NSG 100
EXAM 3
2026 Q&A
CONTAINS:
✓ Medication administration and client refusal decision-making
✓ Pain assessment and prioritization of non-pharmacological
interventions
✓ Insulin preparation and administration (clear vs. cloudy, mixing rules)
✓ Chronic illness management (CHF, diabetes mellitus)
✓ Abdominal assessment and recognition of emergency findings (e.g.,
AAA)
✓ Standard Precautions and Contact Precautions (including C. diff)
✓ Blood transfusion reactions and emergency nursing interventions
✓ Fluid volume deficit assessment and expected laboratory findings
✓ NCLEX-style multiple-choice and select-all-that-apply questions
✓ Detailed rationales emphasizing nursing priorities, safety, and
delegation
,A nurse is preparing to administer a routine medication to a client. The client states, "I don't want to
take that pill; it makes me feel sick." Which of the following actions should the nurse take first?
A) Document the client’s refusal in the medical record.
B) Educate the client on the importance of the medication for their health.
C) Remove the pill from the room and discard it according to protocol.
D) Explore the specific reasons for the client's refusal and previous side effects.
Correct Answer: D) Explore the specific reasons for the client's refusal and previous side effects.
Explanation / Rationale:
The first step in addressing a medication refusal is to understand the client's perspective. While
documentation (Option A) is necessary, it occurs after the interaction. Educating the client (Option B)
is important but cannot be effectively done without knowing the specific side effect the client is
experiencing, as the nurse might need to suggest an alternative or consult the provider. Simply
removing the pill (Option C) dismisses the client's concern. Exploring the reason shows respect for
client autonomy and allows for therapeutic communication and potential problem-solving (e.g.,
administering an antiemetic beforehand or changing the timing).
The nurse is caring for a client who is post-operative day 1 following a total knee replacement. The
client reports pain of 8/10 in the surgical leg. Which non-pharmacological intervention should the
nurse prioritize implementing?
A) Guided imagery
B) Repositioning the leg
C) Applying a warm compress to the incision site
D) Distraction through television
Correct Answer: B) Repositioning the leg
Explanation / Rationale:
While all options are non-pharmacological interventions, repositioning is the priority for a post-
operative surgical client to relieve pressure on the incision and surrounding tissues, which can
,significantly reduce pain. Options A and D are distraction techniques that are effective but secondary
to physiological comfort measures. Option C, applying heat, is generally contraindicated in the
immediate post-operative period (first 24-48 hours) as it can increase swelling and bleeding risk; cold
therapy is usually indicated during this phase.
Select-All-That-Apply: A nurse is observing a client newly diagnosed with Type 2 Diabetes Mellitus
learning to draw up insulin. Which of the following actions indicate the client understands proper
technique? (Select all that apply.)
A) The client pulls air into the syringe equal to the insulin dose before inserting the needle into the
vial.
B) The client injects the air into the vial containing regular insulin first if mixing with NPH insulin.
C) The client draws up the clear insulin before the cloudy insulin.
D) The client rolls the vial of NPH insulin between their hands to mix it.
E) The client cleans the rubber stopper of the vial with an alcohol swab after drawing up the medication.
Correct Answer: A) The client pulls air into the syringe equal to the insulin dose before inserting
the needle into the vial.
C) The client draws up the clear insulin before the cloudy insulin.
D) The client rolls the vial of NPH insulin between their hands to mix it.
Explanation / Rationale:
Option A is correct because injecting air into the vial prevents the formation of a vacuum. Option C is
correct; clear (regular) insulin is always drawn up before cloudy (NPH) insulin to prevent
contaminating the clear vial with the cloudy solution. Option D is correct; rolling the vial mixes the
suspension without creating bubbles, whereas shaking it can denature the proteins. Option B is
incorrect because when mixing insulins, air should be injected into the NPH (cloudy) vial first, then the
Regular (clear) vial, to prevent cross-contamination. Option E is incorrect; the vial should be cleaned
before the needle is inserted, not after.
A client with congestive heart failure (CHF) is complaining of shortness of breath. The nurse notes the
client has bilateral +2 edema in the lower extremities. Which dietary instruction should the nurse
reinforce to the client?
A) "Increase your intake of red meat to boost protein levels."
B) "Restrict your fluid intake to 2 liters per day as prescribed."
, C) "Avoid adding salt to your food at the table and limit processed foods."
D) "Drink a glass of water with every meal to stay hydrated."
Correct Answer: C) "Avoid adding salt to your food at the table and limit processed foods."
Explanation / Rationale:
Sodium causes fluid retention, which exacerbates edema and the symptoms of CHF. A low-sodium diet
is a cornerstone of CHF management. While fluid restriction (Option B) may be prescribed, it is
dependent on specific physician orders and the severity of the condition; sodium restriction is
universally applicable for this symptom presentation. Option A is not specifically indicated and may
increase saturated fat intake. Option D is contraindicated in a fluid-overloaded client.
When assessing a client's abdomen, the nurse notes a pulsating mass in the periumbilical region.
What is the nurse's priority action?
A) Auscultate for bowel sounds.
B) Percuss the borders of the liver.
C) Palpate the mass to determine its consistency.
D) Refer the client for immediate medical evaluation (e.g., ultrasound/CT).
Correct Answer: D) Refer the client for immediate medical evaluation (e.g., ultrasound/CT).
Explanation / Rationale:
A pulsating periumbilical mass is a classic sign of an abdominal aortic aneurysm (AAA). Palpating the
mass (Option C) is contraindicated as it could rupture the aneurysm, leading to life-threatening
hemorrhage. While auscultation and percussion (Options A and B) are parts of an abdominal
assessment, the detection of a potential vascular emergency takes precedence over routine
assessment steps. The nurse should not palpate and should notify the provider immediately.
A nurse is teaching a group of nursing students about the Standard Precautions. Which statement by a
student indicates a need for further teaching?
A) "I should wear gloves whenever there is a potential for contact with blood or body fluids."
B) "I do not need to wear a mask if I am not drawing blood."
EXAM 3
2026 Q&A
CONTAINS:
✓ Medication administration and client refusal decision-making
✓ Pain assessment and prioritization of non-pharmacological
interventions
✓ Insulin preparation and administration (clear vs. cloudy, mixing rules)
✓ Chronic illness management (CHF, diabetes mellitus)
✓ Abdominal assessment and recognition of emergency findings (e.g.,
AAA)
✓ Standard Precautions and Contact Precautions (including C. diff)
✓ Blood transfusion reactions and emergency nursing interventions
✓ Fluid volume deficit assessment and expected laboratory findings
✓ NCLEX-style multiple-choice and select-all-that-apply questions
✓ Detailed rationales emphasizing nursing priorities, safety, and
delegation
,A nurse is preparing to administer a routine medication to a client. The client states, "I don't want to
take that pill; it makes me feel sick." Which of the following actions should the nurse take first?
A) Document the client’s refusal in the medical record.
B) Educate the client on the importance of the medication for their health.
C) Remove the pill from the room and discard it according to protocol.
D) Explore the specific reasons for the client's refusal and previous side effects.
Correct Answer: D) Explore the specific reasons for the client's refusal and previous side effects.
Explanation / Rationale:
The first step in addressing a medication refusal is to understand the client's perspective. While
documentation (Option A) is necessary, it occurs after the interaction. Educating the client (Option B)
is important but cannot be effectively done without knowing the specific side effect the client is
experiencing, as the nurse might need to suggest an alternative or consult the provider. Simply
removing the pill (Option C) dismisses the client's concern. Exploring the reason shows respect for
client autonomy and allows for therapeutic communication and potential problem-solving (e.g.,
administering an antiemetic beforehand or changing the timing).
The nurse is caring for a client who is post-operative day 1 following a total knee replacement. The
client reports pain of 8/10 in the surgical leg. Which non-pharmacological intervention should the
nurse prioritize implementing?
A) Guided imagery
B) Repositioning the leg
C) Applying a warm compress to the incision site
D) Distraction through television
Correct Answer: B) Repositioning the leg
Explanation / Rationale:
While all options are non-pharmacological interventions, repositioning is the priority for a post-
operative surgical client to relieve pressure on the incision and surrounding tissues, which can
,significantly reduce pain. Options A and D are distraction techniques that are effective but secondary
to physiological comfort measures. Option C, applying heat, is generally contraindicated in the
immediate post-operative period (first 24-48 hours) as it can increase swelling and bleeding risk; cold
therapy is usually indicated during this phase.
Select-All-That-Apply: A nurse is observing a client newly diagnosed with Type 2 Diabetes Mellitus
learning to draw up insulin. Which of the following actions indicate the client understands proper
technique? (Select all that apply.)
A) The client pulls air into the syringe equal to the insulin dose before inserting the needle into the
vial.
B) The client injects the air into the vial containing regular insulin first if mixing with NPH insulin.
C) The client draws up the clear insulin before the cloudy insulin.
D) The client rolls the vial of NPH insulin between their hands to mix it.
E) The client cleans the rubber stopper of the vial with an alcohol swab after drawing up the medication.
Correct Answer: A) The client pulls air into the syringe equal to the insulin dose before inserting
the needle into the vial.
C) The client draws up the clear insulin before the cloudy insulin.
D) The client rolls the vial of NPH insulin between their hands to mix it.
Explanation / Rationale:
Option A is correct because injecting air into the vial prevents the formation of a vacuum. Option C is
correct; clear (regular) insulin is always drawn up before cloudy (NPH) insulin to prevent
contaminating the clear vial with the cloudy solution. Option D is correct; rolling the vial mixes the
suspension without creating bubbles, whereas shaking it can denature the proteins. Option B is
incorrect because when mixing insulins, air should be injected into the NPH (cloudy) vial first, then the
Regular (clear) vial, to prevent cross-contamination. Option E is incorrect; the vial should be cleaned
before the needle is inserted, not after.
A client with congestive heart failure (CHF) is complaining of shortness of breath. The nurse notes the
client has bilateral +2 edema in the lower extremities. Which dietary instruction should the nurse
reinforce to the client?
A) "Increase your intake of red meat to boost protein levels."
B) "Restrict your fluid intake to 2 liters per day as prescribed."
, C) "Avoid adding salt to your food at the table and limit processed foods."
D) "Drink a glass of water with every meal to stay hydrated."
Correct Answer: C) "Avoid adding salt to your food at the table and limit processed foods."
Explanation / Rationale:
Sodium causes fluid retention, which exacerbates edema and the symptoms of CHF. A low-sodium diet
is a cornerstone of CHF management. While fluid restriction (Option B) may be prescribed, it is
dependent on specific physician orders and the severity of the condition; sodium restriction is
universally applicable for this symptom presentation. Option A is not specifically indicated and may
increase saturated fat intake. Option D is contraindicated in a fluid-overloaded client.
When assessing a client's abdomen, the nurse notes a pulsating mass in the periumbilical region.
What is the nurse's priority action?
A) Auscultate for bowel sounds.
B) Percuss the borders of the liver.
C) Palpate the mass to determine its consistency.
D) Refer the client for immediate medical evaluation (e.g., ultrasound/CT).
Correct Answer: D) Refer the client for immediate medical evaluation (e.g., ultrasound/CT).
Explanation / Rationale:
A pulsating periumbilical mass is a classic sign of an abdominal aortic aneurysm (AAA). Palpating the
mass (Option C) is contraindicated as it could rupture the aneurysm, leading to life-threatening
hemorrhage. While auscultation and percussion (Options A and B) are parts of an abdominal
assessment, the detection of a potential vascular emergency takes precedence over routine
assessment steps. The nurse should not palpate and should notify the provider immediately.
A nurse is teaching a group of nursing students about the Standard Precautions. Which statement by a
student indicates a need for further teaching?
A) "I should wear gloves whenever there is a potential for contact with blood or body fluids."
B) "I do not need to wear a mask if I am not drawing blood."
