NSG 3130 Exam 3 V2 | NSG 3130
Fundamental Concepts & Skills for
Nursing Practice II | Actual Q&A with
Rationale (NSG3130 Exam 3) | Galen
College of Nursing
1. A nurse is preparing a patient for surgery and notes the patient has been NPO for 8 hours.
What is the primary rationale for maintaining NPO status prior to general anesthesia?
A. To prevent postoperative constipation and bowel obstruction.
B. To ensure the patient experiences less postoperative nausea.
C. To reduce the risk of pulmonary aspiration of gastric contents.
D. To minimize the risk of fluid volume excess during IV therapy.
Answer: C
Rationale: General anesthesia relaxes the muscles and suppresses the gag reflex, which
increases the risk of vomiting. If the stomach contains food or liquid, the patient may
aspirate these contents into the lungs, leading to chemical pneumonitis. Maintaining NPO
status is a critical safety measure used to protect the airway during the perioperative
period.
2. During the preoperative assessment, a patient reports a severe allergy to avocados and
bananas. Which intraoperative complication should the nurse be most concerned about?
A. Allergy to povidone-iodine scrub.
,B. Sensitivity to General Anesthesia agents.
C. Latex allergy cross-reactivity.
D. Malignant Hyperthermia.
Answer: C
Rationale: Patients with allergies to certain fruits, such as avocados, bananas, and
chestnuts, have a higher statistical risk of having a latex allergy. The proteins in these fruits
are similar to the proteins found in natural rubber latex. The nurse must document this and
ensure a latex-free environment is maintained in the operating room to prevent
anaphylaxis.
3. A postoperative patient is being taught how to use an incentive spirometer. Which
instruction by the nurse is correct?
A. Exhale forcefully into the device until the piston reaches the goal.
B. Use the device only if you feel short of breath or start coughing.
C. Inhale slowly and deeply to raise the piston and hold for 3-5 seconds.
D. Perform 2 deep breaths every 4 hours while awake.
Answer: C
Rationale: Incentive spirometry is designed to encourage deep breathing and lung
expansion through sustained maximal inspiration. The patient should inhale slowly to
ensure the alveoli open and then hold their breath to maintain that expansion. This
,intervention is vital for preventing postoperative atelectasis and pneumonia in patients
with reduced mobility.
4. Which member of the surgical team is responsible for maintaining the sterile field and
providing the surgeon with required instruments?
A. Circulating Nurse
B. Anesthesiologist
C. Scrub Nurse
D. Holding Area Nurse
Answer: C
Rationale: The scrub nurse or surgical technologist works directly within the sterile field,
wearing sterile attire and gloves. Their primary duty is to manage sterile equipment and
assist the surgeon during the procedure by passing instruments. The circulating nurse,
meanwhile, remains in the non-sterile area to coordinate care and document the case.
5. A patient is 24 hours postoperative and has not yet voided. What is the nurse’s priority
action?
A. Insert a straight catheter immediately per protocol.
B. Encourage the patient to drink 500 mL of water.
C. Increase the IV fluid rate to stimulate kidney production.
D. Perform a bladder scan to assess for urinary retention.
, Answer: D
Rationale: Postoperative urinary retention is common due to the effects of anesthesia and
narcotics on the bladder’s detrusor muscle. A bladder scan is a non-invasive assessment
tool that determines how much urine is actually in the bladder. This data allows the nurse
to determine if the issue is a lack of production or a failure to empty before pursuing
invasive interventions.
6. A nurse is caring for a patient with a chest tube. Which finding requires immediate
intervention?
A. Occasional bubbling in the water-seal chamber during expiration.
B. Tidaling of the fluid level in the water-seal chamber with breathing.
C. Drainage of 50 mL of serosanguinous fluid in the first hour.
D. Continuous bubbling in the water-seal chamber.
Answer: D
Rationale: Continuous bubbling in the water-seal chamber typically indicates an air leak in
the system or the patient’s pleural space. Intermittent bubbling during coughing or
expiration is normal, as is tidaling, which reflects intrapleural pressure changes. The nurse
must locate the leak and notify the provider if it cannot be resolved to ensure proper lung
re-expansion.
Fundamental Concepts & Skills for
Nursing Practice II | Actual Q&A with
Rationale (NSG3130 Exam 3) | Galen
College of Nursing
1. A nurse is preparing a patient for surgery and notes the patient has been NPO for 8 hours.
What is the primary rationale for maintaining NPO status prior to general anesthesia?
A. To prevent postoperative constipation and bowel obstruction.
B. To ensure the patient experiences less postoperative nausea.
C. To reduce the risk of pulmonary aspiration of gastric contents.
D. To minimize the risk of fluid volume excess during IV therapy.
Answer: C
Rationale: General anesthesia relaxes the muscles and suppresses the gag reflex, which
increases the risk of vomiting. If the stomach contains food or liquid, the patient may
aspirate these contents into the lungs, leading to chemical pneumonitis. Maintaining NPO
status is a critical safety measure used to protect the airway during the perioperative
period.
2. During the preoperative assessment, a patient reports a severe allergy to avocados and
bananas. Which intraoperative complication should the nurse be most concerned about?
A. Allergy to povidone-iodine scrub.
,B. Sensitivity to General Anesthesia agents.
C. Latex allergy cross-reactivity.
D. Malignant Hyperthermia.
Answer: C
Rationale: Patients with allergies to certain fruits, such as avocados, bananas, and
chestnuts, have a higher statistical risk of having a latex allergy. The proteins in these fruits
are similar to the proteins found in natural rubber latex. The nurse must document this and
ensure a latex-free environment is maintained in the operating room to prevent
anaphylaxis.
3. A postoperative patient is being taught how to use an incentive spirometer. Which
instruction by the nurse is correct?
A. Exhale forcefully into the device until the piston reaches the goal.
B. Use the device only if you feel short of breath or start coughing.
C. Inhale slowly and deeply to raise the piston and hold for 3-5 seconds.
D. Perform 2 deep breaths every 4 hours while awake.
Answer: C
Rationale: Incentive spirometry is designed to encourage deep breathing and lung
expansion through sustained maximal inspiration. The patient should inhale slowly to
ensure the alveoli open and then hold their breath to maintain that expansion. This
,intervention is vital for preventing postoperative atelectasis and pneumonia in patients
with reduced mobility.
4. Which member of the surgical team is responsible for maintaining the sterile field and
providing the surgeon with required instruments?
A. Circulating Nurse
B. Anesthesiologist
C. Scrub Nurse
D. Holding Area Nurse
Answer: C
Rationale: The scrub nurse or surgical technologist works directly within the sterile field,
wearing sterile attire and gloves. Their primary duty is to manage sterile equipment and
assist the surgeon during the procedure by passing instruments. The circulating nurse,
meanwhile, remains in the non-sterile area to coordinate care and document the case.
5. A patient is 24 hours postoperative and has not yet voided. What is the nurse’s priority
action?
A. Insert a straight catheter immediately per protocol.
B. Encourage the patient to drink 500 mL of water.
C. Increase the IV fluid rate to stimulate kidney production.
D. Perform a bladder scan to assess for urinary retention.
, Answer: D
Rationale: Postoperative urinary retention is common due to the effects of anesthesia and
narcotics on the bladder’s detrusor muscle. A bladder scan is a non-invasive assessment
tool that determines how much urine is actually in the bladder. This data allows the nurse
to determine if the issue is a lack of production or a failure to empty before pursuing
invasive interventions.
6. A nurse is caring for a patient with a chest tube. Which finding requires immediate
intervention?
A. Occasional bubbling in the water-seal chamber during expiration.
B. Tidaling of the fluid level in the water-seal chamber with breathing.
C. Drainage of 50 mL of serosanguinous fluid in the first hour.
D. Continuous bubbling in the water-seal chamber.
Answer: D
Rationale: Continuous bubbling in the water-seal chamber typically indicates an air leak in
the system or the patient’s pleural space. Intermittent bubbling during coughing or
expiration is normal, as is tidaling, which reflects intrapleural pressure changes. The nurse
must locate the leak and notify the provider if it cannot be resolved to ensure proper lung
re-expansion.
