NURS 104L Fundamentals of Nursing Skills Lab - Actual Exam 3 2026
|WCU
1. When preparing to administer a subcutaneous heparin injection, which action
should the nurse take to minimize bruising?
A. Massage the site vigorously after injecting the medication.
B. Avoid aspirating and do not massage the site after the injection.
C. Apply a cold compress to the site for 15 minutes before the injection.
D. Use a 21-gauge needle to ensure the medication reaches the muscle layer.
Answer: B
Rationale: Aspiration and massage are avoided with heparin to prevent tissue trauma and
hematoma formation.
2. A nurse is preparing to perform tracheostomy care. Which of the following is
the priority nursing action before beginning the procedure?
A. Place the patient in a prone position.
B. Change the tracheostomy ties immediately.
C. Auscultate lung sounds and assess the need for suctioning.
D. Clean the inner cannula with tap water.
Answer: C
Rationale: Assessment is always the first step; lung sounds and the need for suctioning
ensure the patient’s airway is prioritized before cleaning.
,3. When mixing NPH and Regular insulin in a single syringe, what is the correct
sequence of drawing up the medication?
A. Draw up NPH first, then Regular.
B. Draw up both into separate syringes and mix them in a cup.
C. Inject air into Regular, inject air into NPH, draw up NPH, then draw up Regular.
D. Inject air into NPH, inject air into Regular, draw up Regular, then draw up NPH.
Answer: D
Rationale: To prevent contamination, air is injected into the cloudy (NPH) then clear
(Regular), and the clear is drawn up before the cloudy.
4. A nurse is providing wound care for a patient with a Stage III pressure injury.
Which finding indicates the wound is healing by secondary intention?
A. The wound edges are well-approximated with sutures.
B. There is clear evidence of primary closure with surgical glue.
C. The wound is covered with a dry, black eschar.
D. Presence of red, moist granulation tissue in the wound bed.
Answer: D
Rationale: Secondary intention involves wounds that are left open and heal by the
formation of granulation tissue from the bottom up.
5. What is the primary purpose of the Z-track method for intramuscular
injections?
A. To decrease the pain associated with the needle stick.
B. To seal the medication within the muscle and prevent leakage into the subcutaneous tissue.
C. To ensure the needle reaches the subcutaneous layer.
D. To allow for faster absorption of the medication into the bloodstream.
Answer: B
Rationale: The Z-track method creates a zigzag path that prevents irritating medications
from leaking back out of the muscle.
, 6. During a sterile procedure, the nurse notices the edge of the sterile drape is
hanging below the waist level. What should the nurse do?
A. Continue the procedure as long as the center is sterile.
B. Pull the drape back up to the table surface.
C. Consider the portion hanging below the waist as contaminated.
D. Spray the hanging portion with an antiseptic solution.
Answer: C
Rationale: In sterile technique, any object or part of a sterile field that falls below the waist
is considered contaminated.
7. A nurse is inserting an indwelling urinary catheter for a female patient. Which
action is essential to maintain sterility?
A. Opening the sterile kit away from the body to create a sterile field.
B. Holding the catheter 5 inches from the tip during insertion.
C. Using the dominant hand to stabilize the labia.
D. Cleaning the labia minora from the bottom to the top.
Answer: A
Rationale: The first flap of a sterile kit should always be opened away from the body to
avoid reaching over the sterile field.
8. The nurse is verifying NG tube placement. Which method is considered the
most reliable for initial verification?
A. Obtaining a chest or abdominal X-ray.
B. Observing the color of the gastric aspirate.
C. Auscultating a ‘whoosh’ sound over the epigastric area.
D. Testing the pH of the aspirated contents.
Answer: A
Rationale: Radiographic evidence (X-ray) is the gold standard for confirming the
placement of a newly inserted NG tube.
|WCU
1. When preparing to administer a subcutaneous heparin injection, which action
should the nurse take to minimize bruising?
A. Massage the site vigorously after injecting the medication.
B. Avoid aspirating and do not massage the site after the injection.
C. Apply a cold compress to the site for 15 minutes before the injection.
D. Use a 21-gauge needle to ensure the medication reaches the muscle layer.
Answer: B
Rationale: Aspiration and massage are avoided with heparin to prevent tissue trauma and
hematoma formation.
2. A nurse is preparing to perform tracheostomy care. Which of the following is
the priority nursing action before beginning the procedure?
A. Place the patient in a prone position.
B. Change the tracheostomy ties immediately.
C. Auscultate lung sounds and assess the need for suctioning.
D. Clean the inner cannula with tap water.
Answer: C
Rationale: Assessment is always the first step; lung sounds and the need for suctioning
ensure the patient’s airway is prioritized before cleaning.
,3. When mixing NPH and Regular insulin in a single syringe, what is the correct
sequence of drawing up the medication?
A. Draw up NPH first, then Regular.
B. Draw up both into separate syringes and mix them in a cup.
C. Inject air into Regular, inject air into NPH, draw up NPH, then draw up Regular.
D. Inject air into NPH, inject air into Regular, draw up Regular, then draw up NPH.
Answer: D
Rationale: To prevent contamination, air is injected into the cloudy (NPH) then clear
(Regular), and the clear is drawn up before the cloudy.
4. A nurse is providing wound care for a patient with a Stage III pressure injury.
Which finding indicates the wound is healing by secondary intention?
A. The wound edges are well-approximated with sutures.
B. There is clear evidence of primary closure with surgical glue.
C. The wound is covered with a dry, black eschar.
D. Presence of red, moist granulation tissue in the wound bed.
Answer: D
Rationale: Secondary intention involves wounds that are left open and heal by the
formation of granulation tissue from the bottom up.
5. What is the primary purpose of the Z-track method for intramuscular
injections?
A. To decrease the pain associated with the needle stick.
B. To seal the medication within the muscle and prevent leakage into the subcutaneous tissue.
C. To ensure the needle reaches the subcutaneous layer.
D. To allow for faster absorption of the medication into the bloodstream.
Answer: B
Rationale: The Z-track method creates a zigzag path that prevents irritating medications
from leaking back out of the muscle.
, 6. During a sterile procedure, the nurse notices the edge of the sterile drape is
hanging below the waist level. What should the nurse do?
A. Continue the procedure as long as the center is sterile.
B. Pull the drape back up to the table surface.
C. Consider the portion hanging below the waist as contaminated.
D. Spray the hanging portion with an antiseptic solution.
Answer: C
Rationale: In sterile technique, any object or part of a sterile field that falls below the waist
is considered contaminated.
7. A nurse is inserting an indwelling urinary catheter for a female patient. Which
action is essential to maintain sterility?
A. Opening the sterile kit away from the body to create a sterile field.
B. Holding the catheter 5 inches from the tip during insertion.
C. Using the dominant hand to stabilize the labia.
D. Cleaning the labia minora from the bottom to the top.
Answer: A
Rationale: The first flap of a sterile kit should always be opened away from the body to
avoid reaching over the sterile field.
8. The nurse is verifying NG tube placement. Which method is considered the
most reliable for initial verification?
A. Obtaining a chest or abdominal X-ray.
B. Observing the color of the gastric aspirate.
C. Auscultating a ‘whoosh’ sound over the epigastric area.
D. Testing the pH of the aspirated contents.
Answer: A
Rationale: Radiographic evidence (X-ray) is the gold standard for confirming the
placement of a newly inserted NG tube.
