NSG 122 Exam 4 V1 | NSG 122 Nursing
Fundamental Concepts | Herzing | 2026 Q&A with
Rationale (Herzing NSG122 Exam 4 2026)
1. A nurse is assessing a client who is 6 hours postoperative following abdominal surgery. The
client has not voided since the procedure. Which is the priority action for the nurse to take?
A. Perform a bladder scan to assess for urinary retention.
B. Encourage the client to increase oral fluid intake.
C. Insert an indwelling urinary catheter immediately.
D. Notify the provider that the client has not voided.
Correct Answer: A
Explanation: Bladder scanning is a non-invasive method to determine the volume of urine
in the bladder. This assessment should be performed before more invasive measures like
catheterization. The nurse must first confirm if the bladder is full before intervening or
calling the provider.
2. A client is diagnosed with a stage 3 pressure injury on the sacrum. Which of the following
findings should the nurse expect to observe?
A. Non-blanchable erythema of intact skin.
B. Full-thickness tissue loss with visible subcutaneous fat.
C. Partial-thickness loss of dermis appearing as a shallow open ulcer.
,D. Full-thickness tissue loss with exposed bone, tendon, or muscle.
Correct Answer: B
Explanation: A stage 3 pressure injury involves full-thickness tissue loss where
subcutaneous fat may be visible, but bone, tendon, or muscle are not exposed. Slough or
eschar may be present but does not obscure the depth of tissue loss. This stage indicates
significant damage to the integumentary layers requiring targeted wound care.
3. Which of the following electrolyte imbalances is most closely associated with the
development of muscle weakness and cardiac dysrhythmias?
A. Hypokalemia
B. Hypercalcemia
C. Hyponatremia
D. Hypomagnesemia
Correct Answer: A
Explanation: Hypokalemia, or low serum potassium, directly affects the resting membrane
potential of muscle cells, including the heart. This imbalance frequently leads to muscle
weakness, leg cramps, and potentially fatal cardiac arrhythmias. Monitoring potassium
levels is a critical nursing priority for patients on diuretics or with gastrointestinal losses.
4. A nurse is providing discharge teaching for a client with a new colostomy. Which statement
by the client indicates a need for further teaching?
A. I should empty my pouch when it is one-third full.
, B. I will cut the wafer 1/8 inch larger than my stoma.
C. I can expect the stoma to stay a dark purple color.
D. I will clean the skin around the stoma with warm water.
Correct Answer: C
Explanation: A healthy stoma should appear red or pink and moist, similar to the mucous
membranes of the mouth. A dark purple or blue color indicates ischemia or poor blood flow
and must be reported to the surgeon immediately. The other statements reflect correct
ostomy care practices regarding pouch emptying and wafer fitting.
5. The nurse is preparing to administer a cleansing enema to a client. In which position should
the nurse place the client?
A. Dorsal recumbent
B. Right lateral position
C. Left Sims’ position
D. High-Fowler’s position
Correct Answer: C
Explanation: The left Sims’ position allows the enema solution to flow downward by
gravity into the sigmoid colon and rectum. This position also provides better access to the
rectal area and is more comfortable for the client. Using the correct positioning minimizes
the risk of injury and maximizes the effectiveness of the procedure.
Fundamental Concepts | Herzing | 2026 Q&A with
Rationale (Herzing NSG122 Exam 4 2026)
1. A nurse is assessing a client who is 6 hours postoperative following abdominal surgery. The
client has not voided since the procedure. Which is the priority action for the nurse to take?
A. Perform a bladder scan to assess for urinary retention.
B. Encourage the client to increase oral fluid intake.
C. Insert an indwelling urinary catheter immediately.
D. Notify the provider that the client has not voided.
Correct Answer: A
Explanation: Bladder scanning is a non-invasive method to determine the volume of urine
in the bladder. This assessment should be performed before more invasive measures like
catheterization. The nurse must first confirm if the bladder is full before intervening or
calling the provider.
2. A client is diagnosed with a stage 3 pressure injury on the sacrum. Which of the following
findings should the nurse expect to observe?
A. Non-blanchable erythema of intact skin.
B. Full-thickness tissue loss with visible subcutaneous fat.
C. Partial-thickness loss of dermis appearing as a shallow open ulcer.
,D. Full-thickness tissue loss with exposed bone, tendon, or muscle.
Correct Answer: B
Explanation: A stage 3 pressure injury involves full-thickness tissue loss where
subcutaneous fat may be visible, but bone, tendon, or muscle are not exposed. Slough or
eschar may be present but does not obscure the depth of tissue loss. This stage indicates
significant damage to the integumentary layers requiring targeted wound care.
3. Which of the following electrolyte imbalances is most closely associated with the
development of muscle weakness and cardiac dysrhythmias?
A. Hypokalemia
B. Hypercalcemia
C. Hyponatremia
D. Hypomagnesemia
Correct Answer: A
Explanation: Hypokalemia, or low serum potassium, directly affects the resting membrane
potential of muscle cells, including the heart. This imbalance frequently leads to muscle
weakness, leg cramps, and potentially fatal cardiac arrhythmias. Monitoring potassium
levels is a critical nursing priority for patients on diuretics or with gastrointestinal losses.
4. A nurse is providing discharge teaching for a client with a new colostomy. Which statement
by the client indicates a need for further teaching?
A. I should empty my pouch when it is one-third full.
, B. I will cut the wafer 1/8 inch larger than my stoma.
C. I can expect the stoma to stay a dark purple color.
D. I will clean the skin around the stoma with warm water.
Correct Answer: C
Explanation: A healthy stoma should appear red or pink and moist, similar to the mucous
membranes of the mouth. A dark purple or blue color indicates ischemia or poor blood flow
and must be reported to the surgeon immediately. The other statements reflect correct
ostomy care practices regarding pouch emptying and wafer fitting.
5. The nurse is preparing to administer a cleansing enema to a client. In which position should
the nurse place the client?
A. Dorsal recumbent
B. Right lateral position
C. Left Sims’ position
D. High-Fowler’s position
Correct Answer: C
Explanation: The left Sims’ position allows the enema solution to flow downward by
gravity into the sigmoid colon and rectum. This position also provides better access to the
rectal area and is more comfortable for the client. Using the correct positioning minimizes
the risk of injury and maximizes the effectiveness of the procedure.
