Updated NSG 4800 Exam 1, 2, 3 Plus rationales and verified answers
2026/2027 version
1. A nurse is caring for a client who is postoperative following abdominal surgery. The
client reports pain at a level of 8 on a scale of 0 to 10. The nurse administers morphine 4
mg IV. Which of the following actions should the nurse take after administering the
medication?
• A. Document the client's pain level before and after administration
• B. Reassess the client's pain level in 15-30 minutes
• C. Notify the provider of the pain level
• D. Administer a second dose immediately
Answer: B. Reassess the client's pain level in 15-30 minutes
Rationale: After administering IV pain medication, the nurse should reassess the client's pain
level within 15-30 minutes to evaluate the effectiveness of the intervention. Documentation is
important, but reassessment is the priority to determine if further intervention is needed.
2. A nurse is preparing to insert a urinary catheter. Which of the following actions should
the nurse take to maintain sterile technique?
• A. Open the catheter kit away from the sterile field
• B. Place the sterile drape on the bedside table
• C. Don sterile gloves before opening the catheter kit
• D. Maintain sterile gloves above the waist level
Answer: D. Maintain sterile gloves above the waist level
Rationale: Sterile gloved hands should remain above the waist level and within the sterile field
to maintain sterility. The catheter kit should be opened onto the sterile field, and sterile gloves
should be donned after opening the kit.
3. A nurse is providing teaching to a client who has a new diagnosis of type 2 diabetes
mellitus. Which of the following statements indicates the client understands the teaching?
• A. "I will need to check my blood sugar before each meal."
• B. "I will need to take insulin every day."
, • C. "I will be able to eat anything as long as I take my medication."
• D. "I will need to exercise regularly to help control my blood sugar."
Answer: D. "I will need to exercise regularly to help control my blood sugar."
Rationale: Regular exercise helps improve insulin sensitivity and glucose utilization. Clients
with type 2 diabetes may not require insulin initially and should monitor blood glucose as
prescribed. Dietary management is also essential.
4. A nurse is assessing a client who has a history of heart failure. Which of the following
findings should the nurse report to the provider?
• A. Blood pressure of 138/88 mmHg
• B. Weight gain of 2 kg (4.4 lb) in 2 days
• C. Heart rate of 78/min
• D. Respiratory rate of 18/min
Answer: B. Weight gain of 2 kg (4.4 lb) in 2 days
Rationale: Rapid weight gain in a client with heart failure indicates fluid retention and
worsening heart failure. This finding requires immediate notification to the provider. Daily
weight monitoring is essential for early detection.
5. A nurse is providing teaching to a client who is postoperative following a total hip
arthroplasty. Which of the following instructions should the nurse include?
• A. "Avoid crossing your legs at the ankles."
• B. "You may bend at the waist to pick up items."
• C. "Sit in low chairs for comfort."
• D. "Position your legs in adduction when lying down."
Answer: A. "Avoid crossing your legs at the ankles."
Rationale: Clients with a total hip arthroplasty should avoid crossing their legs (adduction) to
prevent dislocation of the hip prosthesis. They should sit in high chairs and avoid bending
forward at the waist.
,6. A nurse is caring for a client who has a prescription for oxygen at 2 L/min via nasal
cannula. The client's oxygen saturation is 94%. Which of the following actions should the
nurse take?
• A. Decrease the oxygen to 1 L/min
• B. Increase the oxygen to 4 L/min
• C. Continue the current oxygen setting
• D. Discontinue the oxygen
Answer: C. Continue the current oxygen setting
Rationale: An oxygen saturation of 94% is within the normal range (≥92-95%). No change in
oxygen therapy is required. The nurse should continue the current setting.
7. A nurse is assessing a client who has chronic pain. Which of the following findings
indicates the client is experiencing chronic pain?
• A. Increased heart rate
• B. Diaphoresis
• C. Depression
• D. Dilated pupils
Answer: C. Depression
Rationale: Chronic pain is often associated with psychological effects such as depression,
anxiety, and sleep disturbances. Physical signs like increased heart rate and diaphoresis are more
commonly associated with acute pain.
8. A nurse is preparing to administer a medication via a nasogastric tube. Which of the
following actions should the nurse take?
• A. Crush enteric-coated tablets before administration
• B. Flush the tube with 15-30 mL of water before and after each medication
• C. Administer all medications together to reduce the number of flushes
• D. Use warm water to flush the tube
Answer: B. Flush the tube with 15-30 mL of water before and after each medication
Rationale: NG tubes should be flushed with 15-30 mL of water before and after each medication
to maintain patency and prevent clogging. Enteric-coated tablets should not be crushed.
, 9. A nurse is providing teaching to a client who has a new prescription for a diuretic.
Which of the following instructions should the nurse include?
• A. "Take the medication at bedtime."
• B. "Take the medication in the morning."
• C. "Take the medication with food."
• D. "Take the medication on an empty stomach."
Answer: B. "Take the medication in the morning."
Rationale: Diuretics should be taken in the morning to prevent nocturia (frequent urination
during the night). This helps the client maintain normal sleep patterns.
10. A nurse is assessing a client who has a history of seizures. Which of the following
actions should the nurse take during a seizure?
• A. Place a tongue depressor in the client's mouth
• B. Restrain the client's arms and legs
• C. Position the client on their side
• D. Administer oral medication
Answer: C. Position the client on their side
Rationale: Positioning the client on their side (lateral position) helps prevent aspiration. The
nurse should never place anything in the client's mouth or restrain the client during a seizure.
11. A nurse is caring for a client who is receiving IV fluids. The nurse notes swelling and
redness at the IV insertion site. Which of the following actions should the nurse take first?
• A. Apply a warm compress to the site
• B. Discontinue the IV and restart in another site
• C. Notify the provider
• D. Slow the rate of the IV infusion
Answer: B. Discontinue the IV and restart in another site
2026/2027 version
1. A nurse is caring for a client who is postoperative following abdominal surgery. The
client reports pain at a level of 8 on a scale of 0 to 10. The nurse administers morphine 4
mg IV. Which of the following actions should the nurse take after administering the
medication?
• A. Document the client's pain level before and after administration
• B. Reassess the client's pain level in 15-30 minutes
• C. Notify the provider of the pain level
• D. Administer a second dose immediately
Answer: B. Reassess the client's pain level in 15-30 minutes
Rationale: After administering IV pain medication, the nurse should reassess the client's pain
level within 15-30 minutes to evaluate the effectiveness of the intervention. Documentation is
important, but reassessment is the priority to determine if further intervention is needed.
2. A nurse is preparing to insert a urinary catheter. Which of the following actions should
the nurse take to maintain sterile technique?
• A. Open the catheter kit away from the sterile field
• B. Place the sterile drape on the bedside table
• C. Don sterile gloves before opening the catheter kit
• D. Maintain sterile gloves above the waist level
Answer: D. Maintain sterile gloves above the waist level
Rationale: Sterile gloved hands should remain above the waist level and within the sterile field
to maintain sterility. The catheter kit should be opened onto the sterile field, and sterile gloves
should be donned after opening the kit.
3. A nurse is providing teaching to a client who has a new diagnosis of type 2 diabetes
mellitus. Which of the following statements indicates the client understands the teaching?
• A. "I will need to check my blood sugar before each meal."
• B. "I will need to take insulin every day."
, • C. "I will be able to eat anything as long as I take my medication."
• D. "I will need to exercise regularly to help control my blood sugar."
Answer: D. "I will need to exercise regularly to help control my blood sugar."
Rationale: Regular exercise helps improve insulin sensitivity and glucose utilization. Clients
with type 2 diabetes may not require insulin initially and should monitor blood glucose as
prescribed. Dietary management is also essential.
4. A nurse is assessing a client who has a history of heart failure. Which of the following
findings should the nurse report to the provider?
• A. Blood pressure of 138/88 mmHg
• B. Weight gain of 2 kg (4.4 lb) in 2 days
• C. Heart rate of 78/min
• D. Respiratory rate of 18/min
Answer: B. Weight gain of 2 kg (4.4 lb) in 2 days
Rationale: Rapid weight gain in a client with heart failure indicates fluid retention and
worsening heart failure. This finding requires immediate notification to the provider. Daily
weight monitoring is essential for early detection.
5. A nurse is providing teaching to a client who is postoperative following a total hip
arthroplasty. Which of the following instructions should the nurse include?
• A. "Avoid crossing your legs at the ankles."
• B. "You may bend at the waist to pick up items."
• C. "Sit in low chairs for comfort."
• D. "Position your legs in adduction when lying down."
Answer: A. "Avoid crossing your legs at the ankles."
Rationale: Clients with a total hip arthroplasty should avoid crossing their legs (adduction) to
prevent dislocation of the hip prosthesis. They should sit in high chairs and avoid bending
forward at the waist.
,6. A nurse is caring for a client who has a prescription for oxygen at 2 L/min via nasal
cannula. The client's oxygen saturation is 94%. Which of the following actions should the
nurse take?
• A. Decrease the oxygen to 1 L/min
• B. Increase the oxygen to 4 L/min
• C. Continue the current oxygen setting
• D. Discontinue the oxygen
Answer: C. Continue the current oxygen setting
Rationale: An oxygen saturation of 94% is within the normal range (≥92-95%). No change in
oxygen therapy is required. The nurse should continue the current setting.
7. A nurse is assessing a client who has chronic pain. Which of the following findings
indicates the client is experiencing chronic pain?
• A. Increased heart rate
• B. Diaphoresis
• C. Depression
• D. Dilated pupils
Answer: C. Depression
Rationale: Chronic pain is often associated with psychological effects such as depression,
anxiety, and sleep disturbances. Physical signs like increased heart rate and diaphoresis are more
commonly associated with acute pain.
8. A nurse is preparing to administer a medication via a nasogastric tube. Which of the
following actions should the nurse take?
• A. Crush enteric-coated tablets before administration
• B. Flush the tube with 15-30 mL of water before and after each medication
• C. Administer all medications together to reduce the number of flushes
• D. Use warm water to flush the tube
Answer: B. Flush the tube with 15-30 mL of water before and after each medication
Rationale: NG tubes should be flushed with 15-30 mL of water before and after each medication
to maintain patency and prevent clogging. Enteric-coated tablets should not be crushed.
, 9. A nurse is providing teaching to a client who has a new prescription for a diuretic.
Which of the following instructions should the nurse include?
• A. "Take the medication at bedtime."
• B. "Take the medication in the morning."
• C. "Take the medication with food."
• D. "Take the medication on an empty stomach."
Answer: B. "Take the medication in the morning."
Rationale: Diuretics should be taken in the morning to prevent nocturia (frequent urination
during the night). This helps the client maintain normal sleep patterns.
10. A nurse is assessing a client who has a history of seizures. Which of the following
actions should the nurse take during a seizure?
• A. Place a tongue depressor in the client's mouth
• B. Restrain the client's arms and legs
• C. Position the client on their side
• D. Administer oral medication
Answer: C. Position the client on their side
Rationale: Positioning the client on their side (lateral position) helps prevent aspiration. The
nurse should never place anything in the client's mouth or restrain the client during a seizure.
11. A nurse is caring for a client who is receiving IV fluids. The nurse notes swelling and
redness at the IV insertion site. Which of the following actions should the nurse take first?
• A. Apply a warm compress to the site
• B. Discontinue the IV and restart in another site
• C. Notify the provider
• D. Slow the rate of the IV infusion
Answer: B. Discontinue the IV and restart in another site
