NSG 100
EXAM 4
2026 Q&A
CONTAINS:
✓ Medication administration safety and allergy cross-sensitivity (penicillin vs.
cephalosporins)
✓ Nursing actions when a medication allergy is identified
✓ Deep vein thrombosis (DVT) management and prevention of pulmonary
embolism
✓ Anticoagulant therapy and contraindicated interventions for DVT
✓ Age-related skin changes and appropriate nursing documentation
✓ Post-operative pain management and opioid safety assessments
✓ Respiratory and sedation assessment prior to IV opioid administration
✓ Clean-catch midstream urine specimen collection teaching
✓ Infection control and Contact Precautions (MRSA)
✓ Correct sequence for donning and removing Personal Protective Equipment
(PPE)
✓ NCLEX-style multiple-choice and select-all-that-apply questions
✓ Detailed rationales emphasizing priority actions, safety, and scope of practice
,A nurse is preparing to administer a prescribed medication to a client. The nurse checks the
medication administration record (MAR) and notes that the client has an allergy to penicillin. The
prescribed medication is cefazolin, a cephalosporin. Which of the following actions should the nurse
take first?
A) Administer the medication because cephalosporins are not related to penicillins.
B) Contact the pharmacist to verify if the cross-sensitivity risk is acceptable for this client.
C) Hold the medication and notify the prescribing provider of the client's allergy history.
D) Ask the client if they are willing to take the medication despite the allergy.
Correct Answer: C) Hold the medication and notify the prescribing provider of the client's allergy
history.
Explanation / Rationale:
The correct action is to hold the medication and notify the provider. Cephalosporins have a cross-
sensitivity risk with penicillins; approximately 1% to 10% of patients with a penicillin allergy will also
react to cephalosporins. Patient safety is the priority, and administering a drug with a potential
allergic reaction without clarification is negligent. While the pharmacist (Option B) is a resource, the
primary responsibility for the immediate safety of the specific patient prescription lies with the nurse
and the prescriber. Option A is incorrect because the relationship exists and poses a risk. Option D is
incorrect; a nurse should not coerce a patient to take a medication that could be harmful.
A client is admitted to the medical-surgical unit with a diagnosis of deep vein thrombosis (DVT). The
nurse initiates measures to prevent the extension of the clot and the development of a pulmonary
embolism. Which of the following interventions should the nurse implement? (Select-All-That-Apply)
A) Encourage ambulation as tolerated.
B) Apply sequential compression devices (SCDs).
C) Massage the affected extremity to relieve pain.
D) Administer anticoagulant therapy as prescribed.
E) Maintain the client on bed rest with the affected limb elevated.
Correct Answer: B) Apply sequential compression devices (SCDs), D) Administer anticoagulant
therapy as prescribed, E) Maintain the client on bed rest with the affected limb elevated.
,Explanation / Rationale:
The initial management of DVT typically involves bed rest to prevent dislodgment of the clot and
elevation of the affected limb to promote venous return and reduce edema. Anticoagulant therapy is
the cornerstone of pharmacological treatment to prevent clot propagation. Sequential compression
devices may be used if anticoagulation is contraindicated or as an adjunct, though care is taken not to
apply them directly over the clot if severe. Option A (Ambulation) is generally contraindicated in the
acute phase until therapeutic anticoagulation levels are achieved. Option C (Massaging the extremity)
is absolutely contraindicated as it can dislodge the clot, causing a pulmonary embolism.
While assessing an older adult client, the nurse notes that the client’s skin is thin, fragile, and tears
easily. The nurse documents this finding as which of the following?
A) Pruritus
B) Xerosis
C) Senile purpura
D) Altered skin integrity
Correct Answer: D) Altered skin integrity
Explanation / Rationale:
"Altered skin integrity" is the appropriate nursing diagnosis or documentation term for skin that is not
intact or shows changes in structure. Thin, fragile skin is a common age-related change due to a loss of
subcutaneous fat and decreased elasticity, making it prone to tearing. Pruritus refers to itching.
Xerosis refers to dry skin. Senile purpura refers to benign, flat, purple patches seen on the skin due to
blood vessel fragility, but the description of "tears easily" points more broadly to the structural
integrity issue described in Option D.
A nurse is caring for a client who is post-operative following a total hip replacement. The client is
rated 8/10 on the pain scale. The nurse has a prescription for morphine sulfate 4 mg IV push every 3
hours as needed for pain. Which of the following actions should the nurse take prior to administering
the medication?
A) Check the client’s respiratory rate and sedation level.
B) Encourage the client to use distraction techniques instead of medication.
C) Administer a saline placebo to see if the pain is real.
D) Wait until the pain rating reaches 10/10 to maximize the efficacy of the drug.
, Correct Answer: A) Check the client’s respiratory rate and sedation level.
Explanation / Rationale:
Opioid analgesics like morphine carry the risk of respiratory depression and sedation. Best practice
and safety protocols require the nurse to assess the client’s baseline respiratory rate and level of
consciousness prior to administration. Option B delays necessary pain relief; non-pharmacological
methods should be used in conjunction with medication, not as a replacement for severe pain. Option
C is unethical and violates the patient's right to treatment. Option D is incorrect; pain should be
treated early to prevent stress on the body, rather than waiting for it to become unbearable.
A nurse is instructing a client on the collection of a clean-catch midstream urine specimen. Which of
the following instructions should the nurse include in the teaching?
A) Collect the first few milliliters of urine voided.
B) Cleanse the urethral meatus from back to front.
C) Void a small amount, stop, then collect the midstream portion.
D) Keep the labia or foreskin retracted while voiding into the cup.
Correct Answer: C) Void a small amount, stop, then collect the midstream portion.
Explanation / Rationale:
The purpose of a clean-catch midstream specimen is to obtain a sample free of contamination from
the distal urethra. The initial stream flushes out contaminants; therefore, the client should void a
small amount, stop, and then collect the subsequent midstream flow. Option A is incorrect because the
first void flushes the urethra of contaminants. Option B is incorrect; cleansing should be performed
front to back (for females) to prevent fecal contamination. Option D is incorrect anatomically; the
client cannot void effectively while holding the tissues retracted in a way that blocks the flow; they
separate, cleanse, release, and then void.
EXAM 4
2026 Q&A
CONTAINS:
✓ Medication administration safety and allergy cross-sensitivity (penicillin vs.
cephalosporins)
✓ Nursing actions when a medication allergy is identified
✓ Deep vein thrombosis (DVT) management and prevention of pulmonary
embolism
✓ Anticoagulant therapy and contraindicated interventions for DVT
✓ Age-related skin changes and appropriate nursing documentation
✓ Post-operative pain management and opioid safety assessments
✓ Respiratory and sedation assessment prior to IV opioid administration
✓ Clean-catch midstream urine specimen collection teaching
✓ Infection control and Contact Precautions (MRSA)
✓ Correct sequence for donning and removing Personal Protective Equipment
(PPE)
✓ NCLEX-style multiple-choice and select-all-that-apply questions
✓ Detailed rationales emphasizing priority actions, safety, and scope of practice
,A nurse is preparing to administer a prescribed medication to a client. The nurse checks the
medication administration record (MAR) and notes that the client has an allergy to penicillin. The
prescribed medication is cefazolin, a cephalosporin. Which of the following actions should the nurse
take first?
A) Administer the medication because cephalosporins are not related to penicillins.
B) Contact the pharmacist to verify if the cross-sensitivity risk is acceptable for this client.
C) Hold the medication and notify the prescribing provider of the client's allergy history.
D) Ask the client if they are willing to take the medication despite the allergy.
Correct Answer: C) Hold the medication and notify the prescribing provider of the client's allergy
history.
Explanation / Rationale:
The correct action is to hold the medication and notify the provider. Cephalosporins have a cross-
sensitivity risk with penicillins; approximately 1% to 10% of patients with a penicillin allergy will also
react to cephalosporins. Patient safety is the priority, and administering a drug with a potential
allergic reaction without clarification is negligent. While the pharmacist (Option B) is a resource, the
primary responsibility for the immediate safety of the specific patient prescription lies with the nurse
and the prescriber. Option A is incorrect because the relationship exists and poses a risk. Option D is
incorrect; a nurse should not coerce a patient to take a medication that could be harmful.
A client is admitted to the medical-surgical unit with a diagnosis of deep vein thrombosis (DVT). The
nurse initiates measures to prevent the extension of the clot and the development of a pulmonary
embolism. Which of the following interventions should the nurse implement? (Select-All-That-Apply)
A) Encourage ambulation as tolerated.
B) Apply sequential compression devices (SCDs).
C) Massage the affected extremity to relieve pain.
D) Administer anticoagulant therapy as prescribed.
E) Maintain the client on bed rest with the affected limb elevated.
Correct Answer: B) Apply sequential compression devices (SCDs), D) Administer anticoagulant
therapy as prescribed, E) Maintain the client on bed rest with the affected limb elevated.
,Explanation / Rationale:
The initial management of DVT typically involves bed rest to prevent dislodgment of the clot and
elevation of the affected limb to promote venous return and reduce edema. Anticoagulant therapy is
the cornerstone of pharmacological treatment to prevent clot propagation. Sequential compression
devices may be used if anticoagulation is contraindicated or as an adjunct, though care is taken not to
apply them directly over the clot if severe. Option A (Ambulation) is generally contraindicated in the
acute phase until therapeutic anticoagulation levels are achieved. Option C (Massaging the extremity)
is absolutely contraindicated as it can dislodge the clot, causing a pulmonary embolism.
While assessing an older adult client, the nurse notes that the client’s skin is thin, fragile, and tears
easily. The nurse documents this finding as which of the following?
A) Pruritus
B) Xerosis
C) Senile purpura
D) Altered skin integrity
Correct Answer: D) Altered skin integrity
Explanation / Rationale:
"Altered skin integrity" is the appropriate nursing diagnosis or documentation term for skin that is not
intact or shows changes in structure. Thin, fragile skin is a common age-related change due to a loss of
subcutaneous fat and decreased elasticity, making it prone to tearing. Pruritus refers to itching.
Xerosis refers to dry skin. Senile purpura refers to benign, flat, purple patches seen on the skin due to
blood vessel fragility, but the description of "tears easily" points more broadly to the structural
integrity issue described in Option D.
A nurse is caring for a client who is post-operative following a total hip replacement. The client is
rated 8/10 on the pain scale. The nurse has a prescription for morphine sulfate 4 mg IV push every 3
hours as needed for pain. Which of the following actions should the nurse take prior to administering
the medication?
A) Check the client’s respiratory rate and sedation level.
B) Encourage the client to use distraction techniques instead of medication.
C) Administer a saline placebo to see if the pain is real.
D) Wait until the pain rating reaches 10/10 to maximize the efficacy of the drug.
, Correct Answer: A) Check the client’s respiratory rate and sedation level.
Explanation / Rationale:
Opioid analgesics like morphine carry the risk of respiratory depression and sedation. Best practice
and safety protocols require the nurse to assess the client’s baseline respiratory rate and level of
consciousness prior to administration. Option B delays necessary pain relief; non-pharmacological
methods should be used in conjunction with medication, not as a replacement for severe pain. Option
C is unethical and violates the patient's right to treatment. Option D is incorrect; pain should be
treated early to prevent stress on the body, rather than waiting for it to become unbearable.
A nurse is instructing a client on the collection of a clean-catch midstream urine specimen. Which of
the following instructions should the nurse include in the teaching?
A) Collect the first few milliliters of urine voided.
B) Cleanse the urethral meatus from back to front.
C) Void a small amount, stop, then collect the midstream portion.
D) Keep the labia or foreskin retracted while voiding into the cup.
Correct Answer: C) Void a small amount, stop, then collect the midstream portion.
Explanation / Rationale:
The purpose of a clean-catch midstream specimen is to obtain a sample free of contamination from
the distal urethra. The initial stream flushes out contaminants; therefore, the client should void a
small amount, stop, and then collect the subsequent midstream flow. Option A is incorrect because the
first void flushes the urethra of contaminants. Option B is incorrect; cleansing should be performed
front to back (for females) to prevent fecal contamination. Option D is incorrect anatomically; the
client cannot void effectively while holding the tissues retracted in a way that blocks the flow; they
separate, cleanse, release, and then void.
