NUR 1023 FSCJ FINAL EXAM/ FSCJ 1023 NUR FINAL EXAM
QUESTIONS AND CORRECT DETAILED ANSWERS A NEW
UPDATED VERSION LATEST 2026-2027 NEWEST UPDATED
QUESTIONS AND ANSWERS WITH DETAILED RATIONALES (
VERIFIED ANSWERS) ALREADY GRADED A+
1. A nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who has oxygen ordered at 2 L/min
via nasal cannula. The client’s spouse asks why the flow rate is low. What is the best response by the nurse?
A. “High oxygen levels can decrease the client’s respiratory drive.”
B. “The client’s lungs cannot tolerate higher flow rates.”
C. “Low flow prevents oxygen toxicity to the alveoli.”
D. “Higher flow would cause severe coughing episodes.”
Rationale: Clients with COPD may have chronic hypercapnia and rely on a hypoxic drive to breathe. High oxygen
concentrations can reduce this drive, leading to hypoventilation and respiratory failure. Correct Answer: A
2. A nurse is assessing a post-operative client for pain. The client describes the pain as 8 on a 0–10 scale and refuses
medication, stating, “I don’t want to become addicted.” What is the nurse’s priority response?
A. “Addiction is rare in hospitalized clients receiving opioids for acute pain.”
B. “You should wait until the pain is severe before taking medication.”
C. “Let’s discuss non-pharmacological methods like repositioning.”
D. “I will document that you refused the medication.”
Rationale: The nurse must first address the client’s concern about addiction with accurate information. In acute pain,
addiction risk is low. Education promotes informed decision-making and pain management. Correct Answer: A
3. Which of the following assessment findings in a client receiving a blood transfusion most likely indicates an acute
hemolytic reaction?
A. Urticaria and itching
B. Fever and chills
C. Lower back pain and dark urine
D. Wheezing and dyspnea
Rationale: Acute hemolytic reactions occur from ABO incompatibility. Hemoglobin released from destroyed RBCs
causes dark urine and renal pain (often lower back). Urticaria suggests allergic reaction; fever/chills are febrile reactions;
wheezing suggests anaphylaxis. Correct Answer: C
4. A nurse is preparing to insert a nasogastric (NG) tube for gastric decompression. In which position should the nurse
place the client?
A. Supine with head flat
B. High Fowler’s with head tilted forward
,C. Left lateral recumbent
D. Trendelenburg position
Rationale: High Fowler’s with head tilted forward closes the trachea and opens the esophagus, facilitating passage of the
NG tube into the esophagus rather than the trachea. Correct Answer: B
5. A client with heart failure has crackles in both lungs, jugular vein distention, and 3+ pitting edema in the lower
extremities. Which dietary modification is most important for the nurse to emphasize?
A. Increase potassium-rich foods
B. *Restrict sodium intake to less than 2 grams/day*
C. Limit fluid intake to 1 liter/day
D. Increase protein consumption
Rationale: Sodium restriction reduces fluid retention in heart failure by decreasing osmotic pressure that holds water in
tissues. Fluid restriction may be added later, but sodium restriction is primary. Correct Answer: B
6. A nurse is assessing an older adult client for dehydration. Which finding is most indicative of fluid volume deficit?
A. Bounding radial pulse
B. Tenting of skin over the sternum
C. Jugular vein distention
D. Crackles in lung bases
Rationale: Tenting (decreased skin turgor) is a late sign of dehydration in older adults due to loss of skin elasticity.
Bounding pulse and JVD indicate fluid overload; crackles suggest pulmonary congestion. Correct Answer: B
7. A client is being discharged on warfarin (Coumadin) after a pulmonary embolism. Which statement by the client
indicates a need for further teaching?
A. “I will eat green leafy vegetables in the same amounts each week.”
B. “I will use a soft toothbrush and electric razor.”
C. “I will take ibuprofen if I get a headache.”
D. “I will have my blood tested regularly for INR levels.”
Rationale: Ibuprofen (NSAID) increases bleeding risk when taken with warfarin. Acetaminophen is safer for pain/
headache. Green leafy vegetables contain vitamin K but can be eaten consistently to maintain stable INR. Correct
Answer: C
8. Which nursing intervention is most effective in preventing ventilator-associated pneumonia (VAP)?
A. Changing the ventilator circuit daily
B. Elevating the head of the bed to 30–45 degrees
C. Suctioning the endotracheal tube every hour
D. Administering prophylactic antibiotics
Rationale: Elevating HOB 30–45° reduces aspiration of gastric contents, a major cause of VAP. Routine circuit changes
are not recommended. Prophylactic antibiotics promote resistance. Correct Answer: B
9. A nurse is providing discharge teaching to a client with a new colostomy. Which statement indicates correct
understanding?
, A. “I will change the ostomy appliance every day.”
B. “I should expect my stool to be liquid and foul-smelling.”
C. “I will avoid carbonated drinks to reduce gas.”
D. “I can take enteric-coated medications as usual.”
Rationale: Carbonated beverages increase gas production, which can distend the colostomy bag and cause discomfort.
Ostomy appliances are changed every 3–7 days. Stool consistency varies by colostomy location. Enteric-coated
medications may not dissolve properly. Correct Answer: C
10. A client with diabetes mellitus type 2 has a blood glucose level of 52 mg/dL and is unconscious. What is the nurse’s
priority action?
A. Give 15 g of oral glucose paste
B. Administer 50% dextrose IV push
C. Inject 1 mg of glucagon subcutaneously
D. Recheck blood glucose in 15 minutes
Rationale: Unconscious clients cannot swallow safely, so IV dextrose is required to rapidly raise blood glucose. Glucagon
is an alternative if no IV access, but IV dextrose is first-line in hospital settings. Correct Answer: B
11. A nurse is performing tracheostomy care. Which action demonstrates proper aseptic technique?
A. Using the same cotton ball to clean each side of the stoma
B. Applying sterile gloves before handling the new inner cannula
C. Reusing the suction catheter for multiple passes
D. Cleaning the stoma with hydrogen peroxide
Rationale: Sterile gloves maintain sterility of the inner cannula. Each cotton ball should be used once. Suction catheters
are single-use. Hydrogen peroxide can irritate stoma tissue; normal saline is preferred. Correct Answer: B
12. Which client is at highest risk for developing a pressure injury?
A. A client with urinary incontinence who is ambulatory
B. *An 85-year-old client with immobility and fecal incontinence*
C. A client with a fractured femur on bed rest for 2 days
D. A client with diabetes who wears compression stockings
Rationale: Immobility, advanced age, and fecal incontinence (which contains enzymes that damage skin) are major risk
factors. Urinary incontinence alone is less damaging than fecal. Correct Answer: B
13. A nurse is monitoring a client receiving IV furosemide (Lasix). Which finding requires immediate intervention?
A. Serum potassium of 3.8 mEq/L
B. Complaint of ringing in the ears
C. Urinary output of 200 mL in 2 hours
D. Blood pressure of 110/70 mm Hg
Rationale: Tinnitus indicates ototoxicity, a serious adverse effect of loop diuretics. Potassium 3.8 is normal. Urine output
200 mL/2 hours is adequate. BP 110/70 is acceptable. Correct Answer: B
QUESTIONS AND CORRECT DETAILED ANSWERS A NEW
UPDATED VERSION LATEST 2026-2027 NEWEST UPDATED
QUESTIONS AND ANSWERS WITH DETAILED RATIONALES (
VERIFIED ANSWERS) ALREADY GRADED A+
1. A nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who has oxygen ordered at 2 L/min
via nasal cannula. The client’s spouse asks why the flow rate is low. What is the best response by the nurse?
A. “High oxygen levels can decrease the client’s respiratory drive.”
B. “The client’s lungs cannot tolerate higher flow rates.”
C. “Low flow prevents oxygen toxicity to the alveoli.”
D. “Higher flow would cause severe coughing episodes.”
Rationale: Clients with COPD may have chronic hypercapnia and rely on a hypoxic drive to breathe. High oxygen
concentrations can reduce this drive, leading to hypoventilation and respiratory failure. Correct Answer: A
2. A nurse is assessing a post-operative client for pain. The client describes the pain as 8 on a 0–10 scale and refuses
medication, stating, “I don’t want to become addicted.” What is the nurse’s priority response?
A. “Addiction is rare in hospitalized clients receiving opioids for acute pain.”
B. “You should wait until the pain is severe before taking medication.”
C. “Let’s discuss non-pharmacological methods like repositioning.”
D. “I will document that you refused the medication.”
Rationale: The nurse must first address the client’s concern about addiction with accurate information. In acute pain,
addiction risk is low. Education promotes informed decision-making and pain management. Correct Answer: A
3. Which of the following assessment findings in a client receiving a blood transfusion most likely indicates an acute
hemolytic reaction?
A. Urticaria and itching
B. Fever and chills
C. Lower back pain and dark urine
D. Wheezing and dyspnea
Rationale: Acute hemolytic reactions occur from ABO incompatibility. Hemoglobin released from destroyed RBCs
causes dark urine and renal pain (often lower back). Urticaria suggests allergic reaction; fever/chills are febrile reactions;
wheezing suggests anaphylaxis. Correct Answer: C
4. A nurse is preparing to insert a nasogastric (NG) tube for gastric decompression. In which position should the nurse
place the client?
A. Supine with head flat
B. High Fowler’s with head tilted forward
,C. Left lateral recumbent
D. Trendelenburg position
Rationale: High Fowler’s with head tilted forward closes the trachea and opens the esophagus, facilitating passage of the
NG tube into the esophagus rather than the trachea. Correct Answer: B
5. A client with heart failure has crackles in both lungs, jugular vein distention, and 3+ pitting edema in the lower
extremities. Which dietary modification is most important for the nurse to emphasize?
A. Increase potassium-rich foods
B. *Restrict sodium intake to less than 2 grams/day*
C. Limit fluid intake to 1 liter/day
D. Increase protein consumption
Rationale: Sodium restriction reduces fluid retention in heart failure by decreasing osmotic pressure that holds water in
tissues. Fluid restriction may be added later, but sodium restriction is primary. Correct Answer: B
6. A nurse is assessing an older adult client for dehydration. Which finding is most indicative of fluid volume deficit?
A. Bounding radial pulse
B. Tenting of skin over the sternum
C. Jugular vein distention
D. Crackles in lung bases
Rationale: Tenting (decreased skin turgor) is a late sign of dehydration in older adults due to loss of skin elasticity.
Bounding pulse and JVD indicate fluid overload; crackles suggest pulmonary congestion. Correct Answer: B
7. A client is being discharged on warfarin (Coumadin) after a pulmonary embolism. Which statement by the client
indicates a need for further teaching?
A. “I will eat green leafy vegetables in the same amounts each week.”
B. “I will use a soft toothbrush and electric razor.”
C. “I will take ibuprofen if I get a headache.”
D. “I will have my blood tested regularly for INR levels.”
Rationale: Ibuprofen (NSAID) increases bleeding risk when taken with warfarin. Acetaminophen is safer for pain/
headache. Green leafy vegetables contain vitamin K but can be eaten consistently to maintain stable INR. Correct
Answer: C
8. Which nursing intervention is most effective in preventing ventilator-associated pneumonia (VAP)?
A. Changing the ventilator circuit daily
B. Elevating the head of the bed to 30–45 degrees
C. Suctioning the endotracheal tube every hour
D. Administering prophylactic antibiotics
Rationale: Elevating HOB 30–45° reduces aspiration of gastric contents, a major cause of VAP. Routine circuit changes
are not recommended. Prophylactic antibiotics promote resistance. Correct Answer: B
9. A nurse is providing discharge teaching to a client with a new colostomy. Which statement indicates correct
understanding?
, A. “I will change the ostomy appliance every day.”
B. “I should expect my stool to be liquid and foul-smelling.”
C. “I will avoid carbonated drinks to reduce gas.”
D. “I can take enteric-coated medications as usual.”
Rationale: Carbonated beverages increase gas production, which can distend the colostomy bag and cause discomfort.
Ostomy appliances are changed every 3–7 days. Stool consistency varies by colostomy location. Enteric-coated
medications may not dissolve properly. Correct Answer: C
10. A client with diabetes mellitus type 2 has a blood glucose level of 52 mg/dL and is unconscious. What is the nurse’s
priority action?
A. Give 15 g of oral glucose paste
B. Administer 50% dextrose IV push
C. Inject 1 mg of glucagon subcutaneously
D. Recheck blood glucose in 15 minutes
Rationale: Unconscious clients cannot swallow safely, so IV dextrose is required to rapidly raise blood glucose. Glucagon
is an alternative if no IV access, but IV dextrose is first-line in hospital settings. Correct Answer: B
11. A nurse is performing tracheostomy care. Which action demonstrates proper aseptic technique?
A. Using the same cotton ball to clean each side of the stoma
B. Applying sterile gloves before handling the new inner cannula
C. Reusing the suction catheter for multiple passes
D. Cleaning the stoma with hydrogen peroxide
Rationale: Sterile gloves maintain sterility of the inner cannula. Each cotton ball should be used once. Suction catheters
are single-use. Hydrogen peroxide can irritate stoma tissue; normal saline is preferred. Correct Answer: B
12. Which client is at highest risk for developing a pressure injury?
A. A client with urinary incontinence who is ambulatory
B. *An 85-year-old client with immobility and fecal incontinence*
C. A client with a fractured femur on bed rest for 2 days
D. A client with diabetes who wears compression stockings
Rationale: Immobility, advanced age, and fecal incontinence (which contains enzymes that damage skin) are major risk
factors. Urinary incontinence alone is less damaging than fecal. Correct Answer: B
13. A nurse is monitoring a client receiving IV furosemide (Lasix). Which finding requires immediate intervention?
A. Serum potassium of 3.8 mEq/L
B. Complaint of ringing in the ears
C. Urinary output of 200 mL in 2 hours
D. Blood pressure of 110/70 mm Hg
Rationale: Tinnitus indicates ototoxicity, a serious adverse effect of loop diuretics. Potassium 3.8 is normal. Urine output
200 mL/2 hours is adequate. BP 110/70 is acceptable. Correct Answer: B
