NSG 3130 Final Exam V3 | 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 assessing a patient’s peripheral IV site and notes warmth, redness, and a
palpable cord along the vein. Which complication is the patient likely experiencing?
A. Infiltration
B. Hematoma
C. Extravasation
D. Phlebitis
Answer: D
Rationale: Phlebitis is characterized by inflammation of the vein, which presents as
redness, warmth, and a palpable cord. In contrast, infiltration involves coolness and
swelling due to fluid leaking into the tissue. The nurse must immediately stop the infusion
and remove the catheter when phlebitis is suspected.
2. While performing a sterile dressing change, the nurse drops a sterile gauze pad onto the
one-inch border of the sterile field. Which action should the nurse take next?
A. Pick up the gauze with sterile forceps and use it.
B. Assume the gauze is sterile since the border is part of the kit.
,C. Use the gauze only for the outer portion of the wound.
D. Consider the gauze contaminated and discard it.
Answer: D
Rationale: The outer one-inch border of a sterile field is considered non-sterile and
contaminated. Any item that touches this border must be discarded to maintain surgical
asepsis. Failure to adhere to this principle increases the risk of healthcare-associated
infections for the patient.
3. A patient returns from surgery and is at risk for atelectasis. Which nursing intervention is
the most effective for preventing this respiratory complication?
A. Administering supplemental oxygen at 2L/min.
B. Maintaining the patient in a supine position.
C. Encouraging the use of an incentive spirometer 10 times every hour.
D. Performing chest physiotherapy twice daily.
Answer: C
Rationale: Incentive spirometry encourages deep breathing and promotes alveolar
expansion, which prevents the collapse of lung tissue known as atelectasis. This
intervention is critical for post-operative patients who may have shallow breathing due to
pain or anesthesia. The nurse should also encourage coughing and frequent position
changes to further mobilize secretions.
, 4. A nurse is caring for a patient with a surgical wound that was left open and is healing
through the formation of granulation tissue. This is known as healing by:
A. Primary intention
B. Quaternary intention
C. Tertiary intention
D. Secondary intention
Answer: D
Rationale: Secondary intention occurs when a wound involves extensive tissue loss and
the edges cannot be approximated. The wound heals from the bottom up with granulation
tissue and eventually forms a larger scar. Primary intention is used for clean surgical
incisions with minimal tissue loss where edges are sutured together.
5. Which clinical manifestation would a nurse expect to find in a patient with a potassium
level of 2.8 mEq/L?
A. Peaked T waves on EKG
B. Hyperactive bowel sounds
C. Increased deep tendon reflexes
D. Muscle weakness and leg cramps
Answer: D
for Nursing Practice II | Actual Q&A with Rationale (NSG3130 Final
Exam) | Galen College of Nursing
1. A nurse is assessing a patient’s peripheral IV site and notes warmth, redness, and a
palpable cord along the vein. Which complication is the patient likely experiencing?
A. Infiltration
B. Hematoma
C. Extravasation
D. Phlebitis
Answer: D
Rationale: Phlebitis is characterized by inflammation of the vein, which presents as
redness, warmth, and a palpable cord. In contrast, infiltration involves coolness and
swelling due to fluid leaking into the tissue. The nurse must immediately stop the infusion
and remove the catheter when phlebitis is suspected.
2. While performing a sterile dressing change, the nurse drops a sterile gauze pad onto the
one-inch border of the sterile field. Which action should the nurse take next?
A. Pick up the gauze with sterile forceps and use it.
B. Assume the gauze is sterile since the border is part of the kit.
,C. Use the gauze only for the outer portion of the wound.
D. Consider the gauze contaminated and discard it.
Answer: D
Rationale: The outer one-inch border of a sterile field is considered non-sterile and
contaminated. Any item that touches this border must be discarded to maintain surgical
asepsis. Failure to adhere to this principle increases the risk of healthcare-associated
infections for the patient.
3. A patient returns from surgery and is at risk for atelectasis. Which nursing intervention is
the most effective for preventing this respiratory complication?
A. Administering supplemental oxygen at 2L/min.
B. Maintaining the patient in a supine position.
C. Encouraging the use of an incentive spirometer 10 times every hour.
D. Performing chest physiotherapy twice daily.
Answer: C
Rationale: Incentive spirometry encourages deep breathing and promotes alveolar
expansion, which prevents the collapse of lung tissue known as atelectasis. This
intervention is critical for post-operative patients who may have shallow breathing due to
pain or anesthesia. The nurse should also encourage coughing and frequent position
changes to further mobilize secretions.
, 4. A nurse is caring for a patient with a surgical wound that was left open and is healing
through the formation of granulation tissue. This is known as healing by:
A. Primary intention
B. Quaternary intention
C. Tertiary intention
D. Secondary intention
Answer: D
Rationale: Secondary intention occurs when a wound involves extensive tissue loss and
the edges cannot be approximated. The wound heals from the bottom up with granulation
tissue and eventually forms a larger scar. Primary intention is used for clean surgical
incisions with minimal tissue loss where edges are sutured together.
5. Which clinical manifestation would a nurse expect to find in a patient with a potassium
level of 2.8 mEq/L?
A. Peaked T waves on EKG
B. Hyperactive bowel sounds
C. Increased deep tendon reflexes
D. Muscle weakness and leg cramps
Answer: D
