Nursing Fundamentals Exam 4 Study Guide 2026 |Galen College
1. A nurse is witnessing a patient sign an informed consent form for surgery.
What is the nurse’s primary responsibility in this process?
A. Explaining the risks and benefits of the procedure
B. Ensuring the patient is signing the form voluntarily
C. Describing alternative treatments to the patient
D. Obtaining the medical history required for the procedure
Answer: B
Rationale: The nurse’s role is to witness the signature, ensuring the patient is competent,
the signature is authentic, and the consent is given voluntarily. Explaining risks and
alternatives is the surgeon’s responsibility.
2. Which of the following is an early clinical manifestation of hypoxia?
A. Restlessness
B. Bradycardia
C. Cyanosis
D. Bradypnea
Answer: A
Rationale: Restlessness, anxiety, and agitation are early signs of hypoxia. Cyanosis and
bradycardia are late signs.
,3. When performing tracheal suctioning, what is the maximum amount of time
the nurse should apply suction?
A. 5 seconds
B. 20 to 25 seconds
C. 10 to 15 seconds
D. 30 seconds
Answer: C
Rationale: Suctioning should be limited to 10-15 seconds to prevent hypoxemia and vagal
stimulation.
4. A patient has a Stage 2 pressure injury. How should the nurse describe this
wound in the documentation?
A. Non-blanchable erythema of intact skin
B. Partial-thickness skin loss with a viable pink or red moist wound bed
C. Full-thickness skin loss with visible adipose tissue
D. Full-thickness skin loss with exposed bone or muscle
Answer: B
Rationale: Stage 2 involves partial-thickness loss of dermis, presenting as a shallow open
ulcer or an intact/ruptured serum-filled blister.
5. A patient’s ABG results are: pH 7.30, PaCO2 52 mmHg, and HCO3 26 mEq/L.
Which acid-base imbalance does this indicate?
A. Respiratory Alkalosis
B. Metabolic Acidosis
C. Respiratory Acidosis
D. Metabolic Alkalosis
Answer: C
Rationale: A pH below 7.35 indicates acidosis. A high PaCO2 (above 45) indicates the
cause is respiratory.
, 6. What is the primary purpose of using an incentive spirometer
postoperatively?
A. To reduce post-surgical pain
B. To clear gastric secretions
C. To increase the patient’s heart rate
D. To promote lung expansion and prevent atelectasis
Answer: D
Rationale: Incentive spirometry encourages deep breathing, which helps inflate the alveoli
and prevent lung collapse (atelectasis).
7. Which electrolyte imbalance is associated with a positive Chvostek’s sign?
A. Hyperkalemia
B. Hypocalcemia
C. Hyponatremia
D. Hypermagnesemia
Answer: B
Rationale: A positive Chvostek’s sign (facial twitching when the facial nerve is tapped) is a
sign of increased neuromuscular excitability due to hypocalcemia.
8. A nurse discovers a patient’s surgical wound has eviscerated. What is the
immediate priority action?
A. Push the organs back into the abdominal cavity
B. Place the patient in a high-Fowler’s position
C. Apply a dry sterile pressure dressing
D. Cover the wound with sterile towels moistened with normal saline
Answer: D
Rationale: Evisceration is a medical emergency. The nurse should cover the protruding
organs with sterile, saline-soaked dressings to keep them moist while waiting for surgical
intervention.
1. A nurse is witnessing a patient sign an informed consent form for surgery.
What is the nurse’s primary responsibility in this process?
A. Explaining the risks and benefits of the procedure
B. Ensuring the patient is signing the form voluntarily
C. Describing alternative treatments to the patient
D. Obtaining the medical history required for the procedure
Answer: B
Rationale: The nurse’s role is to witness the signature, ensuring the patient is competent,
the signature is authentic, and the consent is given voluntarily. Explaining risks and
alternatives is the surgeon’s responsibility.
2. Which of the following is an early clinical manifestation of hypoxia?
A. Restlessness
B. Bradycardia
C. Cyanosis
D. Bradypnea
Answer: A
Rationale: Restlessness, anxiety, and agitation are early signs of hypoxia. Cyanosis and
bradycardia are late signs.
,3. When performing tracheal suctioning, what is the maximum amount of time
the nurse should apply suction?
A. 5 seconds
B. 20 to 25 seconds
C. 10 to 15 seconds
D. 30 seconds
Answer: C
Rationale: Suctioning should be limited to 10-15 seconds to prevent hypoxemia and vagal
stimulation.
4. A patient has a Stage 2 pressure injury. How should the nurse describe this
wound in the documentation?
A. Non-blanchable erythema of intact skin
B. Partial-thickness skin loss with a viable pink or red moist wound bed
C. Full-thickness skin loss with visible adipose tissue
D. Full-thickness skin loss with exposed bone or muscle
Answer: B
Rationale: Stage 2 involves partial-thickness loss of dermis, presenting as a shallow open
ulcer or an intact/ruptured serum-filled blister.
5. A patient’s ABG results are: pH 7.30, PaCO2 52 mmHg, and HCO3 26 mEq/L.
Which acid-base imbalance does this indicate?
A. Respiratory Alkalosis
B. Metabolic Acidosis
C. Respiratory Acidosis
D. Metabolic Alkalosis
Answer: C
Rationale: A pH below 7.35 indicates acidosis. A high PaCO2 (above 45) indicates the
cause is respiratory.
, 6. What is the primary purpose of using an incentive spirometer
postoperatively?
A. To reduce post-surgical pain
B. To clear gastric secretions
C. To increase the patient’s heart rate
D. To promote lung expansion and prevent atelectasis
Answer: D
Rationale: Incentive spirometry encourages deep breathing, which helps inflate the alveoli
and prevent lung collapse (atelectasis).
7. Which electrolyte imbalance is associated with a positive Chvostek’s sign?
A. Hyperkalemia
B. Hypocalcemia
C. Hyponatremia
D. Hypermagnesemia
Answer: B
Rationale: A positive Chvostek’s sign (facial twitching when the facial nerve is tapped) is a
sign of increased neuromuscular excitability due to hypocalcemia.
8. A nurse discovers a patient’s surgical wound has eviscerated. What is the
immediate priority action?
A. Push the organs back into the abdominal cavity
B. Place the patient in a high-Fowler’s position
C. Apply a dry sterile pressure dressing
D. Cover the wound with sterile towels moistened with normal saline
Answer: D
Rationale: Evisceration is a medical emergency. The nurse should cover the protruding
organs with sterile, saline-soaked dressings to keep them moist while waiting for surgical
intervention.
