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NSG 3130 Exam 1 Fundamental Newest Exam
Preparation With Complete Questions And Correct
Answers With Rationales Already Graded A+Brand
New Version!!
QUESTION 1
A client reports acute pain following abdominal surgery. The nurse
administers an opioid analgesic as prescribed. Thirty minutes later, the
client reports that the pain is still at a level of 8 on a scale of 0 to 10.
What is the nurses priority action?
A) Notify the healthcare provider for a different analgesic order.
B) Document the clients pain rating and the medication administered.
C) Reassess the clients pain in 15 minutes and implement non-
pharmacological comfort measures.
D) Instruct the client that full relief is not possible and encourage deep
breathing.
Answer: C
Rationale: The priority after administering a PRN analgesic is to
reassess the patient in an appropriate timeframe (typically 15-30
minutes for IV, 1 hour for PO) and to use adjunctive measures. The
nurse must first determine the effectiveness of the administered drug
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before requesting a new order. Documenting is necessary but not the
immediate priority. Telling the patient full relief is impossible is
dismissive and inaccurate.
QUESTION 2
A nurse is calculating the intake and output for a client over an 8-hour
shift. The client consumes 240 mL of juice, 120 mL of tea, and 90 mL of
water. The client also receives 150 mL of intravenous fluids. The client
voids 400 mL and has 75 mL of emesis. What is the clients net fluid
balance for the shift?
A) +125 mL
B) +25 mL
C) -125 mL
D) -25 mL
Answer: A
Rationale: Total intake = 240 + 120 + 90 + 150 = 600 mL. Total output =
400 + 75 = 475 mL. Net balance = 600 - 475 = +125 mL. This indicates a
positive fluid balance, which is appropriate unless the client has a
condition such as heart failure. The calculation demonstrates accurate
arithmetic and understanding of fluid balance terminology.
QUESTION 3
The nurse is preparing to insert an indwelling urinary catheter. Which
action best maintains sterile technique?
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A) Placing the sterile field at the edge of the bed for easy access.
B) Using clean gloves to handle the catheter once it is removed from
the package.
C) Maintaining the catheter within the sterile field and using sterile
gloves for insertion.
D) Using the same hand to clean the meatus and insert the catheter.
Answer: C
Rationale: Sterile technique requires that the catheter and all items that
enter the urethra remain sterile. Sterile gloves must be worn, and the
catheter should remain on the sterile field. Placing the field at the edge
of the bed increases the risk of contamination. Clean gloves are not
appropriate for insertion; they are used for perineal cleaning. Using the
same hand for cleaning and insertion introduces bacteria.
QUESTION 4
A client with a history of chronic obstructive pulmonary disease has an
oxygen saturation of 86% on room air. The nurse applies a nasal
cannula at 2 L/min. What is the primary goal of this intervention?
A) To achieve an oxygen saturation of 100%
B) To maintain an oxygen saturation of 88% to 92%
C) To suppress the respiratory drive
D) To prevent carbon dioxide narcosis
Answer: B
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Rationale: In clients with COPD, the hypoxic drive may be the primary
stimulus to breathe. Oxygen therapy should be titrated to achieve a
saturation of 88-92% to maintain adequate oxygenation while
preventing the loss of the hypoxic respiratory drive and subsequent
carbon dioxide retention. 100% is too high and dangerous. Suppressing
the respiratory drive is a complication, not a goal.
QUESTION 5
The nurse is performing a physical assessment on a client who is
experiencing edema in the lower extremities. When assessing pitting
edema, the nurse presses the skin and notes a 6-mm indentation that
remains after release. How should the nurse document this finding?
A) 1+ pitting edema
B) 2+ pitting edema
C) 3+ pitting edema
D) 4+ pitting edema
Answer: C
Rationale: Pitting edema is graded on a scale of 1+ to 4+. 1+ is a 2-mm
indentation that disappears rapidly. 2+ is a 4-mm indentation that
disappears in 10-15 seconds. 3+ is a 6-mm indentation that lasts 1-2
minutes. 4+ is an 8-mm indentation that persists for 2-3 minutes.
Therefore, a 6-mm indentation correlates with 3+ edema.
QUESTION 6
NSG 3130 Exam 1 Fundamental Newest Exam
Preparation With Complete Questions And Correct
Answers With Rationales Already Graded A+Brand
New Version!!
QUESTION 1
A client reports acute pain following abdominal surgery. The nurse
administers an opioid analgesic as prescribed. Thirty minutes later, the
client reports that the pain is still at a level of 8 on a scale of 0 to 10.
What is the nurses priority action?
A) Notify the healthcare provider for a different analgesic order.
B) Document the clients pain rating and the medication administered.
C) Reassess the clients pain in 15 minutes and implement non-
pharmacological comfort measures.
D) Instruct the client that full relief is not possible and encourage deep
breathing.
Answer: C
Rationale: The priority after administering a PRN analgesic is to
reassess the patient in an appropriate timeframe (typically 15-30
minutes for IV, 1 hour for PO) and to use adjunctive measures. The
nurse must first determine the effectiveness of the administered drug
,2|Page
before requesting a new order. Documenting is necessary but not the
immediate priority. Telling the patient full relief is impossible is
dismissive and inaccurate.
QUESTION 2
A nurse is calculating the intake and output for a client over an 8-hour
shift. The client consumes 240 mL of juice, 120 mL of tea, and 90 mL of
water. The client also receives 150 mL of intravenous fluids. The client
voids 400 mL and has 75 mL of emesis. What is the clients net fluid
balance for the shift?
A) +125 mL
B) +25 mL
C) -125 mL
D) -25 mL
Answer: A
Rationale: Total intake = 240 + 120 + 90 + 150 = 600 mL. Total output =
400 + 75 = 475 mL. Net balance = 600 - 475 = +125 mL. This indicates a
positive fluid balance, which is appropriate unless the client has a
condition such as heart failure. The calculation demonstrates accurate
arithmetic and understanding of fluid balance terminology.
QUESTION 3
The nurse is preparing to insert an indwelling urinary catheter. Which
action best maintains sterile technique?
,3|Page
A) Placing the sterile field at the edge of the bed for easy access.
B) Using clean gloves to handle the catheter once it is removed from
the package.
C) Maintaining the catheter within the sterile field and using sterile
gloves for insertion.
D) Using the same hand to clean the meatus and insert the catheter.
Answer: C
Rationale: Sterile technique requires that the catheter and all items that
enter the urethra remain sterile. Sterile gloves must be worn, and the
catheter should remain on the sterile field. Placing the field at the edge
of the bed increases the risk of contamination. Clean gloves are not
appropriate for insertion; they are used for perineal cleaning. Using the
same hand for cleaning and insertion introduces bacteria.
QUESTION 4
A client with a history of chronic obstructive pulmonary disease has an
oxygen saturation of 86% on room air. The nurse applies a nasal
cannula at 2 L/min. What is the primary goal of this intervention?
A) To achieve an oxygen saturation of 100%
B) To maintain an oxygen saturation of 88% to 92%
C) To suppress the respiratory drive
D) To prevent carbon dioxide narcosis
Answer: B
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Rationale: In clients with COPD, the hypoxic drive may be the primary
stimulus to breathe. Oxygen therapy should be titrated to achieve a
saturation of 88-92% to maintain adequate oxygenation while
preventing the loss of the hypoxic respiratory drive and subsequent
carbon dioxide retention. 100% is too high and dangerous. Suppressing
the respiratory drive is a complication, not a goal.
QUESTION 5
The nurse is performing a physical assessment on a client who is
experiencing edema in the lower extremities. When assessing pitting
edema, the nurse presses the skin and notes a 6-mm indentation that
remains after release. How should the nurse document this finding?
A) 1+ pitting edema
B) 2+ pitting edema
C) 3+ pitting edema
D) 4+ pitting edema
Answer: C
Rationale: Pitting edema is graded on a scale of 1+ to 4+. 1+ is a 2-mm
indentation that disappears rapidly. 2+ is a 4-mm indentation that
disappears in 10-15 seconds. 3+ is a 6-mm indentation that lasts 1-2
minutes. 4+ is an 8-mm indentation that persists for 2-3 minutes.
Therefore, a 6-mm indentation correlates with 3+ edema.
QUESTION 6
