NSG 3130 Exam 2 V1 | NSG 3130
Fundamental Concepts & Skills for
Nursing Practice II | Actual Q&A with
Rationale (NSG3130 Exam 2) | Galen
College of Nursing
1. A nurse is preparing to administer an intramuscular (IM) injection to an adult client. Which
of the following sites is the preferred location due to the lack of major nerves and blood
vessels?
A. Dorsogluteal
B. Deltoid
C. Vastus Lateralis
D. Ventrogluteal
Answer: D
Rationale: The ventrogluteal site is the preferred injection site for adults because it is
situated away from major nerves and blood vessels. To locate it, the nurse places the palm
over the greater trochanter and the index finger on the anterior superior iliac spine. This
site provides a large muscle mass that safely accommodates larger volumes of medication.
2. A patient is receiving continuous oxygen via a nasal cannula at 3 L/min. The nurse knows
that the approximate fraction of inspired oxygen (FiO2) being delivered is:
A. 24%
,B. 28%
C. 36%
D. 32%
Answer: D
Rationale: Nasal cannulas deliver oxygen at a concentration of approximately 4% for every
liter per minute added to the baseline room air of 21%. At 1 L/min it is 24%, and at 3
L/min it reaches approximately 32%. It is essential for the nurse to monitor the patient’s
respiratory effort and mucous membrane moisture when using this delivery system.
3. While assessing a client’s IV site, the nurse notes coolness, pallor, and swelling at the
insertion point. Which complication of IV therapy is the client likely experiencing?
A. Phlebitis
B. Extravasation
C. Infiltration
D. Thrombosis
Answer: C
Rationale: Infiltration occurs when non-vesicant IV fluid leaks into the surrounding
subcutaneous tissue, causing localized edema and coolness. The nurse must immediately
stop the infusion and remove the catheter to prevent further tissue damage. Following
, removal, the nurse should elevate the extremity and apply a warm or cool compress based
on the type of fluid infused.
4. The nurse is teaching a postoperative client how to use an incentive spirometer. Which
instruction should the nurse include in the teaching?
A. Exhale forcefully into the device until the piston rises.
B. Hold your breath for at least 15 seconds after reaching the goal.
C. Use the device once every 4 hours while awake.
D. Inhale slowly and deeply through the mouthpiece to raise the piston.
Answer: D
Rationale: Incentive spirometry encourages voluntary deep breathing to prevent
atelectasis and pneumonia after surgery. The client should be instructed to inhale slowly
and deeply to maximize lung expansion and keep the piston elevated. This exercise should
typically be performed 10 times every hour while the client is awake.
5. A nurse is performing a sterile wound dressing change. Which action would cause a break
in sterile technique?
A. Reaching over the sterile field to pick up a pair of forceps.
B. Dropping a sterile gauze onto the center of the sterile field.
C. Opening the sterile pack away from the body.
D. Keeping the sterile gloved hands above the waist level.
Fundamental Concepts & Skills for
Nursing Practice II | Actual Q&A with
Rationale (NSG3130 Exam 2) | Galen
College of Nursing
1. A nurse is preparing to administer an intramuscular (IM) injection to an adult client. Which
of the following sites is the preferred location due to the lack of major nerves and blood
vessels?
A. Dorsogluteal
B. Deltoid
C. Vastus Lateralis
D. Ventrogluteal
Answer: D
Rationale: The ventrogluteal site is the preferred injection site for adults because it is
situated away from major nerves and blood vessels. To locate it, the nurse places the palm
over the greater trochanter and the index finger on the anterior superior iliac spine. This
site provides a large muscle mass that safely accommodates larger volumes of medication.
2. A patient is receiving continuous oxygen via a nasal cannula at 3 L/min. The nurse knows
that the approximate fraction of inspired oxygen (FiO2) being delivered is:
A. 24%
,B. 28%
C. 36%
D. 32%
Answer: D
Rationale: Nasal cannulas deliver oxygen at a concentration of approximately 4% for every
liter per minute added to the baseline room air of 21%. At 1 L/min it is 24%, and at 3
L/min it reaches approximately 32%. It is essential for the nurse to monitor the patient’s
respiratory effort and mucous membrane moisture when using this delivery system.
3. While assessing a client’s IV site, the nurse notes coolness, pallor, and swelling at the
insertion point. Which complication of IV therapy is the client likely experiencing?
A. Phlebitis
B. Extravasation
C. Infiltration
D. Thrombosis
Answer: C
Rationale: Infiltration occurs when non-vesicant IV fluid leaks into the surrounding
subcutaneous tissue, causing localized edema and coolness. The nurse must immediately
stop the infusion and remove the catheter to prevent further tissue damage. Following
, removal, the nurse should elevate the extremity and apply a warm or cool compress based
on the type of fluid infused.
4. The nurse is teaching a postoperative client how to use an incentive spirometer. Which
instruction should the nurse include in the teaching?
A. Exhale forcefully into the device until the piston rises.
B. Hold your breath for at least 15 seconds after reaching the goal.
C. Use the device once every 4 hours while awake.
D. Inhale slowly and deeply through the mouthpiece to raise the piston.
Answer: D
Rationale: Incentive spirometry encourages voluntary deep breathing to prevent
atelectasis and pneumonia after surgery. The client should be instructed to inhale slowly
and deeply to maximize lung expansion and keep the piston elevated. This exercise should
typically be performed 10 times every hour while the client is awake.
5. A nurse is performing a sterile wound dressing change. Which action would cause a break
in sterile technique?
A. Reaching over the sterile field to pick up a pair of forceps.
B. Dropping a sterile gauze onto the center of the sterile field.
C. Opening the sterile pack away from the body.
D. Keeping the sterile gloved hands above the waist level.
