NURS 104L Fundamentals of Nursing Skills Lab Exam 4 Prep 2026
|WCU
1. When performing a sterile dressing change, what is the correct action to
maintain the sterile field?
A. Reach across the sterile field to pick up a gauze pad.
B. Open sterile packages with the first flap towards the body.
C. Keep the sterile field within the line of sight at all times.
D. Place the sterile bowl on the very edge of the sterile drape.
Answer: C
Rationale: To maintain a sterile field, it must always be kept within the healthcare
worker’s line of vision. Reaching across the field, opening the first flap toward the body, or
placing items on the 1-inch border contaminates the field.
2. Which landmark is most appropriate for an intramuscular (IM) injection in an
infant?
A. Dorsogluteal
B. Deltoid
C. Vastus lateralis
D. Ventrogluteal
Answer: C
Rationale: The vastus lateralis is the preferred site for IM injections in infants because it is
the most developed muscle at that age.
,3. A nurse is measuring for a nasogastric (NG) tube insertion. Which sequence of
measurement is correct?
A. Ear to nose to xiphoid process
B. Mouth to earlobe to xiphoid process
C. Nose to xiphoid process to umbilicus
D. Nose to earlobe to xiphoid process
Answer: D
Rationale: The standard measurement for NG tube insertion is from the tip of the nose to
the earlobe, and then to the xiphoid process (NEX).
4. Before administering a tube feeding, which pH level indicates the tube is
likely in the stomach?
A. pH of 7.0
B. pH of 8.5
C. pH of 6.0
D. pH of 2.5
Answer: D
Rationale: Gastric contents are acidic, typically having a pH of 1 to 5. A pH higher than 6
may indicate placement in the respiratory tract or intestines.
5. When inserting a Foley catheter into a female patient, the nurse should insert
the catheter how far after urine is visualized?
A. 0.5 inches
B. 4 to 5 inches
C. 1 to 2 inches
D. To the bifurcation
Answer: C
Rationale: Once urine is visualized in the tubing, the nurse should advance the catheter
another 1 to 2 inches (2.5 to 5 cm) to ensure the balloon is in the bladder before inflation.
, 6. What is the first step a nurse should take when a medication error occurs?
A. Complete an incident report.
B. Assess the patient’s condition.
C. Notify the healthcare provider.
D. Call the pharmacy.
Answer: B
Rationale: Patient safety is the priority. The nurse must first assess the patient’s status to
determine if any adverse effects have occurred before notifying providers or completing
paperwork.
7. A patient has an IV site that is cool to the touch, swollen, and pale. These are
signs of:
A. Infiltration
B. Phlebitis
C. Infection
D. Thrombosis
Answer: A
Rationale: Infiltration is characterized by coolness, pallor, and edema at the site. Phlebitis
usually presents with warmth, redness, and a palpable cord.
8. When performing tracheostomy suctioning, what is the maximum duration
for each suction pass?
A. 10 to 15 seconds
B. 5 seconds
C. 20 to 30 seconds
D. As long as secretions are visible
Answer: A
Rationale: To prevent hypoxia and mucosal damage, suctioning should be limited to 10 to
15 seconds per pass.
|WCU
1. When performing a sterile dressing change, what is the correct action to
maintain the sterile field?
A. Reach across the sterile field to pick up a gauze pad.
B. Open sterile packages with the first flap towards the body.
C. Keep the sterile field within the line of sight at all times.
D. Place the sterile bowl on the very edge of the sterile drape.
Answer: C
Rationale: To maintain a sterile field, it must always be kept within the healthcare
worker’s line of vision. Reaching across the field, opening the first flap toward the body, or
placing items on the 1-inch border contaminates the field.
2. Which landmark is most appropriate for an intramuscular (IM) injection in an
infant?
A. Dorsogluteal
B. Deltoid
C. Vastus lateralis
D. Ventrogluteal
Answer: C
Rationale: The vastus lateralis is the preferred site for IM injections in infants because it is
the most developed muscle at that age.
,3. A nurse is measuring for a nasogastric (NG) tube insertion. Which sequence of
measurement is correct?
A. Ear to nose to xiphoid process
B. Mouth to earlobe to xiphoid process
C. Nose to xiphoid process to umbilicus
D. Nose to earlobe to xiphoid process
Answer: D
Rationale: The standard measurement for NG tube insertion is from the tip of the nose to
the earlobe, and then to the xiphoid process (NEX).
4. Before administering a tube feeding, which pH level indicates the tube is
likely in the stomach?
A. pH of 7.0
B. pH of 8.5
C. pH of 6.0
D. pH of 2.5
Answer: D
Rationale: Gastric contents are acidic, typically having a pH of 1 to 5. A pH higher than 6
may indicate placement in the respiratory tract or intestines.
5. When inserting a Foley catheter into a female patient, the nurse should insert
the catheter how far after urine is visualized?
A. 0.5 inches
B. 4 to 5 inches
C. 1 to 2 inches
D. To the bifurcation
Answer: C
Rationale: Once urine is visualized in the tubing, the nurse should advance the catheter
another 1 to 2 inches (2.5 to 5 cm) to ensure the balloon is in the bladder before inflation.
, 6. What is the first step a nurse should take when a medication error occurs?
A. Complete an incident report.
B. Assess the patient’s condition.
C. Notify the healthcare provider.
D. Call the pharmacy.
Answer: B
Rationale: Patient safety is the priority. The nurse must first assess the patient’s status to
determine if any adverse effects have occurred before notifying providers or completing
paperwork.
7. A patient has an IV site that is cool to the touch, swollen, and pale. These are
signs of:
A. Infiltration
B. Phlebitis
C. Infection
D. Thrombosis
Answer: A
Rationale: Infiltration is characterized by coolness, pallor, and edema at the site. Phlebitis
usually presents with warmth, redness, and a palpable cord.
8. When performing tracheostomy suctioning, what is the maximum duration
for each suction pass?
A. 10 to 15 seconds
B. 5 seconds
C. 20 to 30 seconds
D. As long as secretions are visible
Answer: A
Rationale: To prevent hypoxia and mucosal damage, suctioning should be limited to 10 to
15 seconds per pass.
