NURS 103 | Fundamentals of Nursing | Study Guide Exam 3 |
2026/2027 Update WCU
1. A nurse is preparing to administer an intramuscular (IM) injection to a 6-
month-old infant. Which site is the most appropriate for this patient?
A. Dorsogluteal site
B. Ventrogluteal site
C. Deltoid muscle
D. Vastus lateralis site
Answer: D
Rationale: The vastus lateralis is the preferred site for IM injections in infants under 12
months because it is the best-developed muscle at that age.
2. When assessing a patient’s wound, the nurse notes full-thickness skin loss
with visible subcutaneous fat, but no bone or muscle is exposed. How should
this be staged?
A. Stage 1
B. Stage 2
C. Stage 3
D. Stage 4
Answer: C
Rationale: Stage 3 pressure injuries involve full-thickness skin loss where adipose (fat) is
visible, but fascia, muscle, tendons, or bone are not exposed.
,3. A patient is placed on Transmission-Based Precautions for Clostridioides
difficile (C. diff). Which action is mandatory for the nurse?
A. Use an alcohol-based hand rub after exiting the room
B. Wear an N95 respirator mask
C. Wash hands with soap and water after care
D. Maintain the patient in a negative-pressure room
Answer: C
Rationale: C. diff spores are resistant to alcohol-based sanitizers; therefore, mechanical
friction with soap and water is required for removal.
4. Which of the following is a primary nursing intervention to prevent
atelectasis in a postoperative patient?
A. Encouraging use of the incentive spirometer every hour
B. Restricting fluid intake to 1 liter per day
C. Administering prophylactic antibiotics
D. Maintaining the patient in a supine position
Answer: A
Rationale: Incentive spirometry promotes deep breathing and lung expansion, which helps
prevent alveolar collapse (atelectasis).
5. A nurse observes a student nurse preparing to draw up NPH and Regular
insulin in the same syringe. Which action by the student requires correction?
A. Injecting air into the NPH vial first
B. Verifying the dose with a second licensed nurse
C. Injecting air into the Regular vial second
D. Drawing up the NPH insulin before the Regular insulin
Answer: D
Rationale: When mixing insulin, ‘Clear before Cloudy’ is the rule. Regular (clear) must be
drawn before NPH (cloudy) to avoid contaminating the Regular vial with NPH.
, 6. The nurse is caring for a patient with a PCA (Patient-Controlled Analgesia)
pump. Which finding requires immediate intervention?
A. The patient appears drowsy but is easily arousable
B. The patient reports a pain level of 3 out of 10
C. The patient’s respiratory rate is 8 breaths per minute
D. The family member presses the button for the sleeping patient
Answer: C
Rationale: A respiratory rate of 8 indicates significant respiratory depression, a life-
threatening side effect of opioid analgesia.
7. During the assessment of a dark-skinned patient for pressure injuries, the
nurse should focus on which characteristic?
A. Blanching of the skin when pressed
B. The presence of a bright red rash
C. Changes in skin temperature and tissue consistency
D. Evidence of cyanosis in the nail beds
Answer: C
Rationale: In dark-skinned patients, skin may not blanch; assessment relies on localized
changes in temperature, edema, or hardness compared to surrounding tissue.
8. A nurse is reviewing a new medication order that is illegible. What is the most
appropriate action?
A. Ask another nurse to help interpret the order
B. Search for the medication name in the drug handbook
C. Call the prescribing provider to clarify the order
D. Administer what is most likely the intended drug
Answer: C
Rationale: It is the nurse’s legal and professional responsibility to clarify any unclear,
incomplete, or illegible orders with the prescribing provider.
2026/2027 Update WCU
1. A nurse is preparing to administer an intramuscular (IM) injection to a 6-
month-old infant. Which site is the most appropriate for this patient?
A. Dorsogluteal site
B. Ventrogluteal site
C. Deltoid muscle
D. Vastus lateralis site
Answer: D
Rationale: The vastus lateralis is the preferred site for IM injections in infants under 12
months because it is the best-developed muscle at that age.
2. When assessing a patient’s wound, the nurse notes full-thickness skin loss
with visible subcutaneous fat, but no bone or muscle is exposed. How should
this be staged?
A. Stage 1
B. Stage 2
C. Stage 3
D. Stage 4
Answer: C
Rationale: Stage 3 pressure injuries involve full-thickness skin loss where adipose (fat) is
visible, but fascia, muscle, tendons, or bone are not exposed.
,3. A patient is placed on Transmission-Based Precautions for Clostridioides
difficile (C. diff). Which action is mandatory for the nurse?
A. Use an alcohol-based hand rub after exiting the room
B. Wear an N95 respirator mask
C. Wash hands with soap and water after care
D. Maintain the patient in a negative-pressure room
Answer: C
Rationale: C. diff spores are resistant to alcohol-based sanitizers; therefore, mechanical
friction with soap and water is required for removal.
4. Which of the following is a primary nursing intervention to prevent
atelectasis in a postoperative patient?
A. Encouraging use of the incentive spirometer every hour
B. Restricting fluid intake to 1 liter per day
C. Administering prophylactic antibiotics
D. Maintaining the patient in a supine position
Answer: A
Rationale: Incentive spirometry promotes deep breathing and lung expansion, which helps
prevent alveolar collapse (atelectasis).
5. A nurse observes a student nurse preparing to draw up NPH and Regular
insulin in the same syringe. Which action by the student requires correction?
A. Injecting air into the NPH vial first
B. Verifying the dose with a second licensed nurse
C. Injecting air into the Regular vial second
D. Drawing up the NPH insulin before the Regular insulin
Answer: D
Rationale: When mixing insulin, ‘Clear before Cloudy’ is the rule. Regular (clear) must be
drawn before NPH (cloudy) to avoid contaminating the Regular vial with NPH.
, 6. The nurse is caring for a patient with a PCA (Patient-Controlled Analgesia)
pump. Which finding requires immediate intervention?
A. The patient appears drowsy but is easily arousable
B. The patient reports a pain level of 3 out of 10
C. The patient’s respiratory rate is 8 breaths per minute
D. The family member presses the button for the sleeping patient
Answer: C
Rationale: A respiratory rate of 8 indicates significant respiratory depression, a life-
threatening side effect of opioid analgesia.
7. During the assessment of a dark-skinned patient for pressure injuries, the
nurse should focus on which characteristic?
A. Blanching of the skin when pressed
B. The presence of a bright red rash
C. Changes in skin temperature and tissue consistency
D. Evidence of cyanosis in the nail beds
Answer: C
Rationale: In dark-skinned patients, skin may not blanch; assessment relies on localized
changes in temperature, edema, or hardness compared to surrounding tissue.
8. A nurse is reviewing a new medication order that is illegible. What is the most
appropriate action?
A. Ask another nurse to help interpret the order
B. Search for the medication name in the drug handbook
C. Call the prescribing provider to clarify the order
D. Administer what is most likely the intended drug
Answer: C
Rationale: It is the nurse’s legal and professional responsibility to clarify any unclear,
incomplete, or illegible orders with the prescribing provider.
