NURS 104L Fundamentals of Nursing Skills Lab Final Exam 2026 |WCU
1. When assessing a patient’s blood pressure, the nurse notes that the cuff is
too narrow for the patient’s arm circumference. Which of the following results
should the nurse expect?
A. A falsely low systolic reading
B. A falsely high reading
C. An accurate reading if the patient is supine
D. A falsely low diastolic reading
Answer: B
Rationale: Using a blood pressure cuff that is too small or narrow for the limb will result in
a falsely high reading because the cuff cannot effectively occlude the artery without
excessive pressure.
2. A nurse is preparing to administer an intramuscular (IM) injection into the
ventrogluteal site. Which of the following is the correct anatomical landmark for
this site?
A. Acromion process and the axillary line
B. Posterior superior iliac spine and the gluteal fold
C. Vastus lateralis muscle and the knee
D. Greater trochanter, anterior superior iliac spine, and iliac crest
Answer: D
Rationale: To locate the ventrogluteal site, the nurse places the palm over the greater
trochanter, the index finger on the anterior superior iliac spine, and the middle finger
toward the iliac crest.
,3. While performing tracheostomy care, the nurse knows that the maximum
amount of time to apply suctioning should be limited to:
A. 10 to 15 seconds
B. 5 seconds
C. 20 to 30 seconds
D. As long as secretions are visible
Answer: A
Rationale: Suctioning should be limited to 10-15 seconds per pass to prevent hypoxia and
vagal stimulation, which can lead to bradycardia.
4. A nurse is inserting an indwelling urinary catheter for a female patient. Once
urine is visualized in the tubing, what is the nurse’s next action?
A. Advance the catheter another 1 to 2 inches
B. Immediately inflate the balloon
C. Withdraw the catheter 1 inch and secure
D. Stop and ask the patient to cough
Answer: A
Rationale: In female patients, the nurse should advance the catheter an additional 1 to 2
inches after urine return to ensure the balloon is fully inside the bladder before inflation.
5. Which of the following is the most reliable method for verifying the initial
placement of a nasogastric (NG) tube?
A. Auscultating an air bolus over the epigastrium
B. Checking the pH of aspirated gastric contents
C. Radiographic (X-ray) confirmation
D. Submerging the end of the tube in water to check for bubbles
Answer: C
, Rationale: X-ray is the gold standard for verifying initial NG tube placement. While pH
testing is used for ongoing checks, X-ray is required before the first use for feeding or
medication.
6. When mixing Regular insulin and NPH insulin in the same syringe, which of
the following steps must the nurse perform first?
A. Draw up the NPH insulin
B. Draw up the Regular insulin
C. Inject air into the Regular vial
D. Inject air into the NPH vial
Answer: D
Rationale: The correct sequence is air into NPH, air into Regular, draw up Regular, then
draw up NPH (Clear before Cloudy).
7. A patient is on Airborne Precautions. Which of the following personal
protective equipment (PPE) is mandatory for the nurse to wear when entering
the room?
A. Surgical mask
B. N95 respirator
C. Gown and gloves only
D. Face shield and goggles
Answer: B
Rationale: Airborne precautions require the use of an N95 respirator or higher-level
respirator to filter out small droplet nuclei that remain suspended in the air.
1. When assessing a patient’s blood pressure, the nurse notes that the cuff is
too narrow for the patient’s arm circumference. Which of the following results
should the nurse expect?
A. A falsely low systolic reading
B. A falsely high reading
C. An accurate reading if the patient is supine
D. A falsely low diastolic reading
Answer: B
Rationale: Using a blood pressure cuff that is too small or narrow for the limb will result in
a falsely high reading because the cuff cannot effectively occlude the artery without
excessive pressure.
2. A nurse is preparing to administer an intramuscular (IM) injection into the
ventrogluteal site. Which of the following is the correct anatomical landmark for
this site?
A. Acromion process and the axillary line
B. Posterior superior iliac spine and the gluteal fold
C. Vastus lateralis muscle and the knee
D. Greater trochanter, anterior superior iliac spine, and iliac crest
Answer: D
Rationale: To locate the ventrogluteal site, the nurse places the palm over the greater
trochanter, the index finger on the anterior superior iliac spine, and the middle finger
toward the iliac crest.
,3. While performing tracheostomy care, the nurse knows that the maximum
amount of time to apply suctioning should be limited to:
A. 10 to 15 seconds
B. 5 seconds
C. 20 to 30 seconds
D. As long as secretions are visible
Answer: A
Rationale: Suctioning should be limited to 10-15 seconds per pass to prevent hypoxia and
vagal stimulation, which can lead to bradycardia.
4. A nurse is inserting an indwelling urinary catheter for a female patient. Once
urine is visualized in the tubing, what is the nurse’s next action?
A. Advance the catheter another 1 to 2 inches
B. Immediately inflate the balloon
C. Withdraw the catheter 1 inch and secure
D. Stop and ask the patient to cough
Answer: A
Rationale: In female patients, the nurse should advance the catheter an additional 1 to 2
inches after urine return to ensure the balloon is fully inside the bladder before inflation.
5. Which of the following is the most reliable method for verifying the initial
placement of a nasogastric (NG) tube?
A. Auscultating an air bolus over the epigastrium
B. Checking the pH of aspirated gastric contents
C. Radiographic (X-ray) confirmation
D. Submerging the end of the tube in water to check for bubbles
Answer: C
, Rationale: X-ray is the gold standard for verifying initial NG tube placement. While pH
testing is used for ongoing checks, X-ray is required before the first use for feeding or
medication.
6. When mixing Regular insulin and NPH insulin in the same syringe, which of
the following steps must the nurse perform first?
A. Draw up the NPH insulin
B. Draw up the Regular insulin
C. Inject air into the Regular vial
D. Inject air into the NPH vial
Answer: D
Rationale: The correct sequence is air into NPH, air into Regular, draw up Regular, then
draw up NPH (Clear before Cloudy).
7. A patient is on Airborne Precautions. Which of the following personal
protective equipment (PPE) is mandatory for the nurse to wear when entering
the room?
A. Surgical mask
B. N95 respirator
C. Gown and gloves only
D. Face shield and goggles
Answer: B
Rationale: Airborne precautions require the use of an N95 respirator or higher-level
respirator to filter out small droplet nuclei that remain suspended in the air.
