NSG 122 Fundamentals of Nursing Exam 4 |
Herzing University Questions & Answers
2026/2027
SECTION I: PATIENT SAFETY & QUALITY IMPROVEMENT (Questions 1–25)
1. A nurse is caring for a postoperative client who is receiving opioid analgesia.
Which assessment finding is the priority concern?
A. Respiratory rate of 8/min and sedation score of 3
B. Pain rating of 6/10
C. Blood pressure of 118/72 mm Hg
D. Nausea with one episode of emesis
Correct Answer: A
Rationale: Respiratory depression is the most life-threatening adverse
effect of opioid analgesia. A respiratory rate below 10/min combined with deep
sedation requires immediate intervention, including withholding the next dose,
administering naloxone if prescribed, and notifying the provider. Pain, blood
pressure, and nausea are important but are not immediately life-threatening.
2. A nurse is preparing to administer medications to a client. Which action best
demonstrates the use of the "rights" of medication administration?
A. Checking the medication label once before administration
B. Verifying the client's identity using two identifiers
C. Administering the medication without scanning the barcode
D. Documenting the medication before administering it
Correct Answer: B
Rationale: Using two client identifiers (e.g., name and date of birth) is a
critical safety step to prevent medication errors. Medication labels should be
checked at least three times, barcode scanning should be performed when
available, and documentation should occur after administration, not before.
,3. A nurse is caring for a client who has a history of falls. Which intervention is the
priority for fall prevention?
A. Placing the client in a room near the nurses' station
B. Applying a bed alarm and keeping the call light within reach
C. Restraining the client to prevent ambulation
D. Documenting fall risk once per shift
Correct Answer: B
Rationale: Bed alarms and easy access to the call light are direct safety
interventions that alert staff when a high-risk client attempts to get up without
assistance. Restraints are a last resort and require a provider's order. Room
placement and documentation are important but do not directly prevent falls at
the moment of risk.
4. A nurse is implementing the QSEN competency of safety. Which action is the
best example?
A. Administering a medication via the wrong route
B. Reporting a medication near-miss through the facility's event reporting system
C. Ignoring a colleague's unsafe practice to avoid conflict
D. Documenting care without assessing the client
Correct Answer: B
Rationale: QSEN safety competency includes reporting errors and near-
misses to improve systems and prevent future harm. Ignoring unsafe practice,
wrong-route administration, and documenting without assessment are all
violations of safe practice.
5. A nurse is caring for a client who is at risk for aspiration. Which position is
safest for feeding?
,A. Supine
B. High-Fowler's (90 degrees)
C. Trendelenburg
D. Sims'
Correct Answer: B
Rationale: High-Fowler's position uses gravity to keep the airway
protected and facilitates swallowing. Supine and Trendelenburg positions increase
aspiration risk. Sims' position is a side-lying position used for rectal examinations
or enemas, not for feeding an aspiration-risk client.
6. A nurse is assessing a client's fall risk. Which factor places the client at highest
risk?
A. Age 45 with no chronic conditions
B. Age 78 taking a benzodiazepine and a diuretic
C. Age 30 postoperative day 1
D. Age 55 with well-controlled hypertension
Correct Answer: B
Rationale: Older age, sedative medications (benzodiazepines), and
diuretics (which cause frequent urination and urgency) are major fall risk factors.
The combination of impaired cognition from sedatives and increased elimination
needs significantly elevates fall risk.
7. A nurse is preparing to use a mechanical lift to transfer a client. Which action
should the nurse take first?
A. Raise the bed to the highest position
B. Verify the client's weight and the lift's weight capacity
C. Ask the client to stand and pivot independently
D. Apply a gait belt and proceed with a manual lift
Correct Answer: B
, Rationale: Safety requires verifying that the lift's weight capacity exceeds
the client's weight before use. Raising the bed too high or attempting a manual
lift on a client who requires a mechanical lift can result in injury to both the client
and the nurse.
8. A nurse is teaching a client about using a walker. Which statement by the client
indicates correct understanding?
A. "I will lift the walker and place it far in front of me."
B. "I will move the walker, then step into it with my weaker leg first."
C. "I will use the walker only on stairs."
D. "I will lean on the walker with all my weight."
Correct Answer: B
Rationale: The correct sequence when using a walker is to move the
walker forward, then step with the weaker leg first, followed by the stronger leg.
The walker should be placed a comfortable distance ahead, not far. Leaning full
body weight on a walker is unsafe. Walkers are not used on stairs.
9. A nurse is assessing a client for risk of pressure injury. Which finding is most
concerning?
A. Braden Scale score of 22
B. Braden Scale score of 12
C. Moist intact skin
D. Ambulating independently
Correct Answer: B
Rationale: A Braden Scale score of 12 indicates high risk for pressure injury
(scores ≤18 indicate risk). A score of 22 indicates low risk. Moist intact skin and
independent ambulation are protective factors.
Herzing University Questions & Answers
2026/2027
SECTION I: PATIENT SAFETY & QUALITY IMPROVEMENT (Questions 1–25)
1. A nurse is caring for a postoperative client who is receiving opioid analgesia.
Which assessment finding is the priority concern?
A. Respiratory rate of 8/min and sedation score of 3
B. Pain rating of 6/10
C. Blood pressure of 118/72 mm Hg
D. Nausea with one episode of emesis
Correct Answer: A
Rationale: Respiratory depression is the most life-threatening adverse
effect of opioid analgesia. A respiratory rate below 10/min combined with deep
sedation requires immediate intervention, including withholding the next dose,
administering naloxone if prescribed, and notifying the provider. Pain, blood
pressure, and nausea are important but are not immediately life-threatening.
2. A nurse is preparing to administer medications to a client. Which action best
demonstrates the use of the "rights" of medication administration?
A. Checking the medication label once before administration
B. Verifying the client's identity using two identifiers
C. Administering the medication without scanning the barcode
D. Documenting the medication before administering it
Correct Answer: B
Rationale: Using two client identifiers (e.g., name and date of birth) is a
critical safety step to prevent medication errors. Medication labels should be
checked at least three times, barcode scanning should be performed when
available, and documentation should occur after administration, not before.
,3. A nurse is caring for a client who has a history of falls. Which intervention is the
priority for fall prevention?
A. Placing the client in a room near the nurses' station
B. Applying a bed alarm and keeping the call light within reach
C. Restraining the client to prevent ambulation
D. Documenting fall risk once per shift
Correct Answer: B
Rationale: Bed alarms and easy access to the call light are direct safety
interventions that alert staff when a high-risk client attempts to get up without
assistance. Restraints are a last resort and require a provider's order. Room
placement and documentation are important but do not directly prevent falls at
the moment of risk.
4. A nurse is implementing the QSEN competency of safety. Which action is the
best example?
A. Administering a medication via the wrong route
B. Reporting a medication near-miss through the facility's event reporting system
C. Ignoring a colleague's unsafe practice to avoid conflict
D. Documenting care without assessing the client
Correct Answer: B
Rationale: QSEN safety competency includes reporting errors and near-
misses to improve systems and prevent future harm. Ignoring unsafe practice,
wrong-route administration, and documenting without assessment are all
violations of safe practice.
5. A nurse is caring for a client who is at risk for aspiration. Which position is
safest for feeding?
,A. Supine
B. High-Fowler's (90 degrees)
C. Trendelenburg
D. Sims'
Correct Answer: B
Rationale: High-Fowler's position uses gravity to keep the airway
protected and facilitates swallowing. Supine and Trendelenburg positions increase
aspiration risk. Sims' position is a side-lying position used for rectal examinations
or enemas, not for feeding an aspiration-risk client.
6. A nurse is assessing a client's fall risk. Which factor places the client at highest
risk?
A. Age 45 with no chronic conditions
B. Age 78 taking a benzodiazepine and a diuretic
C. Age 30 postoperative day 1
D. Age 55 with well-controlled hypertension
Correct Answer: B
Rationale: Older age, sedative medications (benzodiazepines), and
diuretics (which cause frequent urination and urgency) are major fall risk factors.
The combination of impaired cognition from sedatives and increased elimination
needs significantly elevates fall risk.
7. A nurse is preparing to use a mechanical lift to transfer a client. Which action
should the nurse take first?
A. Raise the bed to the highest position
B. Verify the client's weight and the lift's weight capacity
C. Ask the client to stand and pivot independently
D. Apply a gait belt and proceed with a manual lift
Correct Answer: B
, Rationale: Safety requires verifying that the lift's weight capacity exceeds
the client's weight before use. Raising the bed too high or attempting a manual
lift on a client who requires a mechanical lift can result in injury to both the client
and the nurse.
8. A nurse is teaching a client about using a walker. Which statement by the client
indicates correct understanding?
A. "I will lift the walker and place it far in front of me."
B. "I will move the walker, then step into it with my weaker leg first."
C. "I will use the walker only on stairs."
D. "I will lean on the walker with all my weight."
Correct Answer: B
Rationale: The correct sequence when using a walker is to move the
walker forward, then step with the weaker leg first, followed by the stronger leg.
The walker should be placed a comfortable distance ahead, not far. Leaning full
body weight on a walker is unsafe. Walkers are not used on stairs.
9. A nurse is assessing a client for risk of pressure injury. Which finding is most
concerning?
A. Braden Scale score of 22
B. Braden Scale score of 12
C. Moist intact skin
D. Ambulating independently
Correct Answer: B
Rationale: A Braden Scale score of 12 indicates high risk for pressure injury
(scores ≤18 indicate risk). A score of 22 indicates low risk. Moist intact skin and
independent ambulation are protective factors.
