NURS 1117 FINAL EXAM-ALL QUESTIONS AND ANSWERS PLUS
DETAILED RATIONALES | COMPLETE STUDYGUIDE |
DOWNLOAD INSTANT PDF 2027-2028
1. A nurse is preparing to administer a medication to a client in a clinical setting. Which of
the following checks is considered the first 'right' of medication administration according
to standard safety guidelines?
A. Right dose
B. Right client
C. Right medication
D. Right route
The right client is the first fundamental check in medication safety to ensure the intervention
is directed to the intended individual using two distinct identifiers.
2. A client admitted with severe dehydration is prescribed an intravenous infusion of 0.9%
sodium chloride. How is this particular IV solution classified based on tonicity relative to
plasma?
A. Hypotonic
B. Hypertonic
C. Isotonic
D. Colloidal
0.9% sodium chloride has an effective osmolality similar to extracellular fluid, making it an
isotonic solution that expands intravascular volume without causing fluid shifts.
3. When assessing a client's respiratory status, the nurse notes a respiratory rate of 28
breaths per minute with shallow depth. How should the nurse document this finding?
A. Bradypnea
B. Apnea
C. Orthopnea
D. Tachypnea
,Tachypnea is defined as a persistent, rapid, and typically shallow respiratory rate exceeding
the normal adult baseline of 12 to 20 breaths per minute.
4. A nurse enters a client's room and notices a small fire in a wastepaper basket. Following
the RACE protocol, what action should the nurse take immediately?
A. Extinguish the fire using a fire extinguisher
B. Rescue and remove clients from the immediate danger zone
C. Activate the fire alarm system
D. Confine the fire by closing all doors and windows
Answer: B The RACE protocol prioritizes rescue first by immediately removing any clients and
personnel from immediate danger before activating alarms or fighting the fire.
5. During a routine assessment, a client's blood pressure is measured at 142/92 mmHg.
According to current hypertension guidelines, how should this reading be categorized?
A. Normal blood pressure
B. Elevated blood pressure
C. Stage 1 hypertension
D. Stage 2 hypertension
A blood pressure reading where the systolic is 140 mmHg or higher or the diastolic is 90
mmHg or higher is classified as Stage 2 hypertension.
6. A client expresses anxiety about an upcoming surgical procedure and asks the nurse
whether they should sign the informed consent form. What is the most appropriate nursing
response?
A. "You must sign it now so the surgical team can prepare."
B. "Signing the form simply means you understand the risks and benefits discussed with
your surgeon."
C. "Don't worry about the risks; surgeons perform this procedure safely every day."
D. "If you are hesitant, I will cancel the surgery for you immediately."
The nurse clarifies that the signature verifies the client has received, understood, and
consented to the information explained by the provider regarding risks and benefits.
,7. Which of the following infection control measures is classified as a standard precaution
designed for all hospitalized clients regardless of diagnosis?
A. Wearing an N95 respirator during client interactions
B. Placing the client in a negative-pressure airflow room
C. Performing hand hygiene before and after direct client contact
D. Donning sterile shoe covers before entering the care area
Hand hygiene is a core component of standard precautions intended to reduce transmission of
pathogens in all healthcare settings for every client.
8. A nurse is monitoring a client receiving a blood transfusion who suddenly develops
chills, fever, and lower back pain. What is the immediate priority action?
A. Slow the infusion rate and document the vital signs
B. Stop the transfusion immediately and disconnect the tubing
C. Administer an antipyretic medication as prescribed
D. Notify the blood bank to send a replacement unit
Stopping the transfusion immediately prevents further introduction of incompatible blood
components, preserving the client's safety during an acute transfusion reaction.
9. When documenting client care in an electronic health record, which of the following
practices adheres to legal and professional documentation standards?
A. Recording nursing care before performing the actual intervention
B. Using subjective and biased descriptors like "uncooperative client"
C. Documenting factual, objective, and timely observations of client responses
D. Leaving nursing notes blank for another colleague to fill out at shift change
Accurate documentation requires objective, factual, and timely descriptions of client status
and nursing actions to maintain a legal and professional record.
10. A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen
therapy via nasal cannula at 4 L/min. Why must high-flow oxygen be used cautiously in
clients with chronic hypercapnia?
, A. It can cause immediate respiratory arrest due to oxygen toxicity in lung tissue.
B. It can eliminate the hypoxic drive, leading to decreased respiratory effort and
hypoventilation.
C. It invariably causes severe metabolic alkalosis within minutes of initiation.
D. It dries out the nasal mucosa and leads to epistaxis.
Clients with chronic hypercapnia rely on low oxygen levels to stimulate breathing via the
hypoxic drive; high oxygen loads can suppress this drive and cause hypoventilation.
11. A nurse is assessing a client with fluid volume overload. Which of the following clinical
manifestations is most indicative of this condition?
A. Flat neck veins while in a supine position
B. Bounding peripheral pulses and peripheral edema
C. Poor skin turgor and dry mucous membranes
D. Decreased body weight and concentrated urine output
Fluid volume overload increases intravascular and interstitial volume, manifesting as
bounding pulses, elevated blood pressure, peripheral edema, and crackles.
12. When evaluating a client's wound healing by secondary intention, the nurse expects to
observe which of the following characteristics?
A. Clean surgical incision approximated with sutures
B. Rapid closure with minimal granulation tissue formation
C. Open wound edges with significant granulation tissue and scarring
D. Immediate epithelial regeneration without inflammatory response
Secondary intention healing occurs in open wounds where tissue loss is extensive, requiring
granulation tissue filling and significant scar formation.
13. A client is prescribed digoxin 0.25 mg orally daily. Before administering the medication,
which assessment is essential for the nurse to perform?
A. Palpating peripheral pulses for symmetry
B. Auscultating the apical pulse for one full minute
DETAILED RATIONALES | COMPLETE STUDYGUIDE |
DOWNLOAD INSTANT PDF 2027-2028
1. A nurse is preparing to administer a medication to a client in a clinical setting. Which of
the following checks is considered the first 'right' of medication administration according
to standard safety guidelines?
A. Right dose
B. Right client
C. Right medication
D. Right route
The right client is the first fundamental check in medication safety to ensure the intervention
is directed to the intended individual using two distinct identifiers.
2. A client admitted with severe dehydration is prescribed an intravenous infusion of 0.9%
sodium chloride. How is this particular IV solution classified based on tonicity relative to
plasma?
A. Hypotonic
B. Hypertonic
C. Isotonic
D. Colloidal
0.9% sodium chloride has an effective osmolality similar to extracellular fluid, making it an
isotonic solution that expands intravascular volume without causing fluid shifts.
3. When assessing a client's respiratory status, the nurse notes a respiratory rate of 28
breaths per minute with shallow depth. How should the nurse document this finding?
A. Bradypnea
B. Apnea
C. Orthopnea
D. Tachypnea
,Tachypnea is defined as a persistent, rapid, and typically shallow respiratory rate exceeding
the normal adult baseline of 12 to 20 breaths per minute.
4. A nurse enters a client's room and notices a small fire in a wastepaper basket. Following
the RACE protocol, what action should the nurse take immediately?
A. Extinguish the fire using a fire extinguisher
B. Rescue and remove clients from the immediate danger zone
C. Activate the fire alarm system
D. Confine the fire by closing all doors and windows
Answer: B The RACE protocol prioritizes rescue first by immediately removing any clients and
personnel from immediate danger before activating alarms or fighting the fire.
5. During a routine assessment, a client's blood pressure is measured at 142/92 mmHg.
According to current hypertension guidelines, how should this reading be categorized?
A. Normal blood pressure
B. Elevated blood pressure
C. Stage 1 hypertension
D. Stage 2 hypertension
A blood pressure reading where the systolic is 140 mmHg or higher or the diastolic is 90
mmHg or higher is classified as Stage 2 hypertension.
6. A client expresses anxiety about an upcoming surgical procedure and asks the nurse
whether they should sign the informed consent form. What is the most appropriate nursing
response?
A. "You must sign it now so the surgical team can prepare."
B. "Signing the form simply means you understand the risks and benefits discussed with
your surgeon."
C. "Don't worry about the risks; surgeons perform this procedure safely every day."
D. "If you are hesitant, I will cancel the surgery for you immediately."
The nurse clarifies that the signature verifies the client has received, understood, and
consented to the information explained by the provider regarding risks and benefits.
,7. Which of the following infection control measures is classified as a standard precaution
designed for all hospitalized clients regardless of diagnosis?
A. Wearing an N95 respirator during client interactions
B. Placing the client in a negative-pressure airflow room
C. Performing hand hygiene before and after direct client contact
D. Donning sterile shoe covers before entering the care area
Hand hygiene is a core component of standard precautions intended to reduce transmission of
pathogens in all healthcare settings for every client.
8. A nurse is monitoring a client receiving a blood transfusion who suddenly develops
chills, fever, and lower back pain. What is the immediate priority action?
A. Slow the infusion rate and document the vital signs
B. Stop the transfusion immediately and disconnect the tubing
C. Administer an antipyretic medication as prescribed
D. Notify the blood bank to send a replacement unit
Stopping the transfusion immediately prevents further introduction of incompatible blood
components, preserving the client's safety during an acute transfusion reaction.
9. When documenting client care in an electronic health record, which of the following
practices adheres to legal and professional documentation standards?
A. Recording nursing care before performing the actual intervention
B. Using subjective and biased descriptors like "uncooperative client"
C. Documenting factual, objective, and timely observations of client responses
D. Leaving nursing notes blank for another colleague to fill out at shift change
Accurate documentation requires objective, factual, and timely descriptions of client status
and nursing actions to maintain a legal and professional record.
10. A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen
therapy via nasal cannula at 4 L/min. Why must high-flow oxygen be used cautiously in
clients with chronic hypercapnia?
, A. It can cause immediate respiratory arrest due to oxygen toxicity in lung tissue.
B. It can eliminate the hypoxic drive, leading to decreased respiratory effort and
hypoventilation.
C. It invariably causes severe metabolic alkalosis within minutes of initiation.
D. It dries out the nasal mucosa and leads to epistaxis.
Clients with chronic hypercapnia rely on low oxygen levels to stimulate breathing via the
hypoxic drive; high oxygen loads can suppress this drive and cause hypoventilation.
11. A nurse is assessing a client with fluid volume overload. Which of the following clinical
manifestations is most indicative of this condition?
A. Flat neck veins while in a supine position
B. Bounding peripheral pulses and peripheral edema
C. Poor skin turgor and dry mucous membranes
D. Decreased body weight and concentrated urine output
Fluid volume overload increases intravascular and interstitial volume, manifesting as
bounding pulses, elevated blood pressure, peripheral edema, and crackles.
12. When evaluating a client's wound healing by secondary intention, the nurse expects to
observe which of the following characteristics?
A. Clean surgical incision approximated with sutures
B. Rapid closure with minimal granulation tissue formation
C. Open wound edges with significant granulation tissue and scarring
D. Immediate epithelial regeneration without inflammatory response
Secondary intention healing occurs in open wounds where tissue loss is extensive, requiring
granulation tissue filling and significant scar formation.
13. A client is prescribed digoxin 0.25 mg orally daily. Before administering the medication,
which assessment is essential for the nurse to perform?
A. Palpating peripheral pulses for symmetry
B. Auscultating the apical pulse for one full minute
