NSG 3100 - Funds I: Exam 2 Questions and Answers 2023/2024
1. Which of the following is a cause of bradypnea?
a. Increased activity
b. narcotic analgesics
c. Test anxiety
d. Decreased oxygen saturation
Answer: b. narcotic analgesics
2. A damp/damp dressing is an example of what type of wound debridement?
a. Autolytic
b. Surgical
c. Mechanical
d. Enzymatic
Answer: c. Mechanical
3. What statement describes a stage 2 pressure ulcer?
a. Damage extends to the fascia
b. Skin is intact and does not blanch
c. Presents as open or fluid-filled blister, or shallow crater
d. Base is covered with slough and wound bed cannot be seen
Answer: c. Presents as open or fluid-filled blister, or shallow crater
4. Which statement describes a stage 1 pressure ulcer?
a. Intact skin is purple or maroon
b. Skin is pink or red and does not blanch
c. Presents as open or fluid-filled blister, or shallow crater
d. Base is covered with slough and wound bed cannot be seen
Answer: b. Skin is pink or red and does not blanch
5. Age-related findings related to vital signs in older adults:
a. Heart rate increases; blood pressure decreases
b. Heart rate increases; blood pressure increases
c. Heart rate decreases; blood pressure increases
d. Heart rate decreases; blood pressure decreases
Answer: c. Heart rate decreases; blood pressure increases
6. What is the correct sequence for donning PPE?
a. Gown, goggles, mask, gloves
b. Gown, gloves, goggles, mask
c. Gown, mask, goggles, gloves
d. Goggles, gown, gloves, mask
Answer: c. Gown, mask, goggles, gloves
7. What is the correct sequence for removing (doffing) PPEs?
a. Gloves, gown, goggles, mask
b. Gown, gloves, mask, goggles
c. Goggles, gloves, gown, mask
d. Gloves, goggles, gown, mask
Answer: d. Gloves, goggles, gown, mask
8. Medical asepsis refers to all except?
a. Reduces the spread of microorganisms
b. Objects referred to as clean or dirty
c. Eliminates all pathogens
d. Clean technique
Answer: c. Eliminates all pathogens
9. Wound exudate that is clear and blood-tinged is called what?
a. Sanguinous
b. Purosanguinous
c. Serosanguinous
d. Purulent
Answer: c. Serosanguinous
10. Wound exudate that is thick, creamy yellow or green is called what?
a. Purosanguinous
b. Purulent
c. Serosanguinous
d. Serous
Answer: b. Purulent
11. All of the following are contraindications to heat therapy except ______
a. Active hemorrhage
b. Chronic conditions such as osteoarthritis
c. First 24 hours after traumatic injury
d. Noninflammatory edema
Answer: b. Chronic conditions such as osteoarthritis
12. What is dehiscence?
a. Protrusion of a body organ through an incision
b. Hemorrhaging of the wound
c. Sutured wound ruptures and layers separate
d. Infection of the wound
Answer: c. Sutured wound ruptures and layers separate
13. What is not a sign/symptom of wound infection?
a. Swelling
b. Heat
c. Redness
d. Bruising
Answer: d. Bruising
14. Using a blood pressure cuff that is too small, will result in the reading being what?
a. Falsely low
b. Falsely high
Answer: b. Falsely high
15. The normal range for blood pressure is:
a. systolic 80-110/ diastolic 70-90
b. systolic 90-140/diastolic 60-90
c. systolic 90-120/diastolic 60-80
d. systolic 80-130/diastolic 50-80
Answer: c. systolic 90-120/diastolic 60-80
16. The range for normal temperature is:
a. 96.8 - 98.9
b. 97.6 - 99.5
c. 96.8 - 99.5
d. 98.6 - 99.8
Answer: c. 96.8 - 99.5
17. A patient with what type of disease should be placed in airborne precautions?
a. Herpes Zoster
b. MRSA
c. Tuberculosis
d. Pneumonia
Answer: c. Tuberculosis
18. A pulse oximeter can be placed on all of the following body parts except?
a. Fingers
b. Ear
c. Toes
d. Chest
Answer: d. Chest
19. The nurse is aware that which of the following is an accurate statement about the respiratory
rate?
a. The respiratory rate increases with age.
b. Narcotics slow the respiratory rate.
c. Acute pain decreases the respiratory rate.
d. The respiratory rate is increased with alkalosis.
Answer: b. Narcotics slow the respiratory rate.
20. The nurse instructs the UAP that which of the following methods will obtain a falsely low
blood pressure reading?
a. Using a BP cuff that is too narrow
b. Releasing the pressure value too slowly
c. Assessing the BP after the patient exercises
d. Place the arm above the level of the heart
Answer: d. Place the arm above the level of the heart
21. The adult patient is seen in the 24-hour medical center for heat exhaustion. The nurse
anticipates that treatment will include which of the following?
a. Fluid replacement
b. Antibiotic therapy
c. Hypothermia wraps
d. Tepid water baths
Answer: a. Fluid replacement
22. Upon entering the room, the nurse observes that the patient appears to be tachypneic. The
nurse should:
a. Ask if there have been visitors
b. Have the patient lie flat
c. Take the radial pulse
d. Measure the respiratory rate
Answer: d. Measure the respiratory rate
23. The patient is experiencing pain and asks for medication, which has been ordered by the
provider. The nurse first assesses the vital signs and finds the blood pressure to be 144/82
mmHg, Pulse 88/min., and respirations 24/min. The nurse should:
a. Give the medication as ordered
b. Check again that the patient has pain
c. Withhold the medication
d. Wait 20 min. and check the vital signs again before giving the medication
Answer: a. Give the medication as ordered
24. The patient gets out of bed to go to the bathroom and tells the nurse that he "feels dizzy."
What is the first action the nurse should take?
a. Go for help
b. Take blood pressure
c. Help the patient to sit down
d. Have the patient take deep breaths
Answer: c. Help the patient to sit down
25. A patient asks the nurse about whether her blood pressure is too high. The nurse informs the
patient that the blood pressure associated with stage 2 hypertension is:
a. 120/70
b. 130/80
c. 140/90
d. 160/100
Answer: d. 160/100
26. A primary concern for a patient with orthostatic hypotension is:
a. Risk for falls
b. Fluid overload
c. Oxygen demand
d. Mental confusion
Answer: a. Risk for falls
27. A 79-year-old resident in a long-term care facility is known to "wander at night" and has
fallen in the past. Which of the following is the most appropriate nursing intervention?
a. The patient should be checked frequently during the night
b. An abdominal restraint should be placed on the patient during sleeping hours
c. A radio should be left playing at the bedside to assist in reality orientation
d. The patient should be placed in a room away from the activity of the nurses' station
Answer: a. The patient should be checked frequently during the night
28. The visiting nurse completes an assessment of the ambulatory patient in the home and
determines the nursing diagnosis Risk for injury associated with decreased vision. On the basis
of this assessment, the patient will benefit the most from:
a. Installing fluorescent lighting throughout the home
b. Becoming oriented to the position of the furniture and stairways
c. Maintaining complete bed rest in a hospital bed with side rails
d. Applying physical restraints
Answer: b. Becoming oriented to the position of the furniture and stairways
29. When applying a wrist restraint, the nurse knows that:
a. The padded side is away from the skin
b. It should be removed at least once every shift
c. The straps should be secured with a knot
d. Two fingers' width should fit between the skin and the restraint
Answer: d. Two fingers' width should fit between the skin and the restraint
30. A patient has a 6-inch laceration on his right forearm. An infection develops at the site.
Which of the following is a sign of a local inflammatory response observed by the nurse?
a. Blanching of the skin
b. Edema at the site
c. Decrease in temperature
d. Bruising at the site
Answer: b. Edema at the site
31. The nurse employs surgical aseptic technique when:
a. Disposing syringes in a puncture-proof container
b. Placing soiled linens in a moisture-resistant bag
c. Washing hands before changing a dressing
d. Inserting an intravenous catheter
Answer: d. Inserting an intravenous catheter
32. A patient with active tuberculosis is admitted to the medical center. The nurse recognizes that
admission of this patient to the unit will require the implementation by the staff of:
a. Droplet precautions
b. Airborne precautions
c. Contact precautions
d. Protective precautions
Answer: b. Airborne precautions
33. A patient requires a sterile dressing change for a mid-abdominal surgical incision. An
appropriate intervention for the nurse to implement in maintaining sterile asepsis is to:
a. Put sterile gloves on before opening sterile packages
b. Place the cap of the sterile solution well within the sterile field
c. Place sterile items on the edge of the sterile drape
d. Discard packages that may have been in contact with the area below waist level
Answer: d. Discard packages that may have been in contact with the area below waist level
34. The unit manager observes the new staff nurse perform the following actions for a patient
with isolation precautions. Which of the following actions should the unit manager address and
correct with the new nurse?
a. Keeping a thermometer, stethoscope and BP cuff in the patient's room.
b. Documenting the precautions required in the patient's record
c. Using a particulate respirator mask for the patient who has tuberculosis
d. Coming out of the room in the PPE to quickly get another dressing
Answer: d. Coming out of the room in the PPE to quickly get another dressing
35. Pressure injuries form primarily as a result of:
a. Nitrogen buildup in the underlying tissues
b. Prolonged illness or disease
c. Tissue ischemia
d. Poor hygiene
Answer: c. Tissue ischemia
36. The nurse prepares to irrigate the patient's wound. The primary reason for this procedure is
to:
a. Create scar formation
b. Remove debris from the wound
c. Improve circulation from the wound
d. Decrease irritation from wound drainage
Answer: b. Remove debris from the wound
37. On inspection of the patient's wound, the nurse notes that it appears infected and has a large
amount of exudate. An appropriate dressing for the nurse to select on the basis of the wound
assessment is:
a. Foam
b. Hydrogel
c. Hydrocolloid
d. Transparent film
Answer: a. Foam
38. The nurse is concerned that the patient's midsternal wound is at risk for dehiscence. Which of
the following is the best intervention to prevent this complication?
a. Administering antibiotics to prevent infection
b. Using appropriate sterile technique when changing the dressing
c. Keeping sterile towels and extra dressing supplies near the patient's bed
d. Having the patient splint the incision site when coughing
Answer: d. Having the patient splint the incision site when coughing
39. After an injury, the patient has thick, yellow drainage coming from the wound. The nurse
describes this drainage as:
a. Milky
b. Serous
c. Purulent
d. Serosanguinous
Answer: c. Purulent
40. The nurse has applied a pulse oximeter to the finger of a patient who is hypothermic. The
pulse oximeter does not provide a good reading. What action by the nurse is best?
a. Move the oximeter probe to another finger
b. Remove any fingernail polish present on the fingernail
c. Assess the fingers for good circulation
d. Document that the reading cannot be obtained
Answer: c. Assess the fingers for good circulation
41. A nurse performs orthostatic blood pressure readings on a patient with the following results:
lying 148/76 mmHg, standing 110/60 mmHg. Which action by the nurse is best?
a. Reassesses the blood pressures in 1 hour
b. Reassure the patient that these findings are normal
c. Document the findings and continue to monitor
d. Instruct the patient not to get up without help
Answer: d. Instruct the patient not to get up without help
42. A nurse observes a student taking an adult patient's tympanic temperature. What action by the
student requires the nurse to intervene?
a. Student pulls the pinna of the patient's ear down and back
b. Student washes hands prior to patient contact
c. Student explains the procedure to the patient
d. Student pulls the pinna of the patient's ear up and back
Answer: d. Student pulls the pinna of the patient's ear up and back
43. The nurse receives a hand-off report on four patients. Which patient finding should the nurse
assess first?
a. Pulse oximetry 96%
b. Pulse 42 BPM
c. Blood pressure 102/62 mmHg
d. Respiratory rate 18 breaths/min
Answer: b. Pulse 42 BPM
44. Which patient assessment result would require the nurse to assess that patient further?
a. A 65 -year-old man with a respiratory rate of 10
b. A 50 -year-old man with a BP of 112/60 upon awakening in the morning
c. A 40 -year-old woman with a radial pulse of 68
d. 12 -year-old with a pulse of 92 after ambulating in the hallway
Answer: a. A 65 -year-old man with a respiratory rate of 10
45. The nurse is caring for a woman who had a right-sided mastectomy 2 years ago. What action
by the nurse is most appropriate?
a. Place a sign above the bed: "no BP on the right arm"
b. Place a sign above the bed "BP in legs only"
c. No specific action is needed for this situation
d. Place a sign above the bed: "no continuous BP on the right arm"
Answer: a. Place a sign above the bed: "no BP on the right arm"
46. A nurse is caring for a patient who has orthopnea. (Discomfort when breathing while lying
down flat; common in people with some types of heart or lung conditions.) What action by the
nurse is most appropriate?
a. Medicate the patient for pain as needed
b. Monitor the length of time the patient doesn't breathe
c. Keep the head of the bed elevated
d. Encourage deep breathing and coughing
Answer: c. Keep the head of the bed elevated
47. The nursing faculty member is observing a student taking a patient's carotid pulse. What
action by the student requires intervention by the faculty?
a. Counts pulse for 30 seconds and multiplies by two.
b. Compares pulses in both carotid arteries at the same time.
c. Assesses pulse on one side and then assesses the other side.
d. Performs hand hygiene prior to patient contact.
Answer: b. Compares pulses in both carotid arteries at the same time.
48. A nurse assesses a patient's radial pulse rate to be 110 beats/min and regular. What action by
the nurse is best?
a. Assess the patient for causes of tachycardia
b. Take an apical heart rate and compare the two
c. Notify the patient's health care provider
d. Document the findings in the patient's chart
Answer: a. Assess the patient for causes of tachycardia
49. The nurse is caring for a patient on contact precautions. Which action will be most
appropriate to prevent the spread of disease?
a. Place the patient in a room with negative airflow
b. Wear a gown, gloves, face mask, and goggles for interactions with the patient
c. Transport the patient safely and quickly when going to the radiology department
d. Use a dedicated BP cuff that stays in the room and is used for that patient only
Answer: d. Use a dedicated BP cuff that stays in the room and is used for that patient only
50. The nurse is caring for a group of medical-surgical patients. Which patient is most at risk for
developing an infection?
a. A patient who is in observation for chest pain
b. A patient who has been admitted with dehydration
c. A patient who is recovering from a right total hip surgery
d. A patient who has been admitted for stabilization of heart problems
Answer: c. A patient who is recovering from a right total hip surgery
51. The nurse is caring for a patient with an incision. Which actions will best indicate an
understanding of medical and surgical asepsis for a sterile dressing change?
a. Donning clean goggles, gown, and gloves to dress the wound
b. Donning sterile gown and gloves to remove the wound dressing
c. Utilizing clean gloves to remove the dressing and sterile supplies for the new dressing
d. Utilizing clean gloves to remove the dressing and clean supplies for the new dressing
Answer: c. Utilizing clean gloves to remove the dressing and sterile supplies for the new
dressing
52. The nurse is caring for a school-aged child who has injured the right leg after a bicycle
accident. Which signs and symptoms will the nurse assess for to determine if the child is
experiencing a localized inflammatory response?
a. Malaise, anorexia, enlarged lymph nodes, and increased white blood cells
b. Chest pain, shortness of breath, and nausea and vomiting
c. Dizziness and disorientation to time, date, and place
d. Edema, redness, tenderness, and loss of function
Answer: d. Edema, redness, tenderness, and loss of function
53. The nurse is changing linens for a postoperative patient and feels a prick in the left hand. A
contaminated needle is noted in the linens. For which condition is the nurse most at risk?
a. Diphtheria
b. Hepatitis B
c. Clostridium Difficile
d. Methicillin-resistant Staphylococcus aureus
Answer: b. Hepatitis B
54. The surgical mask the nurse is wearing becomes moist. Which action will the nurse take?
a. Apply a new mask
b. Reapply the mask after it air-dries
c. Change the mask when relieved by the next shift
d. Do not change the mask if the nurse is comfortable
Answer: a. Apply a new mask
55. The nurse is admitting a patient with an infectious disease process. Which question will be
most appropriate for a nurse to ask about the patient's susceptibility to this infectious process?
a. "Do you have a spouse?"
b. "Do you have a chronic disease?"
c. "Do you have any children living in the home?"
d. "Do you have any religious beliefs that will influence your care?"
Answer: b. "Do you have a chronic disease?"
56. The nurse is caring for a group of patients. Which patient will the nurse see first?
a. A patient with Clostridium Difficile in droplet precautions
b. A patient with tuberculosis in airborne precautions
c. A patient with MRSA infection in contact precautions
d. A patient with pneumonia in droplet precautions
Answer: a. A patient with Clostridium Difficile in droplet precautions
57. The nurse is caring for a patient who needs a protective environment. The nurse has provided
the care needed and is now leaving the room. In which order will the nurse remove the personal
protective equipment (PPE), beginning with the first step?
1) Remove eyewear/face shield and goggles.
2) Perform hand hygiene, leave room, and close door.
3) Remove gloves.
4) Untie gown, allow gown to fall from shoulders, and do not touch outside of gown.
5) Remove mask by strings, do not touch outside of mask
Answer:
3) Remove gloves.
1) Remove eyewear/face shield and goggles.
4) Untie gown, allow gown to fall from shoulders, and do not touch outside of gown.
5) Remove mask by strings, do not touch outside of mask
2) Perform hand hygiene, leave room, and close door.
58. The nurse is caring for a postoperative patient. Which finding will alert the nurse to a
potential wound dehiscence?
a. Protrusion of visceral organs through a wound opening
b. Chronic drainage of fluid through the incision site
c. Report by patient that something has given way
d. Drainage that is odorous and purulent
Answer: c. Report by patient that something has given way
59. The nurse is caring for a patient who has experienced a laparoscopic appendectomy. For
which type of healing will the nurse focus the care plan?
a. Partial-thickness repair
b. Secondary intention
c. Tertiary intention
d. Primary intention
Answer: d. Primary intention
60. A nurse is caring for a patient with a wound. Which assessment data will be most important
for the nurse to gather with regard to wound healing?
a. Muscular strength
b. Hemoglobin/Hematocrit
c. Sensation
d. Sleep
Answer: b. Hemoglobin/Hematocrit
61. The nurse is cleansing a wound site. As the nurse administers the procedure, which
intervention should be included?
a. Allow the solution to flow from the most contaminated to the least contaminated
b. Scrub vigorously when applying a noncytotoxic solution to the skin
c. Cleanse in a direction from the least contaminated area
d. Utilize clean gauze and clean gloves to cleanse a site
Answer: c. Cleanse in a direction from the least contaminated area
62. The nurse is caring for a patient who is immobile. The nurse wants to decrease the formation
of pressure ulcers. Which action will the nurse take first?
a. Offer frequent liquids
b. Turn the patient every 2 hours
c. Determine the patient's risk factors
d. Encourage increased quantities of carbohydrates and fats
Answer: c. Determine the patient's risk factors
63. The nurse is caring for a patient with a pressure ulcer on the left hip. The ulcer is black.
Which next step will the nurse anticipate?
a. Monitor the wound
b. Document the wound
c. Debride the wound
d. Manage drainage from the wound
Answer: c. Debride the wound
64. The nurse is caring for a patient on the medical-surgical unit with a wound that has a drain
and a dressing that needs changing. Which action should the nurse take first?
a. Provide analgesic medications as ordered
b. Avoid accidentally removing the drain
c. Don sterile gloves
d. Gather supplies
Answer: a. Provide analgesic medications as ordered
65. Blood pressure cuff (bladder cuff) too narrow
Answer: falsely high
66. Blood pressure cuff (bladder cuff) too wide
Answer: falsely low
67. Arm unsupported during BP reading
Answer: falsely high
68. Insufficient rest before the BP assessment
Answer: falsely high
69. Repeating BP assessment too quickly
Answer: Erroneously high systolic or low diastolic readings
70. Cuff wrapped too loosely or unevenly
Answer: false high reading
71. Deflating cuff too quickly
Answer: falsely low systolic and high diastolic readings
72. Deflating cuff too slowly
Answer: false high diastolic reading
73. Failure to use the same arm consistently
Answer: inconsistent measurements
74. Arm above level of the heart
Answer: false low
75. Assessing immediately after a meal or while client smokes or has pain
Answer: Falsely high
76. Failure to identify auscultatory gap
Answer: falsely low systolic pressure and erroneously low diastolic pressure
