NURS 104L | Fundamentals of Nursing Skills Lab | Exam 4
Comprehensive Study Guide 2026 |WCU
1. A nurse is assessing a patient’s peripheral IV site and notes coolness, pallor,
and swelling around the insertion site. The infusion has slowed. Which
complication is most likely occurring?
A. Phlebitis
B. Infiltration
C. Extravasation
D. Thrombophlebitis
Answer: B
Rationale: Infiltration is characterized by coolness, pallor, and edema as the IV fluid enters
the subcutaneous tissue. Phlebitis would present with warmth and redness.
2. When preparing to administer an intramuscular injection to an infant, which
site is the most appropriate according to evidence-based practice?
A. Dorsogluteal
B. Ventrogluteal
C. Vastus lateralis
D. Deltoid
Answer: C
Rationale: The vastus lateralis is the preferred site for IM injections in infants because it is
the most developed muscle at birth.
,3. The nurse is preparing to mix NPH and Regular insulin in the same syringe.
Which action is correct?
A. Draw up the NPH insulin first, then the Regular insulin.
B. Inject air into the Regular insulin, then air into the NPH insulin.
C. Inject air into the NPH insulin, then draw it up before injecting air into the Regular insulin.
D. Draw up the Regular insulin first, then the NPH insulin.
Answer: D
Rationale: Regular (clear) insulin should be drawn up before NPH (cloudy) insulin to
prevent contamination of the fast-acting insulin with the intermediate-acting insulin.
4. A nurse is performing a sterile dressing change. Which action would violate
the principles of surgical asepsis?
A. Keeping the sterile field within the nurse’s line of vision.
B. Holding sterile items above the level of the waist.
C. Opening the outermost flap of the sterile kit away from the body.
D. Reaching over the sterile field to pick up a gauze pad.
Answer: D
Rationale: Reaching over a sterile field is a violation of surgical asepsis because
microorganisms can drop from the nurse’s arm onto the field.
5. Which assessment finding indicates a Stage 3 pressure injury?
A. Non-blanchable erythema of intact skin.
B. Partial-thickness loss of dermis presenting as a shallow open ulcer.
C. Full-thickness tissue loss with exposed bone, tendon, or muscle.
D. Full-thickness tissue loss with visible subcutaneous fat.
Answer: D
Rationale: Stage 3 pressure injuries involve full-thickness skin loss where subcutaneous
fat may be visible, but bone, tendon, or muscle are not exposed.
, 6. What is the gold standard for verifying the initial placement of a nasogastric
(NG) tube?
A. Auscultating air bolus over the epigastrium.
B. Radiographic (X-ray) confirmation.
C. Observing the patient for coughing or respiratory distress.
D. Testing the pH of aspirated gastric contents.
Answer: B
Rationale: While pH testing is used for ongoing bedside verification, radiographic
confirmation is the only definitive gold standard for initial placement.
7. A nurse is preparing to administer an enema. In which position should the
nurse place the patient?
A. Right-sided Sims’ position
B. Left-sided Sims’ position
C. Supine with knees flexed
D. High-Fowler’s position
Answer: B
Rationale: The left-sided Sims’ position allows the enema solution to flow by gravity into
the sigmoid colon and rectum.
8. While suctioning a patient with a tracheostomy, the nurse should limit each
suction pass to no more than:
A. 5 seconds
B. 1 minute
C. 20 to 30 seconds
D. 10 to 15 seconds
Answer: D
Rationale: Suctioning should be limited to 10-15 seconds per pass to prevent hypoxia and
vagal stimulation.
Comprehensive Study Guide 2026 |WCU
1. A nurse is assessing a patient’s peripheral IV site and notes coolness, pallor,
and swelling around the insertion site. The infusion has slowed. Which
complication is most likely occurring?
A. Phlebitis
B. Infiltration
C. Extravasation
D. Thrombophlebitis
Answer: B
Rationale: Infiltration is characterized by coolness, pallor, and edema as the IV fluid enters
the subcutaneous tissue. Phlebitis would present with warmth and redness.
2. When preparing to administer an intramuscular injection to an infant, which
site is the most appropriate according to evidence-based practice?
A. Dorsogluteal
B. Ventrogluteal
C. Vastus lateralis
D. Deltoid
Answer: C
Rationale: The vastus lateralis is the preferred site for IM injections in infants because it is
the most developed muscle at birth.
,3. The nurse is preparing to mix NPH and Regular insulin in the same syringe.
Which action is correct?
A. Draw up the NPH insulin first, then the Regular insulin.
B. Inject air into the Regular insulin, then air into the NPH insulin.
C. Inject air into the NPH insulin, then draw it up before injecting air into the Regular insulin.
D. Draw up the Regular insulin first, then the NPH insulin.
Answer: D
Rationale: Regular (clear) insulin should be drawn up before NPH (cloudy) insulin to
prevent contamination of the fast-acting insulin with the intermediate-acting insulin.
4. A nurse is performing a sterile dressing change. Which action would violate
the principles of surgical asepsis?
A. Keeping the sterile field within the nurse’s line of vision.
B. Holding sterile items above the level of the waist.
C. Opening the outermost flap of the sterile kit away from the body.
D. Reaching over the sterile field to pick up a gauze pad.
Answer: D
Rationale: Reaching over a sterile field is a violation of surgical asepsis because
microorganisms can drop from the nurse’s arm onto the field.
5. Which assessment finding indicates a Stage 3 pressure injury?
A. Non-blanchable erythema of intact skin.
B. Partial-thickness loss of dermis presenting as a shallow open ulcer.
C. Full-thickness tissue loss with exposed bone, tendon, or muscle.
D. Full-thickness tissue loss with visible subcutaneous fat.
Answer: D
Rationale: Stage 3 pressure injuries involve full-thickness skin loss where subcutaneous
fat may be visible, but bone, tendon, or muscle are not exposed.
, 6. What is the gold standard for verifying the initial placement of a nasogastric
(NG) tube?
A. Auscultating air bolus over the epigastrium.
B. Radiographic (X-ray) confirmation.
C. Observing the patient for coughing or respiratory distress.
D. Testing the pH of aspirated gastric contents.
Answer: B
Rationale: While pH testing is used for ongoing bedside verification, radiographic
confirmation is the only definitive gold standard for initial placement.
7. A nurse is preparing to administer an enema. In which position should the
nurse place the patient?
A. Right-sided Sims’ position
B. Left-sided Sims’ position
C. Supine with knees flexed
D. High-Fowler’s position
Answer: B
Rationale: The left-sided Sims’ position allows the enema solution to flow by gravity into
the sigmoid colon and rectum.
8. While suctioning a patient with a tracheostomy, the nurse should limit each
suction pass to no more than:
A. 5 seconds
B. 1 minute
C. 20 to 30 seconds
D. 10 to 15 seconds
Answer: D
Rationale: Suctioning should be limited to 10-15 seconds per pass to prevent hypoxia and
vagal stimulation.
