NURS 104L: Fundamentals of Nursing Skills Lab Exam 2 2026 |WCU
1. When performing hand hygiene using soap and water, what is the minimum
duration of time a nurse should scrub their hands together with soap to ensure
adequate mechanical removal of microorganisms?
A. 5 to 10 seconds
B. 60 seconds or more
C. 30 to 45 seconds
D. 15 to 20 seconds
Answer: D
Rationale: The CDC recommends scrubbing hands for at least 15 to 20 seconds to
effectively remove transient flora and pathogens through mechanical friction.
2. A nurse is preparing to administer a medication via the intramuscular (IM)
route to an average-sized adult. Which needle gauge and length is most
appropriate for a Ventrogluteal injection?
A. 21-23 gauge, 1.5 inch
B. 18-20 gauge, 1 inch
C. 25-27 gauge, 5/8 inch
D. 23-25 gauge, 0.5 inch
Answer: A
Rationale: For a Ventrogluteal IM injection in an adult, a 21-23 gauge needle that is 1.5
inches long is standard to ensure the medication reaches the deep muscle tissue.
,3. When assessing a patient’s radial pulse, the nurse notes that the rhythm is
irregular. What should be the nurse’s next action to obtain an accurate heart
rate?
A. Auscultate the apical pulse for 60 seconds.
B. Measure the radial pulse for a full minute.
C. Document the irregularity and notify the physician immediately.
D. Use a Doppler ultrasound device on the radial artery.
Answer: A
Rationale: If a peripheral pulse is irregular, the nurse must auscultate the apical pulse for
one full minute to obtain the most accurate heart rate and assessment of the rhythm.
4. A nurse is maintaining a sterile field for a dressing change. Which of the
following actions would result in a contamination of the sterile field?
A. Keeping the sterile field within the line of vision.
B. Opening the outermost flap of a sterile kit away from the body.
C. Placing a sterile gauze pad within the 1-inch border of the sterile drape.
D. Pouring sterile saline into a container without splashing.
Answer: C
Rationale: The outer 1-inch border of a sterile field is considered contaminated. Any
sterile item placed on or touching this border is no longer sterile.
5. A patient has a Stage 2 pressure injury on the sacrum. Which description best
matches this stage?
A. Partial-thickness loss of dermis presenting as a shallow open ulcer.
B. Intact skin with non-blanchable erythema.
C. Full-thickness tissue loss with visible subcutaneous fat.
D. Full-thickness tissue loss with exposed bone, tendon, or muscle.
Answer: A
, Rationale: Stage 2 pressure injuries involve partial-thickness loss of the dermis, often
appearing as a shallow open ulcer with a red-pink wound bed or an intact/ruptured serum-
filled blister.
6. Which of the following is the correct sequence for donning Personal
Protective Equipment (PPE) for a patient on Contact and Droplet precautions?
A. Gloves, Goggles, Mask, Gown
B. Gown, Mask, Goggles, Gloves
C. Mask, Gown, Gloves, Goggles
D. Goggles, Gloves, Gown, Mask
Answer: B
Rationale: The standard sequence for donning PPE is Gown, then Mask or Respirator, then
Goggles or Face Shield, and finally Gloves.
7. When administering an enema, in which position should the nurse place the
patient to facilitate the flow of the solution into the sigmoid colon?
A. High Fowler’s position
B. Supine with legs abducted
C. Left-lateral Sims’ position
D. Right-lateral position with knees flexed
Answer: C
Rationale: The Left Sims’ position uses gravity to help the enema solution flow into the
sigmoid colon and rectum due to the anatomical curve of the colon.
1. When performing hand hygiene using soap and water, what is the minimum
duration of time a nurse should scrub their hands together with soap to ensure
adequate mechanical removal of microorganisms?
A. 5 to 10 seconds
B. 60 seconds or more
C. 30 to 45 seconds
D. 15 to 20 seconds
Answer: D
Rationale: The CDC recommends scrubbing hands for at least 15 to 20 seconds to
effectively remove transient flora and pathogens through mechanical friction.
2. A nurse is preparing to administer a medication via the intramuscular (IM)
route to an average-sized adult. Which needle gauge and length is most
appropriate for a Ventrogluteal injection?
A. 21-23 gauge, 1.5 inch
B. 18-20 gauge, 1 inch
C. 25-27 gauge, 5/8 inch
D. 23-25 gauge, 0.5 inch
Answer: A
Rationale: For a Ventrogluteal IM injection in an adult, a 21-23 gauge needle that is 1.5
inches long is standard to ensure the medication reaches the deep muscle tissue.
,3. When assessing a patient’s radial pulse, the nurse notes that the rhythm is
irregular. What should be the nurse’s next action to obtain an accurate heart
rate?
A. Auscultate the apical pulse for 60 seconds.
B. Measure the radial pulse for a full minute.
C. Document the irregularity and notify the physician immediately.
D. Use a Doppler ultrasound device on the radial artery.
Answer: A
Rationale: If a peripheral pulse is irregular, the nurse must auscultate the apical pulse for
one full minute to obtain the most accurate heart rate and assessment of the rhythm.
4. A nurse is maintaining a sterile field for a dressing change. Which of the
following actions would result in a contamination of the sterile field?
A. Keeping the sterile field within the line of vision.
B. Opening the outermost flap of a sterile kit away from the body.
C. Placing a sterile gauze pad within the 1-inch border of the sterile drape.
D. Pouring sterile saline into a container without splashing.
Answer: C
Rationale: The outer 1-inch border of a sterile field is considered contaminated. Any
sterile item placed on or touching this border is no longer sterile.
5. A patient has a Stage 2 pressure injury on the sacrum. Which description best
matches this stage?
A. Partial-thickness loss of dermis presenting as a shallow open ulcer.
B. Intact skin with non-blanchable erythema.
C. Full-thickness tissue loss with visible subcutaneous fat.
D. Full-thickness tissue loss with exposed bone, tendon, or muscle.
Answer: A
, Rationale: Stage 2 pressure injuries involve partial-thickness loss of the dermis, often
appearing as a shallow open ulcer with a red-pink wound bed or an intact/ruptured serum-
filled blister.
6. Which of the following is the correct sequence for donning Personal
Protective Equipment (PPE) for a patient on Contact and Droplet precautions?
A. Gloves, Goggles, Mask, Gown
B. Gown, Mask, Goggles, Gloves
C. Mask, Gown, Gloves, Goggles
D. Goggles, Gloves, Gown, Mask
Answer: B
Rationale: The standard sequence for donning PPE is Gown, then Mask or Respirator, then
Goggles or Face Shield, and finally Gloves.
7. When administering an enema, in which position should the nurse place the
patient to facilitate the flow of the solution into the sigmoid colon?
A. High Fowler’s position
B. Supine with legs abducted
C. Left-lateral Sims’ position
D. Right-lateral position with knees flexed
Answer: C
Rationale: The Left Sims’ position uses gravity to help the enema solution flow into the
sigmoid colon and rectum due to the anatomical curve of the colon.
