NURS 104L Fundamentals of Nursing Skills Lab - Week 8
Comprehensive Quiz 2026 |WCU
1. When assessing a patient using the Braden Scale, a score of 12 indicates
which level of risk for pressure injury development?
A. Very high risk
B. High risk
C. Moderate risk
D. Mild risk
Answer: B
Rationale: The Braden Scale ranges from 6 to 23. A score of 12 falls into the high-risk
category (typically 10-12). Scores 13-14 are moderate, 15-18 are mild, and 9 or below are
very high risk.
2. A nurse is preparing to insert an indwelling urinary catheter. Which action is
the priority to maintain surgical asepsis?
A. Cleaning the labia minora before the labia majora
B. Maintaining a 1-inch border around the sterile field as non-sterile
C. Inflating the balloon before insertion to check for leaks
D. Donning clean gloves to open the sterile kit
Answer: B
Rationale: In surgical asepsis, the outer 1-inch margin of a sterile field is considered
contaminated. Cleaning order should be outer to inner, and current EBP suggests not pre-
testing balloons for many catheter types to prevent trauma.
,3. Which crutch gait is most appropriate for a patient who has been prescribed
partial weight-bearing on the left leg?
A. 2-point gait
B. 4-point gait
C. 3-point gait
D. Swing-to gait
Answer: C
Rationale: The 3-point gait is used when the patient can bear weight on only one leg; both
crutches and the affected leg move forward together, followed by the unaffected leg.
4. When administering a large-volume cleansing enema, the nurse notes the
patient reports abdominal cramping. What is the immediate nursing action?
A. Stop the procedure and notify the provider
B. Advance the rectal tube an additional 2 inches
C. Lower the enema container to slow the flow rate
D. Encourage the patient to hold their breath
Answer: C
Rationale: Abdominal cramping during an enema usually indicates the fluid is being
administered too rapidly. Lowering the bag slows the rate and reduces cramping; stopping
is only necessary if pain persists.
5. Which assessment finding of a surgical wound indicates the secondary
intention phase of healing?
A. The wound edges are well-approximated with sutures
B. The wound is closed after several days of being left open
C. The wound is left open to fill with granulation tissue
D. The wound edges are held together by skin glue
Answer: C
, Rationale: Secondary intention occurs when a wound involves extensive tissue loss and
edges cannot be approximated; it heals from the base up with granulation tissue.
6. A nurse is applying a wrist restraint to a combative patient. How many fingers
should the nurse be able to insert between the restraint and the patient’s wrist?
A. One finger
B. Two fingers
C. Three fingers
D. Four fingers
Answer: B
Rationale: A two-finger space ensures the restraint is snug enough to be secure but loose
enough to prevent impairment of circulation or nerve damage.
7. The nurse is teaching a patient how to use a cane. On which side should the
patient hold the cane?
A. On the affected (weak) side
B. On whichever side feels more comfortable
C. On the unaffected (strong) side
D. Alternating sides to maintain balance
Answer: C
Rationale: The cane should be held on the unaffected (stronger) side to provide maximum
support and stability for the opposite, weaker limb.
8. Which type of enema is used to lubricate the rectum and colon for easier
stool passage?
A. Oil-retention enema
B. Hypertonic enema
C. Soapsuds enema
D. Carminative enema
Answer: A
Comprehensive Quiz 2026 |WCU
1. When assessing a patient using the Braden Scale, a score of 12 indicates
which level of risk for pressure injury development?
A. Very high risk
B. High risk
C. Moderate risk
D. Mild risk
Answer: B
Rationale: The Braden Scale ranges from 6 to 23. A score of 12 falls into the high-risk
category (typically 10-12). Scores 13-14 are moderate, 15-18 are mild, and 9 or below are
very high risk.
2. A nurse is preparing to insert an indwelling urinary catheter. Which action is
the priority to maintain surgical asepsis?
A. Cleaning the labia minora before the labia majora
B. Maintaining a 1-inch border around the sterile field as non-sterile
C. Inflating the balloon before insertion to check for leaks
D. Donning clean gloves to open the sterile kit
Answer: B
Rationale: In surgical asepsis, the outer 1-inch margin of a sterile field is considered
contaminated. Cleaning order should be outer to inner, and current EBP suggests not pre-
testing balloons for many catheter types to prevent trauma.
,3. Which crutch gait is most appropriate for a patient who has been prescribed
partial weight-bearing on the left leg?
A. 2-point gait
B. 4-point gait
C. 3-point gait
D. Swing-to gait
Answer: C
Rationale: The 3-point gait is used when the patient can bear weight on only one leg; both
crutches and the affected leg move forward together, followed by the unaffected leg.
4. When administering a large-volume cleansing enema, the nurse notes the
patient reports abdominal cramping. What is the immediate nursing action?
A. Stop the procedure and notify the provider
B. Advance the rectal tube an additional 2 inches
C. Lower the enema container to slow the flow rate
D. Encourage the patient to hold their breath
Answer: C
Rationale: Abdominal cramping during an enema usually indicates the fluid is being
administered too rapidly. Lowering the bag slows the rate and reduces cramping; stopping
is only necessary if pain persists.
5. Which assessment finding of a surgical wound indicates the secondary
intention phase of healing?
A. The wound edges are well-approximated with sutures
B. The wound is closed after several days of being left open
C. The wound is left open to fill with granulation tissue
D. The wound edges are held together by skin glue
Answer: C
, Rationale: Secondary intention occurs when a wound involves extensive tissue loss and
edges cannot be approximated; it heals from the base up with granulation tissue.
6. A nurse is applying a wrist restraint to a combative patient. How many fingers
should the nurse be able to insert between the restraint and the patient’s wrist?
A. One finger
B. Two fingers
C. Three fingers
D. Four fingers
Answer: B
Rationale: A two-finger space ensures the restraint is snug enough to be secure but loose
enough to prevent impairment of circulation or nerve damage.
7. The nurse is teaching a patient how to use a cane. On which side should the
patient hold the cane?
A. On the affected (weak) side
B. On whichever side feels more comfortable
C. On the unaffected (strong) side
D. Alternating sides to maintain balance
Answer: C
Rationale: The cane should be held on the unaffected (stronger) side to provide maximum
support and stability for the opposite, weaker limb.
8. Which type of enema is used to lubricate the rectum and colon for easier
stool passage?
A. Oil-retention enema
B. Hypertonic enema
C. Soapsuds enema
D. Carminative enema
Answer: A
