NURS 104L Fundamentals of Nursing Skills Lab - Exam 3 Study Guide
2026 |WCU
1. When preparing a sterile field, which action by the nurse would violate the
principles of surgical asepsis?
A. Reaching across the sterile field to pick up a sterile gauze pad.
B. Maintaining a 1-inch border around the edge of the sterile field as contaminated.
C. Opening the outermost flap of the sterile kit away from the body.
D. Holding sterile items above the level of the waist.
Answer: A
Rationale: Reaching across a sterile field is a violation of surgical asepsis because
microorganisms can drop from the nurse’s arm or clothing onto the sterile surface. The
other actions (opening away, 1-inch border, and keeping items above waist) are correct
practices.
2. Which site is preferred for a 2 mL intramuscular injection in an adult patient
who is cachectic and has limited muscle mass?
A. Deltiod
B. Ventrogluteal
C. Dorsogluteal
D. Vastus lateralis
Answer: B
Rationale: The ventrogluteal site is the preferred and safest site for all adults, including
those with low muscle mass, because it is situated away from major nerves and blood
vessels and provides a large muscle mass.
,3. The nurse is performing tracheostomy suctioning. What is the maximum
duration for each suction pass?
A. 5 seconds
B. Until the airway is clear
C. 20 to 30 seconds
D. 10 to 15 seconds
Answer: D
Rationale: Suctioning should be limited to 10 to 15 seconds per pass to prevent hypoxia
and vagal stimulation. Suction should only be applied while withdrawing the catheter.
4. Before administering a bolus enteral feeding via a nasogastric (NG) tube,
which pH reading of the aspirate best indicates gastric placement?
A. pH of 7.0
B. pH of 3.5
C. pH of 8.2
D. pH of 6.0
Answer: B
Rationale: A pH of 1 to 5 is typical for gastric contents. A pH of 6 or higher suggests the
tube may be in the respiratory tract or the intestines.
5. A nurse is preparing to administer 0.5 mL of a medication subcutaneously to
an average-sized adult. Which needle gauge and length are most appropriate?
A. 22 gauge, 1.5 inch
B. 18 gauge, 1 inch
C. 25 gauge, 5/8 inch
D. 27 gauge, 3/8 inch
Answer: C
Rationale: For a subcutaneous injection in an average adult, a 25 to 27 gauge needle that is
3/8 to 5/8 inches long is standard. A 1.5-inch needle is for IM injections.
, 6. When performing wound irrigation, in which direction should the nurse direct
the flow of the solution?
A. From the most contaminated area to the least contaminated area.
B. From the bottom of the wound to the top.
C. From the least contaminated area to the most contaminated area.
D. In a circular motion starting from the outer edges.
Answer: C
Rationale: To prevent the spread of microorganisms into the wound, irrigation should
flow from the cleanest (least contaminated) part to the dirtiest (most contaminated) part.
7. While inserting an indwelling urinary catheter into a female patient, the
nurse accidentally inserts the catheter into the vagina. What is the nurse’s next
action?
A. Remove the catheter and immediately reinsert it into the meatus.
B. Ask the patient to cough and then redirect the catheter upward.
C. Clean the catheter with an alcohol swab and reinsert it.
D. Leave the catheter in the vagina and obtain a new sterile kit to attempt re-insertion.
Answer: D
Rationale: Leaving the misplaced catheter in the vagina serves as a landmark to help avoid
repeating the mistake. A new sterile kit must be used for the second attempt to maintain
sterility.
8. What is the first action the nurse should take if a patient’s wound shows signs
of evisceration?
A. Push the organs back into the abdominal cavity.
B. Apply a dry sterile dressing to the area.
C. Cover the protruding organs with sterile towels moistened with sterile normal saline.
D. Call the surgeon immediately before doing anything else.
Answer: C
2026 |WCU
1. When preparing a sterile field, which action by the nurse would violate the
principles of surgical asepsis?
A. Reaching across the sterile field to pick up a sterile gauze pad.
B. Maintaining a 1-inch border around the edge of the sterile field as contaminated.
C. Opening the outermost flap of the sterile kit away from the body.
D. Holding sterile items above the level of the waist.
Answer: A
Rationale: Reaching across a sterile field is a violation of surgical asepsis because
microorganisms can drop from the nurse’s arm or clothing onto the sterile surface. The
other actions (opening away, 1-inch border, and keeping items above waist) are correct
practices.
2. Which site is preferred for a 2 mL intramuscular injection in an adult patient
who is cachectic and has limited muscle mass?
A. Deltiod
B. Ventrogluteal
C. Dorsogluteal
D. Vastus lateralis
Answer: B
Rationale: The ventrogluteal site is the preferred and safest site for all adults, including
those with low muscle mass, because it is situated away from major nerves and blood
vessels and provides a large muscle mass.
,3. The nurse is performing tracheostomy suctioning. What is the maximum
duration for each suction pass?
A. 5 seconds
B. Until the airway is clear
C. 20 to 30 seconds
D. 10 to 15 seconds
Answer: D
Rationale: Suctioning should be limited to 10 to 15 seconds per pass to prevent hypoxia
and vagal stimulation. Suction should only be applied while withdrawing the catheter.
4. Before administering a bolus enteral feeding via a nasogastric (NG) tube,
which pH reading of the aspirate best indicates gastric placement?
A. pH of 7.0
B. pH of 3.5
C. pH of 8.2
D. pH of 6.0
Answer: B
Rationale: A pH of 1 to 5 is typical for gastric contents. A pH of 6 or higher suggests the
tube may be in the respiratory tract or the intestines.
5. A nurse is preparing to administer 0.5 mL of a medication subcutaneously to
an average-sized adult. Which needle gauge and length are most appropriate?
A. 22 gauge, 1.5 inch
B. 18 gauge, 1 inch
C. 25 gauge, 5/8 inch
D. 27 gauge, 3/8 inch
Answer: C
Rationale: For a subcutaneous injection in an average adult, a 25 to 27 gauge needle that is
3/8 to 5/8 inches long is standard. A 1.5-inch needle is for IM injections.
, 6. When performing wound irrigation, in which direction should the nurse direct
the flow of the solution?
A. From the most contaminated area to the least contaminated area.
B. From the bottom of the wound to the top.
C. From the least contaminated area to the most contaminated area.
D. In a circular motion starting from the outer edges.
Answer: C
Rationale: To prevent the spread of microorganisms into the wound, irrigation should
flow from the cleanest (least contaminated) part to the dirtiest (most contaminated) part.
7. While inserting an indwelling urinary catheter into a female patient, the
nurse accidentally inserts the catheter into the vagina. What is the nurse’s next
action?
A. Remove the catheter and immediately reinsert it into the meatus.
B. Ask the patient to cough and then redirect the catheter upward.
C. Clean the catheter with an alcohol swab and reinsert it.
D. Leave the catheter in the vagina and obtain a new sterile kit to attempt re-insertion.
Answer: D
Rationale: Leaving the misplaced catheter in the vagina serves as a landmark to help avoid
repeating the mistake. A new sterile kit must be used for the second attempt to maintain
sterility.
8. What is the first action the nurse should take if a patient’s wound shows signs
of evisceration?
A. Push the organs back into the abdominal cavity.
B. Apply a dry sterile dressing to the area.
C. Cover the protruding organs with sterile towels moistened with sterile normal saline.
D. Call the surgeon immediately before doing anything else.
Answer: C
