NSG 3130 Final Exam V2 | NSG 3130
Fundamental Concepts & Skills for
Nursing Practice II | Actual Q&A with
Rationale (NSG3130 Final Exam) | Galen
College of Nursing
1. A nurse is preparing to administer an intramuscular injection to an adult patient in the
ventrogluteal site. Which of the following is the correct landmark for this site?
A. The greater trochanter and the anterior superior iliac spine.
B. The acromion process and the axillary fold.
C. The vastus lateralis muscle on the lateral thigh.
D. The posterior superior iliac spine and the iliac crest.
Answer: A
Rationale: To locate the ventrogluteal site, the nurse places the palm over the greater
trochanter and the index finger on the anterior superior iliac spine. The middle finger is
then extended toward the iliac crest to form a V-shaped triangle. This site is preferred for
many injections because it is situated away from major nerves and blood vessels.
2. A patient is receiving an intravenous infusion and complains of pain at the insertion site.
The nurse notes coolness, swelling, and a sluggish flow rate. Which complication is most likely
occurring?
A. Infiltration
,B. Infection
C. Phlebitis
D. Air embolism
Answer: A
Rationale: Infiltration occurs when IV fluid leaks into the surrounding subcutaneous
tissue, characterized by coolness, pallor, and swelling. This differs from phlebitis, which
typically presents with warmth and redness along the vein path. The nurse should
immediately stop the infusion and elevate the extremity to promote absorption.
3. When performing tracheostomy suctioning, which action by the nurse is essential to
prevent hypoxia?
A. Suctioning for 30 seconds at a time.
B. Maintaining a clean technique during the procedure.
C. Applying suction while inserting the catheter.
D. Hyperoxygenating the patient before the procedure.
Answer: D
Rationale: Hyperoxygenation involves providing 100% oxygen before suctioning to build a
reserve and prevent a drop in oxygen saturation. Suctioning should never exceed 10 to 15
seconds to minimize trauma and hypoxia risks. Suction must only be applied intermittently
while withdrawing the catheter to protect the airway mucosa.
, 4. A nurse is caring for a patient with a Stage 2 pressure injury. What is the defining
characteristic of this stage?
A. Non-blanchable erythema of intact skin.
B. Full-thickness skin loss with visible adipose tissue.
C. Partial-thickness skin loss with a shallow open ulcer.
D. Full-thickness tissue loss with exposed bone or muscle.
Answer: C
Rationale: A Stage 2 pressure injury involves partial-thickness loss of the dermis, often
appearing as a shallow open ulcer or a ruptured blister. Stage 1 is characterized by non-
blanchable redness, while Stage 3 involves subcutaneous fat visibility. Proper assessment
of the wound bed is crucial for selecting the appropriate dressing and treatment plan.
5. While preparing to administer medication, the nurse realizes the dose is higher than the
standard range. What is the most appropriate action?
A. Administer the dose as ordered by the provider.
B. Adjust the dose to the standard range before giving it.
C. Ask another nurse if they have given that dose before.
D. Call the prescribing provider to clarify the order.
Answer: D
Fundamental Concepts & Skills for
Nursing Practice II | Actual Q&A with
Rationale (NSG3130 Final Exam) | Galen
College of Nursing
1. A nurse is preparing to administer an intramuscular injection to an adult patient in the
ventrogluteal site. Which of the following is the correct landmark for this site?
A. The greater trochanter and the anterior superior iliac spine.
B. The acromion process and the axillary fold.
C. The vastus lateralis muscle on the lateral thigh.
D. The posterior superior iliac spine and the iliac crest.
Answer: A
Rationale: To locate the ventrogluteal site, the nurse places the palm over the greater
trochanter and the index finger on the anterior superior iliac spine. The middle finger is
then extended toward the iliac crest to form a V-shaped triangle. This site is preferred for
many injections because it is situated away from major nerves and blood vessels.
2. A patient is receiving an intravenous infusion and complains of pain at the insertion site.
The nurse notes coolness, swelling, and a sluggish flow rate. Which complication is most likely
occurring?
A. Infiltration
,B. Infection
C. Phlebitis
D. Air embolism
Answer: A
Rationale: Infiltration occurs when IV fluid leaks into the surrounding subcutaneous
tissue, characterized by coolness, pallor, and swelling. This differs from phlebitis, which
typically presents with warmth and redness along the vein path. The nurse should
immediately stop the infusion and elevate the extremity to promote absorption.
3. When performing tracheostomy suctioning, which action by the nurse is essential to
prevent hypoxia?
A. Suctioning for 30 seconds at a time.
B. Maintaining a clean technique during the procedure.
C. Applying suction while inserting the catheter.
D. Hyperoxygenating the patient before the procedure.
Answer: D
Rationale: Hyperoxygenation involves providing 100% oxygen before suctioning to build a
reserve and prevent a drop in oxygen saturation. Suctioning should never exceed 10 to 15
seconds to minimize trauma and hypoxia risks. Suction must only be applied intermittently
while withdrawing the catheter to protect the airway mucosa.
, 4. A nurse is caring for a patient with a Stage 2 pressure injury. What is the defining
characteristic of this stage?
A. Non-blanchable erythema of intact skin.
B. Full-thickness skin loss with visible adipose tissue.
C. Partial-thickness skin loss with a shallow open ulcer.
D. Full-thickness tissue loss with exposed bone or muscle.
Answer: C
Rationale: A Stage 2 pressure injury involves partial-thickness loss of the dermis, often
appearing as a shallow open ulcer or a ruptured blister. Stage 1 is characterized by non-
blanchable redness, while Stage 3 involves subcutaneous fat visibility. Proper assessment
of the wound bed is crucial for selecting the appropriate dressing and treatment plan.
5. While preparing to administer medication, the nurse realizes the dose is higher than the
standard range. What is the most appropriate action?
A. Administer the dose as ordered by the provider.
B. Adjust the dose to the standard range before giving it.
C. Ask another nurse if they have given that dose before.
D. Call the prescribing provider to clarify the order.
Answer: D
