NUR 109 FOUNDATIONS IN NURSING
FINAL EXAM 200 NGN STYLE
QUESTIONS AND ANSWERS WITH
RATIONALES A+ VERIFIED STUDY GUIDE
2026/2027
1. A nursing student is preparing to perform a focused assessment on a
68-year-old patient admitted with community-acquired pneumonia; the
student reviews the nursing process and recognizes that the FIRST step
in providing safe, individualized care is to:
A) Implement interventions to improve the patient's oxygenation status
B) Evaluate the effectiveness of the antibiotic therapy ordered by the
provider
C) Collect comprehensive and accurate assessment data about the
patient's respiratory status
D) Formulate a nursing diagnosis of impaired gas exchange related to
alveolar inflammation
The nursing process follows the ADPIE sequence: Assessment,
Diagnosis, Planning, Implementation, Evaluation. Assessment is always
the foundational first step because all subsequent decisions depend on
accurate, comprehensive data collection. Without thorough assessment,
interventions may be misdirected, diagnoses inaccurate, and outcomes
unachievable. While implementing oxygenation interventions,
evaluating antibiotics, and formulating diagnoses are important, they all
occur AFTER assessment is completed.
2. A registered nurse is delegating tasks to a licensed practical nurse
(LPN) and an unlicensed assistive personnel (UAP) on a medical-
surgical unit; which task is MOST appropriate for the nurse to assign to
the UAP?
A) Administering oral medications to a stable patient with hypertension
B) Assisting a postoperative patient with ambulation to the bathroom for
the first time after surgery
,C) Performing a sterile dressing change on a patient with a surgical
wound
D) Assessing a patient's pain level and documenting the findings in the
electronic health record
Unlicensed assistive personnel (UAP) are trained to perform activities of
daily living (ADLs) such as bathing, feeding, toileting, and ambulation
under the supervision of a licensed nurse. Assisting with ambulation falls
within the UAP scope of practice. Medication administration, sterile
procedures, and patient assessment require licensed nursing judgment
and clinical decision-making skills that are outside the UAP role. The RN
retains accountability for delegation decisions and must ensure tasks
match the delegatee's competency.
3. A nurse is caring for a patient who speaks limited English and requires
education about postoperative care; the patient's adult daughter offers to
translate; the nurse recognizes that the BEST approach to ensure
accurate communication and informed consent is to:
A) Accept the daughter's offer since she is familiar with the patient's
cultural beliefs and preferences
B) Request a qualified medical interpreter through the hospital's
interpreter services department
C) Use a smartphone translation app to communicate key instructions
quickly and efficiently
D) Provide written instructions in English and ask the daughter to
review them with the patient later
Professional medical interpreters are trained in medical terminology,
confidentiality standards, cultural mediation, and accurate bidirectional
communication. Using family members as interpreters risks errors in
translation, breaches of patient privacy, omission of sensitive
information, and potential conflicts of interest. Smartphone apps are not
validated for medical interpretation and may produce dangerous
inaccuracies. Federal regulations and accreditation standards require
healthcare organizations to provide qualified interpreters for patients
with limited English proficiency.
4. A nurse is preparing to administer medications to a patient and
follows the "rights" of medication administration; after verifying the
patient's identity using two identifiers, the nurse checks the medication
,label against the MAR three times; which additional "right" is CRITICAL
to assess BEFORE administering any medication to prevent harm?
A) Right documentation
B) Right reason
C) Right assessment (e.g., vital signs, laboratory values, allergies)
D) Right to refuse
The "right assessment" requires the nurse to evaluate patient-specific
factors that could affect medication safety before administration.
Examples include holding a beta-blocker if heart rate is <60 bpm,
withholding digoxin if potassium is low, checking blood pressure before
antihypertensives, or confirming no allergies exist. This step prevents
administering medications that could cause harm based on the patient's
current physiological status. While documentation, understanding the
reason, and respecting refusal are important, they do not prevent
immediate physiological harm like an inappropriate medication dose
could.
5. A nurse is caring for a patient who is at high risk for falls; the patient
has a history of orthostatic hypotension and is taking antihypertensive
medications; which intervention should the nurse implement FIRST to
promote patient safety?
A) Place the patient in a room near the nurses' station for frequent
observation
B) Teach the patient to change positions slowly and dangle at the bedside
before standing
C) Apply a bed alarm and keep the bed in the lowest position with side
rails up
D) Request a provider order for a physical therapy consult for gait
training
Patient education empowers self-management and addresses the root
cause of the fall risk: orthostatic hypotension. Teaching slow position
changes and dangling allows the cardiovascular system time to adjust,
reducing dizziness and fall risk. Environmental modifications (room
placement, alarms, bed position) and referrals are important secondary
interventions, but they do not equip the patient with skills to prevent
, falls independently. Safety interventions should always prioritize patient
education and least-restrictive approaches first.
6. A nurse is performing hand hygiene before entering a patient's room;
the patient is on contact precautions for Clostridioides difficile infection;
the nurse understands that which method of hand hygiene is MOST
effective for preventing transmission of C. diff spores?
A) Alcohol-based hand rub for 20 seconds
B) Soap and water with friction for at least 20 seconds
C) Chlorhexidine gluconate surgical scrub for 2 minutes
D) Antimicrobial wipes followed by alcohol-based hand rub
Clostridioides difficile produces spores that are resistant to alcohol-
based hand sanitizers. Mechanical removal through handwashing with
soap and water and friction is required to physically remove spores from
the skin. Alcohol-based rubs are effective against most pathogens but
NOT spore-forming organisms like C. diff or viruses like norovirus.
Chlorhexidine is useful for surgical scrubs but does not specifically target
spores. This is a fundamental infection control principle for contact
precautions involving spore-forming bacteria.
7. A nurse is assessing a patient's vital signs and notes a temperature of
101.8°F (38.8°C), heart rate of 112 bpm, respiratory rate of 24
breaths/min, and blood pressure of 98/62 mmHg; the patient reports
chills and generalized body aches; the nurse recognizes these findings as
consistent with which physiological response?
A) Hypothermia due to environmental exposure
B) Fever (pyrexia) as part of the inflammatory response to infection
C) Hypovolemic shock secondary to fluid loss
D) Autonomic dysreflexia related to spinal cord injury
Fever triggers a cascade of physiological responses: increased metabolic
rate raises heart rate to meet oxygen demands; tachypnea helps
eliminate excess heat through respiration; vasodilation can cause mild
hypotension; and chills occur as the hypothalamus resets the body's
thermostat upward. These findings collectively represent the classic
presentation of pyrexia during an inflammatory or infectious process.
Hypothermia would present with low temperature and bradycardia;
hypovolemic shock would show more profound hypotension and
FINAL EXAM 200 NGN STYLE
QUESTIONS AND ANSWERS WITH
RATIONALES A+ VERIFIED STUDY GUIDE
2026/2027
1. A nursing student is preparing to perform a focused assessment on a
68-year-old patient admitted with community-acquired pneumonia; the
student reviews the nursing process and recognizes that the FIRST step
in providing safe, individualized care is to:
A) Implement interventions to improve the patient's oxygenation status
B) Evaluate the effectiveness of the antibiotic therapy ordered by the
provider
C) Collect comprehensive and accurate assessment data about the
patient's respiratory status
D) Formulate a nursing diagnosis of impaired gas exchange related to
alveolar inflammation
The nursing process follows the ADPIE sequence: Assessment,
Diagnosis, Planning, Implementation, Evaluation. Assessment is always
the foundational first step because all subsequent decisions depend on
accurate, comprehensive data collection. Without thorough assessment,
interventions may be misdirected, diagnoses inaccurate, and outcomes
unachievable. While implementing oxygenation interventions,
evaluating antibiotics, and formulating diagnoses are important, they all
occur AFTER assessment is completed.
2. A registered nurse is delegating tasks to a licensed practical nurse
(LPN) and an unlicensed assistive personnel (UAP) on a medical-
surgical unit; which task is MOST appropriate for the nurse to assign to
the UAP?
A) Administering oral medications to a stable patient with hypertension
B) Assisting a postoperative patient with ambulation to the bathroom for
the first time after surgery
,C) Performing a sterile dressing change on a patient with a surgical
wound
D) Assessing a patient's pain level and documenting the findings in the
electronic health record
Unlicensed assistive personnel (UAP) are trained to perform activities of
daily living (ADLs) such as bathing, feeding, toileting, and ambulation
under the supervision of a licensed nurse. Assisting with ambulation falls
within the UAP scope of practice. Medication administration, sterile
procedures, and patient assessment require licensed nursing judgment
and clinical decision-making skills that are outside the UAP role. The RN
retains accountability for delegation decisions and must ensure tasks
match the delegatee's competency.
3. A nurse is caring for a patient who speaks limited English and requires
education about postoperative care; the patient's adult daughter offers to
translate; the nurse recognizes that the BEST approach to ensure
accurate communication and informed consent is to:
A) Accept the daughter's offer since she is familiar with the patient's
cultural beliefs and preferences
B) Request a qualified medical interpreter through the hospital's
interpreter services department
C) Use a smartphone translation app to communicate key instructions
quickly and efficiently
D) Provide written instructions in English and ask the daughter to
review them with the patient later
Professional medical interpreters are trained in medical terminology,
confidentiality standards, cultural mediation, and accurate bidirectional
communication. Using family members as interpreters risks errors in
translation, breaches of patient privacy, omission of sensitive
information, and potential conflicts of interest. Smartphone apps are not
validated for medical interpretation and may produce dangerous
inaccuracies. Federal regulations and accreditation standards require
healthcare organizations to provide qualified interpreters for patients
with limited English proficiency.
4. A nurse is preparing to administer medications to a patient and
follows the "rights" of medication administration; after verifying the
patient's identity using two identifiers, the nurse checks the medication
,label against the MAR three times; which additional "right" is CRITICAL
to assess BEFORE administering any medication to prevent harm?
A) Right documentation
B) Right reason
C) Right assessment (e.g., vital signs, laboratory values, allergies)
D) Right to refuse
The "right assessment" requires the nurse to evaluate patient-specific
factors that could affect medication safety before administration.
Examples include holding a beta-blocker if heart rate is <60 bpm,
withholding digoxin if potassium is low, checking blood pressure before
antihypertensives, or confirming no allergies exist. This step prevents
administering medications that could cause harm based on the patient's
current physiological status. While documentation, understanding the
reason, and respecting refusal are important, they do not prevent
immediate physiological harm like an inappropriate medication dose
could.
5. A nurse is caring for a patient who is at high risk for falls; the patient
has a history of orthostatic hypotension and is taking antihypertensive
medications; which intervention should the nurse implement FIRST to
promote patient safety?
A) Place the patient in a room near the nurses' station for frequent
observation
B) Teach the patient to change positions slowly and dangle at the bedside
before standing
C) Apply a bed alarm and keep the bed in the lowest position with side
rails up
D) Request a provider order for a physical therapy consult for gait
training
Patient education empowers self-management and addresses the root
cause of the fall risk: orthostatic hypotension. Teaching slow position
changes and dangling allows the cardiovascular system time to adjust,
reducing dizziness and fall risk. Environmental modifications (room
placement, alarms, bed position) and referrals are important secondary
interventions, but they do not equip the patient with skills to prevent
, falls independently. Safety interventions should always prioritize patient
education and least-restrictive approaches first.
6. A nurse is performing hand hygiene before entering a patient's room;
the patient is on contact precautions for Clostridioides difficile infection;
the nurse understands that which method of hand hygiene is MOST
effective for preventing transmission of C. diff spores?
A) Alcohol-based hand rub for 20 seconds
B) Soap and water with friction for at least 20 seconds
C) Chlorhexidine gluconate surgical scrub for 2 minutes
D) Antimicrobial wipes followed by alcohol-based hand rub
Clostridioides difficile produces spores that are resistant to alcohol-
based hand sanitizers. Mechanical removal through handwashing with
soap and water and friction is required to physically remove spores from
the skin. Alcohol-based rubs are effective against most pathogens but
NOT spore-forming organisms like C. diff or viruses like norovirus.
Chlorhexidine is useful for surgical scrubs but does not specifically target
spores. This is a fundamental infection control principle for contact
precautions involving spore-forming bacteria.
7. A nurse is assessing a patient's vital signs and notes a temperature of
101.8°F (38.8°C), heart rate of 112 bpm, respiratory rate of 24
breaths/min, and blood pressure of 98/62 mmHg; the patient reports
chills and generalized body aches; the nurse recognizes these findings as
consistent with which physiological response?
A) Hypothermia due to environmental exposure
B) Fever (pyrexia) as part of the inflammatory response to infection
C) Hypovolemic shock secondary to fluid loss
D) Autonomic dysreflexia related to spinal cord injury
Fever triggers a cascade of physiological responses: increased metabolic
rate raises heart rate to meet oxygen demands; tachypnea helps
eliminate excess heat through respiration; vasodilation can cause mild
hypotension; and chills occur as the hypothalamus resets the body's
thermostat upward. These findings collectively represent the classic
presentation of pyrexia during an inflammatory or infectious process.
Hypothermia would present with low temperature and bradycardia;
hypovolemic shock would show more profound hypotension and
