NSG 4800 exam 1,2,3 500 Questions
With Answers Graded A+ Assured
Success
1. A nurse obtains orthostatic vital signs on a client who reports dizziness when standing. Which
finding represents a significant orthostatic blood pressure change?
A. A decrease of 5 mm Hg systolic
B. A decrease of 10 mm Hg systolic
C. A decrease of 20 mm Hg systolic
D. An increase of 10 mm Hg systolic
Correct Answer: C. A decrease of 20 mm Hg systolic
Rationale: A decrease of approximately 20 mm Hg systolic or 10 mm Hg diastolic after position
changes is consistent with orthostatic hypotension. The nurse should protect the client from
falls, assist with position changes, and assess contributing factors such as dehydration or
medications.
2. A client with suspected pulmonary tuberculosis is admitted to the hospital. Which infection-
control intervention is most appropriate?
A. Place the client in a room with positive pressure
B. Wear a surgical mask when entering the room
C. Place the client in a negative-pressure room and use an N95 respirator
D. Use contact precautions only
Correct Answer: C. Place the client in a negative-pressure room and use an N95 respirator
Rationale: Tuberculosis is transmitted through airborne particles. Airborne precautions include
a negative-pressure room and a fit-tested respirator such as an N95. Docsity
3. Which action is appropriate when a nurse discovers a small fire in a client's room?
A. Immediately leave the unit
B. Rescue clients from immediate danger
C. Open the windows
D. Activate the sprinkler system manually
,Correct Answer: B. Rescue clients from immediate danger
Rationale: RACE begins with Rescue clients from immediate danger, followed by Alarm,
Confine, and Extinguish/Evacuate. Safety of clients takes priority.
4. Which action corresponds to the "A" in PASS when using a fire extinguisher?
A. Alert the fire department
B. Aim at the base of the fire
C. Activate the sprinkler
D. Assess the room
Correct Answer: B. Aim at the base of the fire
Rationale: PASS means Pull the pin, Aim at the base, Squeeze the handle, and Sweep from side
to side.
5. Which intervention is part of standard precautions?
A. Using an N95 respirator for every client
B. Wearing gloves when contact with body fluids is anticipated
C. Placing every client in a private room
D. Using a negative-pressure room for all admissions
Correct Answer: B. Wearing gloves when contact with body fluids is anticipated
Rationale: Standard precautions apply to all clients and include hand hygiene and appropriate
personal protective equipment based on the anticipated exposure.
6. A client has Clostridioides difficile infection. Which intervention is most appropriate?
A. Use airborne precautions
B. Use contact precautions and appropriate hand hygiene
C. Use droplet precautions
D. Place the client in a positive-pressure room
Correct Answer: B. Use contact precautions and appropriate hand hygiene
,Rationale: C. difficile requires contact precautions. Hand hygiene is especially important
because alcohol-based hand sanitizer is less effective against spores than soap-and-water
washing.
7. A client with influenza is admitted. Which precaution should the nurse initiate?
A. Airborne
B. Contact only
C. Droplet
D. Protective isolation
Correct Answer: C. Droplet
Rationale: Influenza is primarily transmitted through respiratory droplets. A surgical mask and
appropriate precautions are required.
8. Which client should the nurse assess first?
A. Client requesting assistance with bathing
B. Client with chronic arthritis reporting pain of 5/10
C. Client with new-onset stridor
D. Client waiting for discharge instructions
Correct Answer: C. Client with new-onset stridor
Rationale: Stridor indicates possible upper-airway obstruction. Airway problems take priority
under the ABC framework.
9. A postoperative client suddenly becomes restless and has an oxygen saturation of 86%. What
should the nurse do first?
A. Administer the prescribed analgesic
B. Assess airway and breathing and provide oxygen as indicated
C. Document the finding
D. Encourage oral fluids
Correct Answer: B. Assess airway and breathing and provide oxygen as indicated
, Rationale: Restlessness can be an early sign of hypoxemia. The nurse must immediately address
airway and breathing before less urgent interventions. Current NSG 4800 practice materials
emphasize clinical prioritization and emergency response. DocMerit
10. Which client has the greatest priority?
A. Client with a temperature of 37.8°C
B. Client with chronic back pain
C. Client with a respiratory rate of 8/min after receiving an opioid
D. Client requesting a meal
Correct Answer: C. Client with a respiratory rate of 8/min after receiving an opioid
Rationale: Opioids can cause respiratory depression. A respiratory rate of 8/min is potentially
life-threatening and requires immediate assessment and intervention.
11. A nurse is caring for a client who received morphine. Which assessment is the priority?
A. Bowel sounds
B. Skin temperature
C. Respiratory rate and depth
D. Appetite
Correct Answer: C. Respiratory rate and depth
Rationale: Respiratory depression is the most serious acute adverse effect of opioid therapy.
12. Which medication reverses opioid-induced respiratory depression?
A. Protamine sulfate
B. Naloxone
C. Flumazenil
D. Vitamin K
Correct Answer: B. Naloxone
Rationale: Naloxone is an opioid antagonist used to reverse opioid effects, particularly
respiratory depression. Flumazenil reverses benzodiazepine effects.
With Answers Graded A+ Assured
Success
1. A nurse obtains orthostatic vital signs on a client who reports dizziness when standing. Which
finding represents a significant orthostatic blood pressure change?
A. A decrease of 5 mm Hg systolic
B. A decrease of 10 mm Hg systolic
C. A decrease of 20 mm Hg systolic
D. An increase of 10 mm Hg systolic
Correct Answer: C. A decrease of 20 mm Hg systolic
Rationale: A decrease of approximately 20 mm Hg systolic or 10 mm Hg diastolic after position
changes is consistent with orthostatic hypotension. The nurse should protect the client from
falls, assist with position changes, and assess contributing factors such as dehydration or
medications.
2. A client with suspected pulmonary tuberculosis is admitted to the hospital. Which infection-
control intervention is most appropriate?
A. Place the client in a room with positive pressure
B. Wear a surgical mask when entering the room
C. Place the client in a negative-pressure room and use an N95 respirator
D. Use contact precautions only
Correct Answer: C. Place the client in a negative-pressure room and use an N95 respirator
Rationale: Tuberculosis is transmitted through airborne particles. Airborne precautions include
a negative-pressure room and a fit-tested respirator such as an N95. Docsity
3. Which action is appropriate when a nurse discovers a small fire in a client's room?
A. Immediately leave the unit
B. Rescue clients from immediate danger
C. Open the windows
D. Activate the sprinkler system manually
,Correct Answer: B. Rescue clients from immediate danger
Rationale: RACE begins with Rescue clients from immediate danger, followed by Alarm,
Confine, and Extinguish/Evacuate. Safety of clients takes priority.
4. Which action corresponds to the "A" in PASS when using a fire extinguisher?
A. Alert the fire department
B. Aim at the base of the fire
C. Activate the sprinkler
D. Assess the room
Correct Answer: B. Aim at the base of the fire
Rationale: PASS means Pull the pin, Aim at the base, Squeeze the handle, and Sweep from side
to side.
5. Which intervention is part of standard precautions?
A. Using an N95 respirator for every client
B. Wearing gloves when contact with body fluids is anticipated
C. Placing every client in a private room
D. Using a negative-pressure room for all admissions
Correct Answer: B. Wearing gloves when contact with body fluids is anticipated
Rationale: Standard precautions apply to all clients and include hand hygiene and appropriate
personal protective equipment based on the anticipated exposure.
6. A client has Clostridioides difficile infection. Which intervention is most appropriate?
A. Use airborne precautions
B. Use contact precautions and appropriate hand hygiene
C. Use droplet precautions
D. Place the client in a positive-pressure room
Correct Answer: B. Use contact precautions and appropriate hand hygiene
,Rationale: C. difficile requires contact precautions. Hand hygiene is especially important
because alcohol-based hand sanitizer is less effective against spores than soap-and-water
washing.
7. A client with influenza is admitted. Which precaution should the nurse initiate?
A. Airborne
B. Contact only
C. Droplet
D. Protective isolation
Correct Answer: C. Droplet
Rationale: Influenza is primarily transmitted through respiratory droplets. A surgical mask and
appropriate precautions are required.
8. Which client should the nurse assess first?
A. Client requesting assistance with bathing
B. Client with chronic arthritis reporting pain of 5/10
C. Client with new-onset stridor
D. Client waiting for discharge instructions
Correct Answer: C. Client with new-onset stridor
Rationale: Stridor indicates possible upper-airway obstruction. Airway problems take priority
under the ABC framework.
9. A postoperative client suddenly becomes restless and has an oxygen saturation of 86%. What
should the nurse do first?
A. Administer the prescribed analgesic
B. Assess airway and breathing and provide oxygen as indicated
C. Document the finding
D. Encourage oral fluids
Correct Answer: B. Assess airway and breathing and provide oxygen as indicated
, Rationale: Restlessness can be an early sign of hypoxemia. The nurse must immediately address
airway and breathing before less urgent interventions. Current NSG 4800 practice materials
emphasize clinical prioritization and emergency response. DocMerit
10. Which client has the greatest priority?
A. Client with a temperature of 37.8°C
B. Client with chronic back pain
C. Client with a respiratory rate of 8/min after receiving an opioid
D. Client requesting a meal
Correct Answer: C. Client with a respiratory rate of 8/min after receiving an opioid
Rationale: Opioids can cause respiratory depression. A respiratory rate of 8/min is potentially
life-threatening and requires immediate assessment and intervention.
11. A nurse is caring for a client who received morphine. Which assessment is the priority?
A. Bowel sounds
B. Skin temperature
C. Respiratory rate and depth
D. Appetite
Correct Answer: C. Respiratory rate and depth
Rationale: Respiratory depression is the most serious acute adverse effect of opioid therapy.
12. Which medication reverses opioid-induced respiratory depression?
A. Protamine sulfate
B. Naloxone
C. Flumazenil
D. Vitamin K
Correct Answer: B. Naloxone
Rationale: Naloxone is an opioid antagonist used to reverse opioid effects, particularly
respiratory depression. Flumazenil reverses benzodiazepine effects.
