NFDN 1002 NURSING FOUNDATIONS II FINAL EXAM-ALL
QUESTIONS AND ANSWERS PLUS DETAILED RATIONALES |
COMPLETE STUDYGUIDE | DOWNLOAD INSTANT PDF 2027-
2028
1. A nurse is caring for a client who has been receiving oxygen at 2 L/min by nasal cannula.
The client becomes increasingly restless and has an oxygen saturation of 86%. Which
action should the nurse take first?
A. Encourage the client to cough and deep breathe
B. Increase oxygen flow according to the prescribed protocol and reassess
C. Place the client in a supine position
D. Administer the prescribed opioid medication
Answer: B
The immediate priority is to address hypoxemia. The nurse should increase oxygen as
permitted by the prescription or protocol, optimize positioning, and promptly reassess the
client's respiratory status.
2. A postoperative client reports sudden pain and tightness in the chest and develops
shortness of breath. Which complication should the nurse suspect?
A. Atelectasis
B. Pneumonia
C. Pulmonary embolism
D. Fluid overload
Answer: C
Sudden dyspnea and chest discomfort after surgery are classic warning signs of pulmonary
embolism. The nurse should treat the change as an emergency and initiate immediate
assessment and intervention.
3. A nurse is teaching a client how to use an incentive spirometer after abdominal surgery.
Which instruction is most appropriate?
A. Exhale forcefully into the device
B. Use the device only when shortness of breath occurs
,C. Inhale slowly and deeply through the mouthpiece
D. Breathe rapidly several times through the mouthpiece
Answer: C
The incentive spirometer promotes alveolar expansion by encouraging slow, sustained
inspiration. Regular use helps prevent postoperative atelectasis.
4. A client receiving IV fluids develops crackles, increasing dyspnea, and peripheral edema.
What should the nurse do first?
A. Stop or slow the infusion according to the clinical situation and assess the client
B. Encourage the client to drink additional fluids
C. Place the client in a flat position
D. Increase the IV infusion rate
Answer: A
Crackles, dyspnea, and edema suggest fluid volume excess. The nurse should immediately
assess the client and address the IV infusion to prevent worsening pulmonary congestion.
5. Which assessment finding most strongly indicates dehydration in an adult client?
A. Bounding pulse
B. Distended neck veins
C. Moist mucous membranes
D. Concentrated urine with decreased output
Answer: D
Dehydration commonly causes decreased urine production and concentrated urine because
the kidneys conserve water. Other findings may include dry mucous membranes, tachycardia,
and orthostatic changes.
6. A nurse is caring for a client with dysphagia following a stroke. Which intervention is
most appropriate during meals?
A. Position the client upright and maintain the position after eating
B. Offer thin liquids first
,C. Encourage the client to eat quickly
D. Place food on the weaker side of the mouth
Answer: A
An upright position reduces aspiration risk. The client should remain upright after meals, and
food and liquid consistency should follow the swallowing evaluation and prescribed plan.
7. A client with diabetes is prescribed rapid-acting insulin before meals. Which nursing
action is most important before administering the medication?
A. Check the client's temperature
B. Verify that the meal is available or will be provided promptly
C. Restrict oral fluids
D. Ask the client to ambulate
Answer: B
Rapid-acting insulin can significantly lower blood glucose soon after administration.
Ensuring timely food availability reduces the risk of hypoglycemia.
8. A nurse enters a client's room and finds the client sitting on the floor beside the bed.
What should the nurse do first?
A. Help the client immediately back into bed
B. Complete an incident report
C. Assess the client for injury and level of consciousness
D. Notify the client's family
Answer: C
The priority after a fall is assessment for injury. The nurse should not move the client
unnecessarily until injuries, including possible spinal or head trauma, have been assessed.
9. Which intervention is most effective for preventing pressure injuries in a client who is
immobile?
A. Massage reddened bony prominences
B. Reposition the client regularly and reduce pressure on vulnerable areas
, C. Limit protein intake
D. Keep the client's skin continuously moist
Answer: B
Regular repositioning and pressure redistribution reduce prolonged tissue compression and
are fundamental components of pressure-injury prevention.
10. A nurse assesses a client with a reddened area over the sacrum that does not blanch
when pressure is applied. The skin remains intact. How should this finding be interpreted?
A. Stage 1 pressure injury
B. Stage 2 pressure injury
C. Stage 3 pressure injury
D. Deep tissue pressure injury
Answer: A
A stage 1 pressure injury involves intact skin with persistent nonblanchable erythema. Early
recognition allows prompt pressure-relieving interventions.
11. A client receiving opioid analgesia is difficult to arouse and has respirations of 7/min.
Which medication should the nurse anticipate administering?
A. Flumazenil
B. Naloxone
C. Protamine sulfate
D. Vitamin K
Answer: B
Naloxone is an opioid antagonist used to reverse significant opioid-induced respiratory
depression. Airway and breathing support remain immediate priorities.
12. A nurse is assessing a client before administering morphine. Which finding requires the
nurse to withhold the medication and notify the appropriate provider?
A. Pain rated 7/10
B. Respiratory rate of 8/min
QUESTIONS AND ANSWERS PLUS DETAILED RATIONALES |
COMPLETE STUDYGUIDE | DOWNLOAD INSTANT PDF 2027-
2028
1. A nurse is caring for a client who has been receiving oxygen at 2 L/min by nasal cannula.
The client becomes increasingly restless and has an oxygen saturation of 86%. Which
action should the nurse take first?
A. Encourage the client to cough and deep breathe
B. Increase oxygen flow according to the prescribed protocol and reassess
C. Place the client in a supine position
D. Administer the prescribed opioid medication
Answer: B
The immediate priority is to address hypoxemia. The nurse should increase oxygen as
permitted by the prescription or protocol, optimize positioning, and promptly reassess the
client's respiratory status.
2. A postoperative client reports sudden pain and tightness in the chest and develops
shortness of breath. Which complication should the nurse suspect?
A. Atelectasis
B. Pneumonia
C. Pulmonary embolism
D. Fluid overload
Answer: C
Sudden dyspnea and chest discomfort after surgery are classic warning signs of pulmonary
embolism. The nurse should treat the change as an emergency and initiate immediate
assessment and intervention.
3. A nurse is teaching a client how to use an incentive spirometer after abdominal surgery.
Which instruction is most appropriate?
A. Exhale forcefully into the device
B. Use the device only when shortness of breath occurs
,C. Inhale slowly and deeply through the mouthpiece
D. Breathe rapidly several times through the mouthpiece
Answer: C
The incentive spirometer promotes alveolar expansion by encouraging slow, sustained
inspiration. Regular use helps prevent postoperative atelectasis.
4. A client receiving IV fluids develops crackles, increasing dyspnea, and peripheral edema.
What should the nurse do first?
A. Stop or slow the infusion according to the clinical situation and assess the client
B. Encourage the client to drink additional fluids
C. Place the client in a flat position
D. Increase the IV infusion rate
Answer: A
Crackles, dyspnea, and edema suggest fluid volume excess. The nurse should immediately
assess the client and address the IV infusion to prevent worsening pulmonary congestion.
5. Which assessment finding most strongly indicates dehydration in an adult client?
A. Bounding pulse
B. Distended neck veins
C. Moist mucous membranes
D. Concentrated urine with decreased output
Answer: D
Dehydration commonly causes decreased urine production and concentrated urine because
the kidneys conserve water. Other findings may include dry mucous membranes, tachycardia,
and orthostatic changes.
6. A nurse is caring for a client with dysphagia following a stroke. Which intervention is
most appropriate during meals?
A. Position the client upright and maintain the position after eating
B. Offer thin liquids first
,C. Encourage the client to eat quickly
D. Place food on the weaker side of the mouth
Answer: A
An upright position reduces aspiration risk. The client should remain upright after meals, and
food and liquid consistency should follow the swallowing evaluation and prescribed plan.
7. A client with diabetes is prescribed rapid-acting insulin before meals. Which nursing
action is most important before administering the medication?
A. Check the client's temperature
B. Verify that the meal is available or will be provided promptly
C. Restrict oral fluids
D. Ask the client to ambulate
Answer: B
Rapid-acting insulin can significantly lower blood glucose soon after administration.
Ensuring timely food availability reduces the risk of hypoglycemia.
8. A nurse enters a client's room and finds the client sitting on the floor beside the bed.
What should the nurse do first?
A. Help the client immediately back into bed
B. Complete an incident report
C. Assess the client for injury and level of consciousness
D. Notify the client's family
Answer: C
The priority after a fall is assessment for injury. The nurse should not move the client
unnecessarily until injuries, including possible spinal or head trauma, have been assessed.
9. Which intervention is most effective for preventing pressure injuries in a client who is
immobile?
A. Massage reddened bony prominences
B. Reposition the client regularly and reduce pressure on vulnerable areas
, C. Limit protein intake
D. Keep the client's skin continuously moist
Answer: B
Regular repositioning and pressure redistribution reduce prolonged tissue compression and
are fundamental components of pressure-injury prevention.
10. A nurse assesses a client with a reddened area over the sacrum that does not blanch
when pressure is applied. The skin remains intact. How should this finding be interpreted?
A. Stage 1 pressure injury
B. Stage 2 pressure injury
C. Stage 3 pressure injury
D. Deep tissue pressure injury
Answer: A
A stage 1 pressure injury involves intact skin with persistent nonblanchable erythema. Early
recognition allows prompt pressure-relieving interventions.
11. A client receiving opioid analgesia is difficult to arouse and has respirations of 7/min.
Which medication should the nurse anticipate administering?
A. Flumazenil
B. Naloxone
C. Protamine sulfate
D. Vitamin K
Answer: B
Naloxone is an opioid antagonist used to reverse significant opioid-induced respiratory
depression. Airway and breathing support remain immediate priorities.
12. A nurse is assessing a client before administering morphine. Which finding requires the
nurse to withhold the medication and notify the appropriate provider?
A. Pain rated 7/10
B. Respiratory rate of 8/min
