The nurse understands that:
A. The reading is inaccurate and should be ignored.
B. An SpO2 of 88 to 92 percent is generally acceptable for patients with COPD due to their reliance on hypoxic drive.
C. The patient should be placed on 100 percent oxygen via non-rebreather.
D. The reading is too high; reduce the oxygen.
Correct Answer: B
Rationale: For most patients with COPD, an SpO2 of 88 to 92 percent is the target range. Higher oxygen levels can suppress the hypoxic
drive and lead to CO2 retention. Excessive oxygen can worsen hypercapnia. Blood gases are needed to fully evaluate respiratory status.
8. A nurse is caring for a patient with a fever of 102 degrees Fahrenheit. The patient is diaphoretic and reports chills. The
priority nursing intervention is to:
A. Apply a cooling blanket immediately.
B. Encourage oral fluid intake, monitor vital signs, and administer antipyretics as ordered.
C. Restrict fluids to prevent fluid overload.
D. Bathe the patient in ice water.
Correct Answer: B
Rationale: Fever increases metabolic rate and fluid losses through sweating. The nurse should encourage oral fluids, administer
antipyretics per order, monitor vital signs, and use tepid sponging if needed. Ice water baths cause shivering, which increases core
temperature. Cooling blankets are used for hyperthermia, not simple fever.
, 9. A nurse is assessing an adult patient's radial pulse and notes an irregular rhythm. The appropriate action is to:
A. Document the rate only.
B. Auscultate an apical pulse for 1 full minute and compare to the radial pulse to identify any pulse deficit.
C. Recheck the radial pulse in 4 hours.
D. Apply oxygen at 2 liters via nasal cannula.
Correct Answer: B
Rationale: An irregular radial pulse requires auscultation of the apical pulse for a full 60 seconds. Comparing the apical and radial rates
identifies a pulse deficit, indicating that not all heartbeats are perfusing to the periphery. Pulse deficits are common in atrial fibrillation
and warrant provider notification.
10. A nurse is teaching a patient about home blood pressure monitoring. The nurse should instruct the patient to:
A. Measure blood pressure immediately after exercising.
B. Sit quietly for 5 minutes with feet flat on the floor and arm supported at heart level before measuring.
C. Use any size cuff that fits over the arm.
D. Take the reading after drinking caffeinated coffee.
Correct Answer: B
Rationale: Accurate home blood pressure monitoring requires the patient to sit quietly for 5 minutes with feet flat on the floor, back
supported, and arm at heart level. Caffeine, exercise, and smoking can transiently elevate readings. An appropriately sized cuff is
essential for accuracy.
11. A nurse is caring for a patient on contact precautions for Clostridioides difficile infection. The minimum personal
protective equipment required for entry to the room is:
A. Surgical mask only.
B. Gown and gloves.
C. N95 respirator and eye protection.
D. Goggles only.
Correct Answer: B
Rationale: C. difficile spores are transmitted via the fecal-oral route and require contact precautions with gown and gloves.
Soap-and-water handwashing (not alcohol-based hand rubs) is required because alcohol does not kill spores. N95 respirators are for
airborne precautions.
12. A nurse is performing hand hygiene before patient contact. The patient has no known multidrug-resistant organism.
Which type of hand hygiene is appropriate?
A. Alcohol-based hand rub for at least 15 seconds if hands are not visibly soiled.
B. Surgical scrub with chlorhexidine for 5 minutes.
C. Soap and water for 30 seconds only.
D. No hand hygiene needed for routine contact.
Correct Answer: A
Rationale: Alcohol-based hand rub is the preferred method for routine hand hygiene when hands are not visibly soiled. It is fast, effective
against most pathogens, and better tolerated by staff. Soap and water is required for visible soiling, C. difficile, norovirus, or Bacillus
anthracis.
