NSG 3130 Fundamental II Final Assessment (patient
safety, clinical procedures, communication, and
professional responsibilities) Latest Updated
Q1. A nurse is preparing to administer an intramuscular injection. Which site is safest
for an adult?
A. Deltoid
B. Ventrogluteal
B. Dorsogluteal
C. Vastus lateralis
Rationale: The ventrogluteal site avoids major nerves and blood vessels, making it the
safest IM site for adults.
Q2. A patient with a Foley catheter develops cloudy urine and fever. What is the priority
nursing action?
A. Increase fluid intake
B. Notify the healthcare provider
B. Irrigate the catheter
C. Remove the catheter immediately
Rationale: Cloudy urine and fever suggest infection; provider notification ensures timely
treatment.
Q3. Which intervention best prevents pressure ulcers in immobile patients?
A. Apply warm compresses
B. Reposition every 2 hours
B. Massage reddened areas
C. Increase protein intake only
Rationale: Frequent repositioning reduces pressure and promotes circulation,
preventing skin breakdown.
Q4. Before administering digoxin, the nurse should:
A. Check blood pressure
B. Assess apical pulse for 1 minute
B. Check respiratory rate
C. Assess oxygen saturation
Rationale: Digoxin can cause bradycardia; pulse assessment ensures safe
administration.
Q5. A patient with diabetes reports tingling in the feet. This is most likely:
A. Hypoglycemia
B. Peripheral neuropathy
B. Deep vein thrombosis
C. Electrolyte imbalance
,Rationale: Chronic hyperglycemia damages peripheral nerves, causing tingling or
numbness.
Q6. Which PPE is required for a patient with airborne precautions?
A. Surgical mask
B. N95 respirator
B. Gloves only
C. Gown only
Rationale: Airborne pathogens (e.g., TB) require N95 respirators for effective protection.
Q7. A nurse is teaching a patient about insulin administration. Which statement
indicates correct understanding?
A. “I will inject insulin into the same spot daily.”
B. “I will rotate injection sites within the same region.”
B. “I will massage the site after injection.”
C. “I will store insulin in the freezer.”
Rationale: Rotation prevents lipodystrophy while maintaining consistent absorption.
Q8. Which nursing action demonstrates therapeutic communication?
A. “Don’t worry, everything will be fine.”
B. “Tell me more about how you’re feeling.”
B. “You should stop thinking negatively.”
C. “I know exactly how you feel.”
Rationale: Open-ended questions encourage patient expression and build trust.
Q9. A patient is prescribed a diuretic. Which lab value should the nurse monitor closely?
A. Hemoglobin
B. Potassium
B. Calcium
C. Glucose
Rationale: Diuretics can cause hypokalemia, leading to cardiac complications.
Q10. The nurse is caring for a patient with dysphagia. Which intervention is most
appropriate?
A. Offer thin liquids
B. Provide thickened liquids
B. Encourage rapid eating
C. Position patient flat during meals
Rationale: Thickened liquids reduce aspiration risk in patients with swallowing
difficulties.
Q11. A patient is on fall precautions. Which intervention is most effective?
A. Place bed in high position
B. Keep call light within reach
B. Encourage patient to ambulate alone
C. Remove nonslip footwear
, Rationale: Ensures patient can request help before attempting unsafe movement.
Q12. Which finding requires immediate intervention in a patient receiving IV fluids?
A. Clear lung sounds
B. Crackles in lungs
B. Warm extremities
C. Pink mucous membranes
Rationale: Indicates fluid overload and risk of pulmonary edema.
Q13. A nurse is teaching deep breathing exercises. Which instruction is correct?
A. “Breathe shallowly through your mouth.”
B. “Inhale slowly through your nose, hold, then exhale through pursed lips.”
B. “Take rapid breaths to expand lungs.”
C. “Exhale quickly to clear airways.”
Rationale: Promotes lung expansion and oxygenation.
Q14. Which patient statement indicates correct use of a cane?
A. “I will hold the cane on my weak side.”
B. “I will hold the cane on my strong side.”
B. “I will move the cane with my strong leg.”
C. “I will place the cane behind me.”
Rationale: Cane is held on strong side to support weak side movement.
Q15. A nurse is preparing to administer blood transfusion. What is the priority action?
A. Warm the blood before infusion
B. Verify patient identity with another nurse
B. Administer through any IV line
C. Infuse rapidly to prevent clotting
Rationale: Patient identity verification prevents transfusion errors.
Q16. Which nursing action prevents catheter-associated urinary tract infection (CAUTI)?
A. Maintain catheter indefinitely
B. Keep drainage bag below bladder level
B. Disconnect tubing frequently
C. Irrigate catheter daily
Rationale: Prevents backflow of urine and bacterial contamination.
Q17. A patient reports pain rated 8/10. What is the nurse’s priority?
A. Document pain score
B. Administer prescribed analgesic
B. Encourage distraction techniques
C. Reassess in 2 hours
Rationale: Severe pain requires prompt pharmacologic intervention.
Q18. Which technique is correct for sterile gloving?
A. Touch outside of glove with bare hand
safety, clinical procedures, communication, and
professional responsibilities) Latest Updated
Q1. A nurse is preparing to administer an intramuscular injection. Which site is safest
for an adult?
A. Deltoid
B. Ventrogluteal
B. Dorsogluteal
C. Vastus lateralis
Rationale: The ventrogluteal site avoids major nerves and blood vessels, making it the
safest IM site for adults.
Q2. A patient with a Foley catheter develops cloudy urine and fever. What is the priority
nursing action?
A. Increase fluid intake
B. Notify the healthcare provider
B. Irrigate the catheter
C. Remove the catheter immediately
Rationale: Cloudy urine and fever suggest infection; provider notification ensures timely
treatment.
Q3. Which intervention best prevents pressure ulcers in immobile patients?
A. Apply warm compresses
B. Reposition every 2 hours
B. Massage reddened areas
C. Increase protein intake only
Rationale: Frequent repositioning reduces pressure and promotes circulation,
preventing skin breakdown.
Q4. Before administering digoxin, the nurse should:
A. Check blood pressure
B. Assess apical pulse for 1 minute
B. Check respiratory rate
C. Assess oxygen saturation
Rationale: Digoxin can cause bradycardia; pulse assessment ensures safe
administration.
Q5. A patient with diabetes reports tingling in the feet. This is most likely:
A. Hypoglycemia
B. Peripheral neuropathy
B. Deep vein thrombosis
C. Electrolyte imbalance
,Rationale: Chronic hyperglycemia damages peripheral nerves, causing tingling or
numbness.
Q6. Which PPE is required for a patient with airborne precautions?
A. Surgical mask
B. N95 respirator
B. Gloves only
C. Gown only
Rationale: Airborne pathogens (e.g., TB) require N95 respirators for effective protection.
Q7. A nurse is teaching a patient about insulin administration. Which statement
indicates correct understanding?
A. “I will inject insulin into the same spot daily.”
B. “I will rotate injection sites within the same region.”
B. “I will massage the site after injection.”
C. “I will store insulin in the freezer.”
Rationale: Rotation prevents lipodystrophy while maintaining consistent absorption.
Q8. Which nursing action demonstrates therapeutic communication?
A. “Don’t worry, everything will be fine.”
B. “Tell me more about how you’re feeling.”
B. “You should stop thinking negatively.”
C. “I know exactly how you feel.”
Rationale: Open-ended questions encourage patient expression and build trust.
Q9. A patient is prescribed a diuretic. Which lab value should the nurse monitor closely?
A. Hemoglobin
B. Potassium
B. Calcium
C. Glucose
Rationale: Diuretics can cause hypokalemia, leading to cardiac complications.
Q10. The nurse is caring for a patient with dysphagia. Which intervention is most
appropriate?
A. Offer thin liquids
B. Provide thickened liquids
B. Encourage rapid eating
C. Position patient flat during meals
Rationale: Thickened liquids reduce aspiration risk in patients with swallowing
difficulties.
Q11. A patient is on fall precautions. Which intervention is most effective?
A. Place bed in high position
B. Keep call light within reach
B. Encourage patient to ambulate alone
C. Remove nonslip footwear
, Rationale: Ensures patient can request help before attempting unsafe movement.
Q12. Which finding requires immediate intervention in a patient receiving IV fluids?
A. Clear lung sounds
B. Crackles in lungs
B. Warm extremities
C. Pink mucous membranes
Rationale: Indicates fluid overload and risk of pulmonary edema.
Q13. A nurse is teaching deep breathing exercises. Which instruction is correct?
A. “Breathe shallowly through your mouth.”
B. “Inhale slowly through your nose, hold, then exhale through pursed lips.”
B. “Take rapid breaths to expand lungs.”
C. “Exhale quickly to clear airways.”
Rationale: Promotes lung expansion and oxygenation.
Q14. Which patient statement indicates correct use of a cane?
A. “I will hold the cane on my weak side.”
B. “I will hold the cane on my strong side.”
B. “I will move the cane with my strong leg.”
C. “I will place the cane behind me.”
Rationale: Cane is held on strong side to support weak side movement.
Q15. A nurse is preparing to administer blood transfusion. What is the priority action?
A. Warm the blood before infusion
B. Verify patient identity with another nurse
B. Administer through any IV line
C. Infuse rapidly to prevent clotting
Rationale: Patient identity verification prevents transfusion errors.
Q16. Which nursing action prevents catheter-associated urinary tract infection (CAUTI)?
A. Maintain catheter indefinitely
B. Keep drainage bag below bladder level
B. Disconnect tubing frequently
C. Irrigate catheter daily
Rationale: Prevents backflow of urine and bacterial contamination.
Q17. A patient reports pain rated 8/10. What is the nurse’s priority?
A. Document pain score
B. Administer prescribed analgesic
B. Encourage distraction techniques
C. Reassess in 2 hours
Rationale: Severe pain requires prompt pharmacologic intervention.
Q18. Which technique is correct for sterile gloving?
A. Touch outside of glove with bare hand
