NURS 104L Fundamentals of Nursing Skills Lab - Module Exam 4 2026
|WCU
1. A nurse is preparing to administer an intramuscular injection to an adult
patient in the ventrogluteal site. Which of the following is the correct
anatomical landmark for this site?
A. The lateral aspect of the lower leg.
B. The middle third of the muscle between the greater trochanter and the knee.
C. The heel of the hand on the greater trochanter with the index finger on the anterior superior iliac spine.
D. Three finger-breadths below the acromion process.
Answer: C
Rationale: The ventrogluteal site is located by placing the palm over the greater
trochanter, the index finger on the anterior superior iliac spine, and the middle finger
toward the iliac crest.
2. When performing a sterile dressing change, which action by the nurse would
contaminate the sterile field?
A. Opening a sterile package away from the body.
B. Dropping a sterile item onto the field from 6 inches above.
C. Keeping the sterile field at waist level.
D. Reaching over the sterile field to pick up a gauze pad.
Answer: D
Rationale: Reaching over a sterile field is a breach of sterile technique because
microorganisms can fall from the nurse’s non-sterile sleeve or arm onto the field.
,3. A patient with a suspected Clostridium difficile (C. diff) infection requires the
nurse to perform hand hygiene. Which method is most effective?
A. Using an alcohol-based hand rub for 15 seconds.
B. Washing hands with antimicrobial soap and water.
C. Wiping hands with a chlorhexidine gluconate (CHG) wipe.
D. Rinsing hands with hot water only.
Answer: B
Rationale: C. diff spores are resistant to alcohol-based rubs; physical scrubbing with soap
and water is required to mechanically remove the spores.
4. The nurse is suctioning a patient with a tracheostomy. What is the maximum
amount of time the nurse should apply suction during a single pass?
A. 5 seconds
B. 20 to 25 seconds
C. 10 to 15 seconds
D. 30 seconds
Answer: C
Rationale: Suctioning should be limited to 10-15 seconds to prevent hypoxia and vagal
stimulation.
5. Which of the following is the priority nursing action before administering a
medication via a Nasogastric (NG) tube?
A. Flushing the tube with 30 mL of air.
B. Verifying the tube placement using pH testing or X-ray.
C. Checking the gastric residual volume.
D. Warming the medication to room temperature.
Answer: B
Rationale: Verifying placement is the safety priority to ensure the medication is delivered
to the stomach and not the lungs.
, 6. When inserting an indwelling urinary catheter in a female patient, where
should the nurse place the lubricant?
A. On the labia minora.
B. On the nurse’s sterile glove.
C. Inside the urethral meatus.
D. 1 to 2 inches of the catheter tip.
Answer: D
Rationale: Lubricating the tip of the catheter (approx. 1-2 inches for females) reduces
friction and trauma to the urethral mucosa during insertion.
7. A nurse is administering a sublingual medication. Which instruction should be
given to the patient?
A. Place the tablet under the tongue and let it dissolve completely.
B. Drink a full glass of water after the tablet dissolves.
C. Chew the tablet thoroughly before swallowing.
D. Hold the tablet between the cheek and the gum.
Answer: A
Rationale: Sublingual medications must be placed under the tongue to be absorbed
through the highly vascular oral mucosa, bypassing the digestive system.
8. The nurse identifies that an IV site is cool to the touch, swollen, and the
patient reports pain. These are signs of:
A. Phlebitis
B. Infection
C. Infiltration
D. Thrombus
Answer: C
Rationale: Infiltration is characterized by coolness, swelling (edema), and pain as IV fluid
leaks into the surrounding tissue.
|WCU
1. A nurse is preparing to administer an intramuscular injection to an adult
patient in the ventrogluteal site. Which of the following is the correct
anatomical landmark for this site?
A. The lateral aspect of the lower leg.
B. The middle third of the muscle between the greater trochanter and the knee.
C. The heel of the hand on the greater trochanter with the index finger on the anterior superior iliac spine.
D. Three finger-breadths below the acromion process.
Answer: C
Rationale: The ventrogluteal site is located by placing the palm over the greater
trochanter, the index finger on the anterior superior iliac spine, and the middle finger
toward the iliac crest.
2. When performing a sterile dressing change, which action by the nurse would
contaminate the sterile field?
A. Opening a sterile package away from the body.
B. Dropping a sterile item onto the field from 6 inches above.
C. Keeping the sterile field at waist level.
D. Reaching over the sterile field to pick up a gauze pad.
Answer: D
Rationale: Reaching over a sterile field is a breach of sterile technique because
microorganisms can fall from the nurse’s non-sterile sleeve or arm onto the field.
,3. A patient with a suspected Clostridium difficile (C. diff) infection requires the
nurse to perform hand hygiene. Which method is most effective?
A. Using an alcohol-based hand rub for 15 seconds.
B. Washing hands with antimicrobial soap and water.
C. Wiping hands with a chlorhexidine gluconate (CHG) wipe.
D. Rinsing hands with hot water only.
Answer: B
Rationale: C. diff spores are resistant to alcohol-based rubs; physical scrubbing with soap
and water is required to mechanically remove the spores.
4. The nurse is suctioning a patient with a tracheostomy. What is the maximum
amount of time the nurse should apply suction during a single pass?
A. 5 seconds
B. 20 to 25 seconds
C. 10 to 15 seconds
D. 30 seconds
Answer: C
Rationale: Suctioning should be limited to 10-15 seconds to prevent hypoxia and vagal
stimulation.
5. Which of the following is the priority nursing action before administering a
medication via a Nasogastric (NG) tube?
A. Flushing the tube with 30 mL of air.
B. Verifying the tube placement using pH testing or X-ray.
C. Checking the gastric residual volume.
D. Warming the medication to room temperature.
Answer: B
Rationale: Verifying placement is the safety priority to ensure the medication is delivered
to the stomach and not the lungs.
, 6. When inserting an indwelling urinary catheter in a female patient, where
should the nurse place the lubricant?
A. On the labia minora.
B. On the nurse’s sterile glove.
C. Inside the urethral meatus.
D. 1 to 2 inches of the catheter tip.
Answer: D
Rationale: Lubricating the tip of the catheter (approx. 1-2 inches for females) reduces
friction and trauma to the urethral mucosa during insertion.
7. A nurse is administering a sublingual medication. Which instruction should be
given to the patient?
A. Place the tablet under the tongue and let it dissolve completely.
B. Drink a full glass of water after the tablet dissolves.
C. Chew the tablet thoroughly before swallowing.
D. Hold the tablet between the cheek and the gum.
Answer: A
Rationale: Sublingual medications must be placed under the tongue to be absorbed
through the highly vascular oral mucosa, bypassing the digestive system.
8. The nurse identifies that an IV site is cool to the touch, swollen, and the
patient reports pain. These are signs of:
A. Phlebitis
B. Infection
C. Infiltration
D. Thrombus
Answer: C
Rationale: Infiltration is characterized by coolness, swelling (edema), and pain as IV fluid
leaks into the surrounding tissue.
