NURS 104L | Fundamentals of Nursing Skills Lab | Week 11 Quiz 2026
|WCU
1. A nurse is assessing a patient’s peripheral IV site and notes coolness, pallor,
and swelling. What is the most likely complication?
A. Phlebitis
B. Extravasation
C. Infiltration
D. Cellulitis
Answer: C
Rationale: Infiltration occurs when IV fluid leaks into surrounding tissue, causing coolness,
pallor, and edema. Phlebitis is characterized by warmth and redness.
2. When performing tracheostomy suctioning, what is the maximum
recommended duration for a single suction pass?
A. 5 seconds
B. 15 seconds
C. 20 seconds
D. 30 seconds
Answer: B
Rationale: Suctioning should be limited to 10-15 seconds to prevent hypoxia and trauma
to the tracheal mucosa.
,3. Which part of a sterile field is considered contaminated even if it has not
been touched?
A. The outer 1-inch border
B. The equipment placed in the middle
C. The center of the sterile drape
D. The sterile gloves of the operator
Answer: A
Rationale: Standard sterile technique dictates that the outer 1-inch border of a sterile field
is considered contaminated.
4. When preparing to mix Regular and NPH insulin in a single syringe, which step
should the nurse perform first?
A. Draw up the NPH insulin
B. Draw up the Regular insulin
C. Inject air into the NPH vial
D. Inject air into the Regular vial
Answer: C
Rationale: The correct sequence is air into NPH, air into Regular, draw Regular, then draw
NPH (Clear before Cloudy).
5. In the SBAR communication tool, which component includes the patient’s
current vital signs and mental status?
A. Situation
B. Assessment
C. Background
D. Recommendation
Answer: B
Rationale: Assessment covers clinical findings like vital signs and current status. Situation
is the reason for contact; Background is history; Recommendation is the plan.
, 6. A nurse is inserting a Foley catheter into a female patient. If the catheter is
inadvertently inserted into the vagina, what is the correct action?
A. Remove it and re-insert into the meatus
B. Leave it in place as a landmark and get a new kit
C. Wipe it with betadine and re-insert
D. Inflate the balloon to secure it
Answer: B
Rationale: Leaving the misplaced catheter in the vagina helps identify the correct location
(the meatus) and prevents repeating the error with a new, sterile kit.
7. What is the preferred site for a deep intramuscular (IM) injection in an adult?
A. Dorsogluteal
B. Deltoid
C. Ventrogluteal
D. Vastus Lateralis
Answer: C
Rationale: The ventrogluteal site is preferred for IM injections because it is away from
major nerves and blood vessels.
8. When assessing a chest tube drainage system, the nurse notes constant
bubbling in the water seal chamber. This likely indicates:
A. The lung has fully re-expanded
B. The system is functioning normally
C. An air leak in the system
D. The suction is set too high
Answer: C
Rationale: Intermittent bubbling is normal (tidaling), but constant bubbling in the water
seal chamber suggests a leak in the drainage system or at the insertion site.
|WCU
1. A nurse is assessing a patient’s peripheral IV site and notes coolness, pallor,
and swelling. What is the most likely complication?
A. Phlebitis
B. Extravasation
C. Infiltration
D. Cellulitis
Answer: C
Rationale: Infiltration occurs when IV fluid leaks into surrounding tissue, causing coolness,
pallor, and edema. Phlebitis is characterized by warmth and redness.
2. When performing tracheostomy suctioning, what is the maximum
recommended duration for a single suction pass?
A. 5 seconds
B. 15 seconds
C. 20 seconds
D. 30 seconds
Answer: B
Rationale: Suctioning should be limited to 10-15 seconds to prevent hypoxia and trauma
to the tracheal mucosa.
,3. Which part of a sterile field is considered contaminated even if it has not
been touched?
A. The outer 1-inch border
B. The equipment placed in the middle
C. The center of the sterile drape
D. The sterile gloves of the operator
Answer: A
Rationale: Standard sterile technique dictates that the outer 1-inch border of a sterile field
is considered contaminated.
4. When preparing to mix Regular and NPH insulin in a single syringe, which step
should the nurse perform first?
A. Draw up the NPH insulin
B. Draw up the Regular insulin
C. Inject air into the NPH vial
D. Inject air into the Regular vial
Answer: C
Rationale: The correct sequence is air into NPH, air into Regular, draw Regular, then draw
NPH (Clear before Cloudy).
5. In the SBAR communication tool, which component includes the patient’s
current vital signs and mental status?
A. Situation
B. Assessment
C. Background
D. Recommendation
Answer: B
Rationale: Assessment covers clinical findings like vital signs and current status. Situation
is the reason for contact; Background is history; Recommendation is the plan.
, 6. A nurse is inserting a Foley catheter into a female patient. If the catheter is
inadvertently inserted into the vagina, what is the correct action?
A. Remove it and re-insert into the meatus
B. Leave it in place as a landmark and get a new kit
C. Wipe it with betadine and re-insert
D. Inflate the balloon to secure it
Answer: B
Rationale: Leaving the misplaced catheter in the vagina helps identify the correct location
(the meatus) and prevents repeating the error with a new, sterile kit.
7. What is the preferred site for a deep intramuscular (IM) injection in an adult?
A. Dorsogluteal
B. Deltoid
C. Ventrogluteal
D. Vastus Lateralis
Answer: C
Rationale: The ventrogluteal site is preferred for IM injections because it is away from
major nerves and blood vessels.
8. When assessing a chest tube drainage system, the nurse notes constant
bubbling in the water seal chamber. This likely indicates:
A. The lung has fully re-expanded
B. The system is functioning normally
C. An air leak in the system
D. The suction is set too high
Answer: C
Rationale: Intermittent bubbling is normal (tidaling), but constant bubbling in the water
seal chamber suggests a leak in the drainage system or at the insertion site.
