NSG 3130 Fundamental Concepts Skills Nursing
II ACTUAL EXAM 2026/2027: 100% Verified
Questions & Correct Answers
Question 1:
A 68-year-old post-cholecystectomy client has a T-tube draining 450 mL of green-brown bile in the
first 8 h. The nurse’s priority action is to:
A. Clamp the tube and notify the surgeon.
B. Document the output and monitor for signs of dehydration.
C. Irrigate the tube with 30 mL normal saline.
D. Lower the bag below the incision and milk the tubing.
Correct Answer: B
Rationale: Initial high bile output is expected; accurate I&O and hydration assessment follow
evidence-based post-op care (Perry & Potter 2026).
Question 2:
,A client with a Stage III sacral pressure injury is receiving negative-pressure wound therapy
(NPWT) at –125 mmHg. During dressing change the nurse notes foam adherent to granulation
tissue. The nurse should:
A. Rapidly remove the foam to minimize pain.
B. Irrigate under the foam with sterile saline to loosen before removal.
C. Apply lidocaine gel and remove immediately.
D. Stop therapy and leave old foam in place.
Correct Answer: B
Rationale: Sterile irrigation loosens adherent foam without disrupting new tissue (WOCN 2025).
Question 3:
A client’s serum K⁺ is 3.2 mEq/L after 24 h of nasogastric suction. The nurse anticipates the
physician will order:
A. PO potassium chloride 40 mEq q8h
B. IV potassium chloride 10 mEq over 1 h, max 20 mEq/L
C. Kayexalate enema
D. No intervention until level is <3.0 mEq/L
,Correct Answer: B
Rationale: IV replacement is indicated for moderate hypokalemia with ongoing losses; max 20
mEq/L prevents vein irritation (ASPEN 2025).
Question 4:
A post-op hip replacement client has a Jackson-Pratt (JP) drain with 80 mL serosanguinous output
4 h post-placement. The nurse should:
A. Strip the tubing to increase patency.
B. Compress the drain and re-establish suction per protocol.
C. Remove the drain and apply pressure dressing.
D. Open the port and empty only if >100 mL.
Correct Answer: B
Rationale: Maintaining negative pressure ensures continued drainage and prevents clot formation
(Craven 2026).
Question 5:
The nurse is delegating care for four clients. Which task is most appropriate to assign to an
experienced AP?
, A. Empty and measure JP drain output for stable client
B. Reinforce sterile dressing change for fresh post-op client
C. Assess neurovascular status of a 12-hour-old forearm fracture
D. Perform sterile suctioning of new tracheostomy
Correct Answer: A
Rationale: Emptying a JP is a routine, non-sterile measurement task within AP scope when
competency validated (NCSBN 2025).
Question 6:
A client with a new colostomy reports, “Nothing has come out for two days.” The nurse assesses
stoma color as dusky purple. The nurse’s priority is to:
A. Increase PO fluids and ambulate.
B. Notify surgeon immediately of possible ischemia.
C. Insert a lubricated finger to break up stool.
D. Apply a heat pad to stimulate peristalsis.
Correct Answer: B
II ACTUAL EXAM 2026/2027: 100% Verified
Questions & Correct Answers
Question 1:
A 68-year-old post-cholecystectomy client has a T-tube draining 450 mL of green-brown bile in the
first 8 h. The nurse’s priority action is to:
A. Clamp the tube and notify the surgeon.
B. Document the output and monitor for signs of dehydration.
C. Irrigate the tube with 30 mL normal saline.
D. Lower the bag below the incision and milk the tubing.
Correct Answer: B
Rationale: Initial high bile output is expected; accurate I&O and hydration assessment follow
evidence-based post-op care (Perry & Potter 2026).
Question 2:
,A client with a Stage III sacral pressure injury is receiving negative-pressure wound therapy
(NPWT) at –125 mmHg. During dressing change the nurse notes foam adherent to granulation
tissue. The nurse should:
A. Rapidly remove the foam to minimize pain.
B. Irrigate under the foam with sterile saline to loosen before removal.
C. Apply lidocaine gel and remove immediately.
D. Stop therapy and leave old foam in place.
Correct Answer: B
Rationale: Sterile irrigation loosens adherent foam without disrupting new tissue (WOCN 2025).
Question 3:
A client’s serum K⁺ is 3.2 mEq/L after 24 h of nasogastric suction. The nurse anticipates the
physician will order:
A. PO potassium chloride 40 mEq q8h
B. IV potassium chloride 10 mEq over 1 h, max 20 mEq/L
C. Kayexalate enema
D. No intervention until level is <3.0 mEq/L
,Correct Answer: B
Rationale: IV replacement is indicated for moderate hypokalemia with ongoing losses; max 20
mEq/L prevents vein irritation (ASPEN 2025).
Question 4:
A post-op hip replacement client has a Jackson-Pratt (JP) drain with 80 mL serosanguinous output
4 h post-placement. The nurse should:
A. Strip the tubing to increase patency.
B. Compress the drain and re-establish suction per protocol.
C. Remove the drain and apply pressure dressing.
D. Open the port and empty only if >100 mL.
Correct Answer: B
Rationale: Maintaining negative pressure ensures continued drainage and prevents clot formation
(Craven 2026).
Question 5:
The nurse is delegating care for four clients. Which task is most appropriate to assign to an
experienced AP?
, A. Empty and measure JP drain output for stable client
B. Reinforce sterile dressing change for fresh post-op client
C. Assess neurovascular status of a 12-hour-old forearm fracture
D. Perform sterile suctioning of new tracheostomy
Correct Answer: A
Rationale: Emptying a JP is a routine, non-sterile measurement task within AP scope when
competency validated (NCSBN 2025).
Question 6:
A client with a new colostomy reports, “Nothing has come out for two days.” The nurse assesses
stoma color as dusky purple. The nurse’s priority is to:
A. Increase PO fluids and ambulate.
B. Notify surgeon immediately of possible ischemia.
C. Insert a lubricated finger to break up stool.
D. Apply a heat pad to stimulate peristalsis.
Correct Answer: B
