NURS 103 Fundamentals of Nursing Module Exam 2 2026 |WCU
1. When assessing a patient for orthostatic hypotension, which finding indicates
a positive result?
A. A decrease in systolic blood pressure by 20 mmHg or more within 3 minutes of standing
B. An increase in diastolic blood pressure by 5 mmHg after sitting
C. A decrease in systolic blood pressure by 10 mmHg after standing
D. An increase in heart rate by 5 beats per minute upon position change
Answer: A
Rationale: Orthostatic hypotension is defined as a drop in systolic blood pressure of at
least 20 mmHg or a drop in diastolic blood pressure of at least 10 mmHg within 3 minutes
of standing.
2. Which action is essential for the nurse to perform first after a medication
error occurs?
A. Assess the patient’s condition and vital signs
B. Complete an incident or occurrence report
C. Notify the healthcare provider of the error
D. Inform the nurse manager or supervisor
Answer: A
Rationale: The nurse’s priority is always the safety and assessment of the patient. Once the
patient is stable and evaluated, the provider and supervisor can be notified, followed by
documentation.
,3. A nurse is preparing to administer an intramuscular injection using the Z-track
method. What is the primary purpose of this technique?
A. To reduce the risk of hitting a bone during the injection
B. To ensure the medication is absorbed faster into the bloodstream
C. To prevent the medication from leaking back into the subcutaneous tissue
D. To decrease the pain associated with a large needle gauge
Answer: C
Rationale: The Z-track method creates a zigzag path that seals the medication in the
muscle tissue and prevents leakage into the subcutaneous layer, which can cause irritation.
4. Which laboratory value is the most sensitive indicator of a patient’s current
nutritional status?
A. Serum Albumin
B. Prealbumin
C. Hemoglobin
D. Total Protein
Answer: B
Rationale: Prealbumin has a half-life of 2 days, making it a much more sensitive indicator
of recent changes in nutritional status compared to albumin, which has a half-life of 21
days.
5. The nurse is caring for a patient with Clostridium difficile (C. diff). Which hand
hygiene practice is mandatory?
A. Using alcohol-based hand rub for at least 15 seconds
B. Washing hands with soap and water
C. Applying sterile gloves before entering the room
D. Wiping hands with 70 percent isopropyl alcohol pads
Answer: B
, Rationale: Alcohol-based rubs are ineffective against C. diff spores. Physical scrubbing
with soap and water is required to mechanically remove the spores from the hands.
6. During a sterile procedure, the nurse notices the edge of the sterile drape is
hanging below the waist level. What should the nurse do?
A. Consider only the part above the waist sterile
B. Consider the entire drape contaminated
C. Avoid touching the part hanging below the waist
D. Pull the drape back up to the waist level
Answer: B
Rationale: Any part of a sterile field that falls below the waist is considered contaminated.
If any part of the drape is contaminated, the entire field is compromised.
7. A patient is at high risk for skin breakdown. Which Braden Scale score would
indicate the highest level of risk?
A. 23
B. 18
C. 9
D. 14
Answer: C
Rationale: On the Braden Scale, lower scores indicate a higher risk for pressure injury
development. A score of 9 or less represents very high risk.
8. When performing tracheostomy care, which action by the nurse is
appropriate?
A. Apply suction while inserting the catheter into the airway
B. Cut a standard gauze pad to fit around the tracheostomy tube
C. Use a cotton-tipped applicator to clean the outer cannula
D. Clean the inner cannula with sterile normal saline
Answer: D
1. When assessing a patient for orthostatic hypotension, which finding indicates
a positive result?
A. A decrease in systolic blood pressure by 20 mmHg or more within 3 minutes of standing
B. An increase in diastolic blood pressure by 5 mmHg after sitting
C. A decrease in systolic blood pressure by 10 mmHg after standing
D. An increase in heart rate by 5 beats per minute upon position change
Answer: A
Rationale: Orthostatic hypotension is defined as a drop in systolic blood pressure of at
least 20 mmHg or a drop in diastolic blood pressure of at least 10 mmHg within 3 minutes
of standing.
2. Which action is essential for the nurse to perform first after a medication
error occurs?
A. Assess the patient’s condition and vital signs
B. Complete an incident or occurrence report
C. Notify the healthcare provider of the error
D. Inform the nurse manager or supervisor
Answer: A
Rationale: The nurse’s priority is always the safety and assessment of the patient. Once the
patient is stable and evaluated, the provider and supervisor can be notified, followed by
documentation.
,3. A nurse is preparing to administer an intramuscular injection using the Z-track
method. What is the primary purpose of this technique?
A. To reduce the risk of hitting a bone during the injection
B. To ensure the medication is absorbed faster into the bloodstream
C. To prevent the medication from leaking back into the subcutaneous tissue
D. To decrease the pain associated with a large needle gauge
Answer: C
Rationale: The Z-track method creates a zigzag path that seals the medication in the
muscle tissue and prevents leakage into the subcutaneous layer, which can cause irritation.
4. Which laboratory value is the most sensitive indicator of a patient’s current
nutritional status?
A. Serum Albumin
B. Prealbumin
C. Hemoglobin
D. Total Protein
Answer: B
Rationale: Prealbumin has a half-life of 2 days, making it a much more sensitive indicator
of recent changes in nutritional status compared to albumin, which has a half-life of 21
days.
5. The nurse is caring for a patient with Clostridium difficile (C. diff). Which hand
hygiene practice is mandatory?
A. Using alcohol-based hand rub for at least 15 seconds
B. Washing hands with soap and water
C. Applying sterile gloves before entering the room
D. Wiping hands with 70 percent isopropyl alcohol pads
Answer: B
, Rationale: Alcohol-based rubs are ineffective against C. diff spores. Physical scrubbing
with soap and water is required to mechanically remove the spores from the hands.
6. During a sterile procedure, the nurse notices the edge of the sterile drape is
hanging below the waist level. What should the nurse do?
A. Consider only the part above the waist sterile
B. Consider the entire drape contaminated
C. Avoid touching the part hanging below the waist
D. Pull the drape back up to the waist level
Answer: B
Rationale: Any part of a sterile field that falls below the waist is considered contaminated.
If any part of the drape is contaminated, the entire field is compromised.
7. A patient is at high risk for skin breakdown. Which Braden Scale score would
indicate the highest level of risk?
A. 23
B. 18
C. 9
D. 14
Answer: C
Rationale: On the Braden Scale, lower scores indicate a higher risk for pressure injury
development. A score of 9 or less represents very high risk.
8. When performing tracheostomy care, which action by the nurse is
appropriate?
A. Apply suction while inserting the catheter into the airway
B. Cut a standard gauze pad to fit around the tracheostomy tube
C. Use a cotton-tipped applicator to clean the outer cannula
D. Clean the inner cannula with sterile normal saline
Answer: D
