NURS 104L Fundamentals of Nursing Skills Lab - Week 14
Comprehensive Final Review 2026 |WCU
1. A nurse is preparing to perform a sterile dressing change. While setting up the
sterile field, a small amount of sterile saline splashes onto the sterile drape.
What is the nurse’s most appropriate action?
A. Continue the procedure as long as the saline was sterile.
B. Place a second sterile drape directly over the wet area.
C. Consider the field contaminated and start over with new supplies.
D. Wipe the area with a sterile gauze pad and proceed.
Answer: C
Rationale: Capillary action (wicking) occurs when a sterile surface becomes wet, allowing
microorganisms from the unsterile surface underneath to migrate through the drape, thus
contaminating the field.
2. When inserting an indwelling urinary catheter in a female patient, the nurse
accidentally inserts the catheter into the vagina. What should the nurse do
next?
A. Remove the catheter and immediately attempt to re-insert it into the meatus.
B. Clean the catheter with alcohol and re-insert.
C. Ask the patient to cough and push the catheter further in.
D. Leave the catheter in the vagina as a landmark and obtain a new sterile kit.
Answer: D
Rationale: Leaving the misplaced catheter in the vagina helps the nurse identify the
correct anatomical landmarks and prevents repeating the same error while using a new,
sterile kit for the second attempt.
,3. A nurse is assessing a pressure injury and notes full-thickness skin loss with
visible subcutaneous fat, but no bone, tendon, or muscle is exposed. How
should this be staged?
A. Stage 2
B. Stage 3
C. Stage 4
D. Unstageable
Answer: B
Rationale: Stage 3 pressure injuries involve full-thickness skin loss where adipose (fat) is
visible, but deeper structures like fascia, muscle, or bone are not yet exposed.
4. During tracheostomy suctioning, the nurse notes the patient’s heart rate has
decreased from 78 bpm to 54 bpm. Which action should be taken first?
A. Stop suctioning immediately and oxygenate the patient.
B. Increase the suction pressure to finish sooner.
C. Complete the suctioning pass as quickly as possible.
D. Administer atropine as per standing orders.
Answer: A
Rationale: A drop in heart rate (bradycardia) during suctioning often indicates vagal
stimulation or hypoxia. The nurse must stop the procedure immediately and provide 100%
oxygen.
5. The nurse is administering an IM injection using the Z-track technique. What
is the primary purpose of this method?
A. To ensure the needle reaches the bone.
B. To speed up the absorption of the medication.
C. To reduce the pain of the needle stick.
D. To prevent the medication from leaking into the subcutaneous tissue.
Answer: D
, Rationale: The Z-track method seals the medication within the muscle and prevents it
from tracking back through the needle track into the subcutaneous tissue, which reduces
irritation and staining.
6. What is the most reliable method for confirming the initial placement of a
nasogastric (NG) tube?
A. Auscultating for an air bolus over the epigastrium.
B. Testing the pH of aspirated gastric contents.
C. Radiographic (X-ray) visualization.
D. Checking for bubbles when the tube end is placed in water.
Answer: C
Rationale: An X-ray is the ‘gold standard’ and most reliable method for confirming the
anatomical position of an NG tube before administering any feedings or medications.
7. A nurse is administering a large-volume cleansing enema. The patient
complains of sudden abdominal cramping. What should the nurse do?
A. Stop the procedure and notify the provider.
B. Speed up the flow to finish the procedure faster.
C. Encourage the patient to hold their breath.
D. Lower the enema container to slow the rate of flow.
Answer: D
Rationale: If a patient experiences cramping during an enema, the nurse should lower the
bag to decrease the infusion rate/pressure, which usually relieves the cramping and allows
the procedure to continue.
Comprehensive Final Review 2026 |WCU
1. A nurse is preparing to perform a sterile dressing change. While setting up the
sterile field, a small amount of sterile saline splashes onto the sterile drape.
What is the nurse’s most appropriate action?
A. Continue the procedure as long as the saline was sterile.
B. Place a second sterile drape directly over the wet area.
C. Consider the field contaminated and start over with new supplies.
D. Wipe the area with a sterile gauze pad and proceed.
Answer: C
Rationale: Capillary action (wicking) occurs when a sterile surface becomes wet, allowing
microorganisms from the unsterile surface underneath to migrate through the drape, thus
contaminating the field.
2. When inserting an indwelling urinary catheter in a female patient, the nurse
accidentally inserts the catheter into the vagina. What should the nurse do
next?
A. Remove the catheter and immediately attempt to re-insert it into the meatus.
B. Clean the catheter with alcohol and re-insert.
C. Ask the patient to cough and push the catheter further in.
D. Leave the catheter in the vagina as a landmark and obtain a new sterile kit.
Answer: D
Rationale: Leaving the misplaced catheter in the vagina helps the nurse identify the
correct anatomical landmarks and prevents repeating the same error while using a new,
sterile kit for the second attempt.
,3. A nurse is assessing a pressure injury and notes full-thickness skin loss with
visible subcutaneous fat, but no bone, tendon, or muscle is exposed. How
should this be staged?
A. Stage 2
B. Stage 3
C. Stage 4
D. Unstageable
Answer: B
Rationale: Stage 3 pressure injuries involve full-thickness skin loss where adipose (fat) is
visible, but deeper structures like fascia, muscle, or bone are not yet exposed.
4. During tracheostomy suctioning, the nurse notes the patient’s heart rate has
decreased from 78 bpm to 54 bpm. Which action should be taken first?
A. Stop suctioning immediately and oxygenate the patient.
B. Increase the suction pressure to finish sooner.
C. Complete the suctioning pass as quickly as possible.
D. Administer atropine as per standing orders.
Answer: A
Rationale: A drop in heart rate (bradycardia) during suctioning often indicates vagal
stimulation or hypoxia. The nurse must stop the procedure immediately and provide 100%
oxygen.
5. The nurse is administering an IM injection using the Z-track technique. What
is the primary purpose of this method?
A. To ensure the needle reaches the bone.
B. To speed up the absorption of the medication.
C. To reduce the pain of the needle stick.
D. To prevent the medication from leaking into the subcutaneous tissue.
Answer: D
, Rationale: The Z-track method seals the medication within the muscle and prevents it
from tracking back through the needle track into the subcutaneous tissue, which reduces
irritation and staining.
6. What is the most reliable method for confirming the initial placement of a
nasogastric (NG) tube?
A. Auscultating for an air bolus over the epigastrium.
B. Testing the pH of aspirated gastric contents.
C. Radiographic (X-ray) visualization.
D. Checking for bubbles when the tube end is placed in water.
Answer: C
Rationale: An X-ray is the ‘gold standard’ and most reliable method for confirming the
anatomical position of an NG tube before administering any feedings or medications.
7. A nurse is administering a large-volume cleansing enema. The patient
complains of sudden abdominal cramping. What should the nurse do?
A. Stop the procedure and notify the provider.
B. Speed up the flow to finish the procedure faster.
C. Encourage the patient to hold their breath.
D. Lower the enema container to slow the rate of flow.
Answer: D
Rationale: If a patient experiences cramping during an enema, the nurse should lower the
bag to decrease the infusion rate/pressure, which usually relieves the cramping and allows
the procedure to continue.
