ETELPMOC • 4 MAXE
Nursing Fundamentals
NF College of Nursing & Health Sciences
B U I L D I N G T H E F O U N D AT I O N F O R N U R S I N G E X C E L L E N C E
FUNDAMENTALS
Fundamentals of Nursing — Exam 4
CO M P L E T E CO M P R E H E N S I V E R E V I E W — W O U N D C A R E , P R E SS U R E I N J U R I E S , S K I N I N T E G R I TY &
E L I M I N AT I O N
INSTITUTION Nursing Fundamentals Program EXAM TYPE Nursing Fundamentals Exam 4
PROGRAM RN Nursing Program ACADEMIC YEAR
EXAM TITLE Exam 4 — Wound Care, Pressure Injuries & TOTAL QUESTIONS Complete Study Guide — All Topics
Elimination
COURSE TITLE Nursing Fundamentals FORMAT Multiple Choice — Select the Single Best
Answer
EXAMINATION INSTRUCTIONS
▸ Select the single best answer for each question unless otherwise specified.
▸ This comprehensive Exam 4 covers wound care (evisceration, dehiscence, sterile field, irrigation, dressings), pressure injury
staging (Stage 1-3, granulation tissue), skin integrity (epidermis, melanocytes, aging changes), elimination (constipation,
enemas, colostomy/ileostomy teaching), and perioperative care.
▸ Correct answers and detailed rationales appear below each question.
▸ All content is derived from Nursing Fundamentals Exam 4 core concepts.
SECTION I — WOUND CARE, SURGICAL COMPLICATIONS & STERILE Part
TECHNIQUE A
1. A patient with constipation bears down (Valsalva maneuver). How can this technique affect vital signs?
A. Increased heart rate and blood pressure.
B. Decreased heart rate (vagal maneuver).
C. Increased respiratory rate only.
D. No effect on vital signs.
CORRECT ANSWER B — Decreased heart rate (vagal maneuver).
RATIONALE The Valsalva maneuver (bearing down against a closed glottis) stimulates the vagus nerve, causing
parasympathetic activation and bradycardia. This can be dangerous in cardiac patients. It also increases
intrathoracic pressure and decreases venous return.
, 2. You see a small section of bowel protruding from an abdominal surgical site. What do you do FIRST?
A. Notify the surgeon and prepare for emergency surgery.
B. Apply a moist saline dressing.
C. Push the bowel back into the wound.
D. Apply a dry sterile dressing.
CORRECT ANSWER B — Apply a moist saline dressing.
RATIONALE Evisceration (organ protrusion) is a surgical emergency. The FIRST action is to cover the exposed organs with
sterile saline-moistened dressings to prevent tissue drying and infection. Never push organs back in. After
covering, notify the surgeon and prepare for emergency return to OR.
3. A patient who had a hysterectomy has wound evisceration. What is your first intervention?
A. Call the surgeon immediately.
B. Put moist saline dressing on the wound.
C. Administer pain medication.
D. Take vital signs.
CORRECT ANSWER B — Put moist saline dressing on the wound.
RATIONALE Evisceration requires immediate covering with sterile saline-moistened dressings to protect exposed organs
from drying and contamination. This is the priority intervention before notifying the surgeon. Vital signs and
pain medication follow. Never attempt to reinsert protruding organs.
4. During wound irrigation of a patient's leg, what is considered contaminating the sterile field?
A. Pouring sterile solution from a height of 6 inches.
B. Place sterile supplies within the 1-inch border of the sterile field.
C. Using sterile gloves to handle sterile supplies.
D. Keeping the sterile field above waist level.
CORRECT ANSWER B — Place sterile supplies within the 1-inch border of the sterile field.
RATIONALE The outer 1-inch (2.5 cm) border of a sterile field is considered contaminated. Sterile supplies must be placed
well within this border. Pouring from appropriate height (A), using sterile gloves (C), and maintaining field
above waist level (D) are all correct sterile technique practices.
5. Discharge planning should begin:
A. On the day of discharge.
B. During admission of the client.
C. 24 hours before discharge.
D. When the physician writes the discharge order.
CORRECT ANSWER B — Begin during admission of the client.
RATIONALE Discharge planning begins at admission to identify needs, arrange services, and ensure a safe transition. The
IDEAL discharge model: Include, Discuss, Educate, Assess, Listen. Pain (C) is a reason to postpone teaching—
the patient cannot focus on learning when in pain.
Nursing Fundamentals
NF College of Nursing & Health Sciences
B U I L D I N G T H E F O U N D AT I O N F O R N U R S I N G E X C E L L E N C E
FUNDAMENTALS
Fundamentals of Nursing — Exam 4
CO M P L E T E CO M P R E H E N S I V E R E V I E W — W O U N D C A R E , P R E SS U R E I N J U R I E S , S K I N I N T E G R I TY &
E L I M I N AT I O N
INSTITUTION Nursing Fundamentals Program EXAM TYPE Nursing Fundamentals Exam 4
PROGRAM RN Nursing Program ACADEMIC YEAR
EXAM TITLE Exam 4 — Wound Care, Pressure Injuries & TOTAL QUESTIONS Complete Study Guide — All Topics
Elimination
COURSE TITLE Nursing Fundamentals FORMAT Multiple Choice — Select the Single Best
Answer
EXAMINATION INSTRUCTIONS
▸ Select the single best answer for each question unless otherwise specified.
▸ This comprehensive Exam 4 covers wound care (evisceration, dehiscence, sterile field, irrigation, dressings), pressure injury
staging (Stage 1-3, granulation tissue), skin integrity (epidermis, melanocytes, aging changes), elimination (constipation,
enemas, colostomy/ileostomy teaching), and perioperative care.
▸ Correct answers and detailed rationales appear below each question.
▸ All content is derived from Nursing Fundamentals Exam 4 core concepts.
SECTION I — WOUND CARE, SURGICAL COMPLICATIONS & STERILE Part
TECHNIQUE A
1. A patient with constipation bears down (Valsalva maneuver). How can this technique affect vital signs?
A. Increased heart rate and blood pressure.
B. Decreased heart rate (vagal maneuver).
C. Increased respiratory rate only.
D. No effect on vital signs.
CORRECT ANSWER B — Decreased heart rate (vagal maneuver).
RATIONALE The Valsalva maneuver (bearing down against a closed glottis) stimulates the vagus nerve, causing
parasympathetic activation and bradycardia. This can be dangerous in cardiac patients. It also increases
intrathoracic pressure and decreases venous return.
, 2. You see a small section of bowel protruding from an abdominal surgical site. What do you do FIRST?
A. Notify the surgeon and prepare for emergency surgery.
B. Apply a moist saline dressing.
C. Push the bowel back into the wound.
D. Apply a dry sterile dressing.
CORRECT ANSWER B — Apply a moist saline dressing.
RATIONALE Evisceration (organ protrusion) is a surgical emergency. The FIRST action is to cover the exposed organs with
sterile saline-moistened dressings to prevent tissue drying and infection. Never push organs back in. After
covering, notify the surgeon and prepare for emergency return to OR.
3. A patient who had a hysterectomy has wound evisceration. What is your first intervention?
A. Call the surgeon immediately.
B. Put moist saline dressing on the wound.
C. Administer pain medication.
D. Take vital signs.
CORRECT ANSWER B — Put moist saline dressing on the wound.
RATIONALE Evisceration requires immediate covering with sterile saline-moistened dressings to protect exposed organs
from drying and contamination. This is the priority intervention before notifying the surgeon. Vital signs and
pain medication follow. Never attempt to reinsert protruding organs.
4. During wound irrigation of a patient's leg, what is considered contaminating the sterile field?
A. Pouring sterile solution from a height of 6 inches.
B. Place sterile supplies within the 1-inch border of the sterile field.
C. Using sterile gloves to handle sterile supplies.
D. Keeping the sterile field above waist level.
CORRECT ANSWER B — Place sterile supplies within the 1-inch border of the sterile field.
RATIONALE The outer 1-inch (2.5 cm) border of a sterile field is considered contaminated. Sterile supplies must be placed
well within this border. Pouring from appropriate height (A), using sterile gloves (C), and maintaining field
above waist level (D) are all correct sterile technique practices.
5. Discharge planning should begin:
A. On the day of discharge.
B. During admission of the client.
C. 24 hours before discharge.
D. When the physician writes the discharge order.
CORRECT ANSWER B — Begin during admission of the client.
RATIONALE Discharge planning begins at admission to identify needs, arrange services, and ensure a safe transition. The
IDEAL discharge model: Include, Discuss, Educate, Assess, Listen. Pain (C) is a reason to postpone teaching—
the patient cannot focus on learning when in pain.
