NSG 100 EXAM BANK 2026 GERMANNA COLLEGE |
QUESTIONS & ANSWERS WITH RATIONALES
EXAMS 1-4 | NURSING FUNDAMENTALS COMPREHENSIVE
FINAL EXAM STUDY GUIDE LATEST UPDATE –
GUARANTEED PASS
EXAM 1 - FOUNDATIONS OF NURSING PRACTICE (QUESTIONS 1-90)
1. The nurse prioritizes care for a patient who is recovering from a below-the-
knee amputation secondary to complications of diabetes mellitus. Which
intervention is identified as the priority for this patient using Maslow's hierarchy
of needs?
A. The nurse teaches the patient how to properly change dressings on the right-
leg amputation site.
B. The nurse teaches the patient proper home safety techniques to prevent
diabetic wounds.
C. The patient joins the local American Diabetes Association support group.
D. The patient attends classes to deal with body image.
Answer: A
Rationale: When prioritizing care based on Maslow's hierarchy of needs,
physiological needs will come before safety, social, and esteem needs. Caring for
an amputation site is meeting a physiological need. Attending a class to deal with
body-image issues addresses an esteem need. Teaching the patient about safety
techniques to prevent diabetic wounds addresses a safety need. Joining a support
group meets an esteem need.
2. The nurse is prioritizing patient care as low, medium, or high priority for the
current assignment. Which patient should the nurse identify as having a high-
priority circumstance? (Select all that apply.)
A. A patient with emphysema and a pulse oximeter reading of 88 (impaired gas
exchange)
B. A patient who is receiving a blood thinner (Risk for bleeding)
C. A confused older patient (Acute confusion)
1
, D. A patient who is experiencing bouts of diarrhea
E. A patient with congestive heart failure and shortness of breath (Ineffective
breathing pattern)
Answer: A, B, E
Rationale: High-priority circumstances include patients with a risk for bleeding,
such as a patient receiving blood thinners such as warfarin (Coumadin). Impaired
gas exchange (SpO2 of 88) and ineffective breathing pattern (SOB with CHF) are
life-threatening and require immediate intervention. Confusion and diarrhea are
important but not immediately life-threatening.
3. A nurse is preparing to administer medication to a patient. Which of the
following is the nurse's priority action prior to medication administration?
A. Verify the patient's room number
B. Check the patient's identification using two identifiers
C. Ask the patient what medication they are receiving
D. Review the patient's allergies
Answer: B
Rationale: Patient identification using two identifiers (e.g., name and date of
birth) is the priority to ensure the right patient receives the medication. While
reviewing allergies is important, identification comes first to prevent medication
errors.
4. The nurse is caring for a patient who is post-operative day 1 after abdominal
surgery. Which finding requires immediate intervention?
A. Heart rate of 88 beats per minute
B. Respiratory rate of 22 breaths per minute
C. Temperature of 101.2°F (38.4°C)
D. Blood pressure of 118/72 mmHg
Answer: C
Rationale: An elevated temperature (101.2°F) on post-operative day 1 may
indicate infection or other complications and requires immediate intervention.
The other vital signs are within normal limits.
2
,5. A patient is being discharged home after a stroke. The nurse is teaching the
family about safety precautions. Which of the following is the most important
teaching point?
A. Keep the home temperature at 72°F
B. Install grab bars in the bathroom
C. Provide a low-sodium diet
D. Schedule follow-up appointments
Answer: B
Rationale: Fall prevention is a priority safety concern for stroke patients due to
mobility deficits. Grab bars reduce fall risk in the bathroom, where falls commonly
occur.
6. The nurse is assessing a patient's pain level using a 0-10 numeric rating scale.
The patient rates the pain as 8. Which action should the nurse take first?
A. Administer prescribed analgesic medication
B. Reassess pain in 30 minutes
C. Document the pain rating
D. Notify the healthcare provider
Answer: A
Rationale: Severe pain (8/10) requires prompt pharmacological intervention.
The nurse should administer prescribed analgesia and then reassess effectiveness.
7. A nurse is providing oral care to an unconscious patient. Which action is most
important to prevent aspiration?
A. Position the patient in a semi-Fowler's position
B. Turn the patient's head to the side
C. Use a soft toothbrush
D. Apply petroleum jelly to the lips
Answer: B
Rationale: Turning the head to the side allows fluids to drain from the mouth,
preventing aspiration into the airway.
3
, 8. The nurse is preparing to insert a Foley catheter. Which of the following is the
correct order of steps?
A. Cleanse the perineum, open the sterile kit, insert the catheter, inflate the
balloon
B. Open the sterile kit, apply sterile gloves, cleanse the perineum, insert the
catheter, inflate the balloon
C. Apply sterile gloves, open the sterile kit, cleanse the perineum, insert the
catheter, inflate the balloon
D. Open the sterile kit, cleanse the perineum, apply sterile gloves, insert the
catheter, inflate the balloon
Answer: B
Rationale: Maintaining sterility is paramount. The correct sequence is: open
sterile kit, apply sterile gloves, cleanse the perineum with sterile solution, insert
the catheter, then inflate the balloon.
9. A nurse is assessing a patient's skin. The nurse notes an area of non-blanchable
redness over the patient's coccyx. This finding is consistent with which stage of
pressure injury?
A. Stage 1 pressure injury
B. Stage 2 pressure injury
C. Stage 3 pressure injury
D. Deep tissue pressure injury
Answer: A
Rationale: Stage 1 pressure injury presents as intact skin with non-blanchable
erythema. Stage 2 involves partial-thickness skin loss. Stage 3 involves full-
thickness tissue loss.
10. The nurse is teaching a patient about fall prevention in the hospital. Which
statement by the patient indicates a need for further teaching?
A. "I will call for help when I need to get up."
B. "I can get up on my own if I feel steady."
C. "I will keep my call light within reach."
D. "I will wear my non-slip socks."
4
QUESTIONS & ANSWERS WITH RATIONALES
EXAMS 1-4 | NURSING FUNDAMENTALS COMPREHENSIVE
FINAL EXAM STUDY GUIDE LATEST UPDATE –
GUARANTEED PASS
EXAM 1 - FOUNDATIONS OF NURSING PRACTICE (QUESTIONS 1-90)
1. The nurse prioritizes care for a patient who is recovering from a below-the-
knee amputation secondary to complications of diabetes mellitus. Which
intervention is identified as the priority for this patient using Maslow's hierarchy
of needs?
A. The nurse teaches the patient how to properly change dressings on the right-
leg amputation site.
B. The nurse teaches the patient proper home safety techniques to prevent
diabetic wounds.
C. The patient joins the local American Diabetes Association support group.
D. The patient attends classes to deal with body image.
Answer: A
Rationale: When prioritizing care based on Maslow's hierarchy of needs,
physiological needs will come before safety, social, and esteem needs. Caring for
an amputation site is meeting a physiological need. Attending a class to deal with
body-image issues addresses an esteem need. Teaching the patient about safety
techniques to prevent diabetic wounds addresses a safety need. Joining a support
group meets an esteem need.
2. The nurse is prioritizing patient care as low, medium, or high priority for the
current assignment. Which patient should the nurse identify as having a high-
priority circumstance? (Select all that apply.)
A. A patient with emphysema and a pulse oximeter reading of 88 (impaired gas
exchange)
B. A patient who is receiving a blood thinner (Risk for bleeding)
C. A confused older patient (Acute confusion)
1
, D. A patient who is experiencing bouts of diarrhea
E. A patient with congestive heart failure and shortness of breath (Ineffective
breathing pattern)
Answer: A, B, E
Rationale: High-priority circumstances include patients with a risk for bleeding,
such as a patient receiving blood thinners such as warfarin (Coumadin). Impaired
gas exchange (SpO2 of 88) and ineffective breathing pattern (SOB with CHF) are
life-threatening and require immediate intervention. Confusion and diarrhea are
important but not immediately life-threatening.
3. A nurse is preparing to administer medication to a patient. Which of the
following is the nurse's priority action prior to medication administration?
A. Verify the patient's room number
B. Check the patient's identification using two identifiers
C. Ask the patient what medication they are receiving
D. Review the patient's allergies
Answer: B
Rationale: Patient identification using two identifiers (e.g., name and date of
birth) is the priority to ensure the right patient receives the medication. While
reviewing allergies is important, identification comes first to prevent medication
errors.
4. The nurse is caring for a patient who is post-operative day 1 after abdominal
surgery. Which finding requires immediate intervention?
A. Heart rate of 88 beats per minute
B. Respiratory rate of 22 breaths per minute
C. Temperature of 101.2°F (38.4°C)
D. Blood pressure of 118/72 mmHg
Answer: C
Rationale: An elevated temperature (101.2°F) on post-operative day 1 may
indicate infection or other complications and requires immediate intervention.
The other vital signs are within normal limits.
2
,5. A patient is being discharged home after a stroke. The nurse is teaching the
family about safety precautions. Which of the following is the most important
teaching point?
A. Keep the home temperature at 72°F
B. Install grab bars in the bathroom
C. Provide a low-sodium diet
D. Schedule follow-up appointments
Answer: B
Rationale: Fall prevention is a priority safety concern for stroke patients due to
mobility deficits. Grab bars reduce fall risk in the bathroom, where falls commonly
occur.
6. The nurse is assessing a patient's pain level using a 0-10 numeric rating scale.
The patient rates the pain as 8. Which action should the nurse take first?
A. Administer prescribed analgesic medication
B. Reassess pain in 30 minutes
C. Document the pain rating
D. Notify the healthcare provider
Answer: A
Rationale: Severe pain (8/10) requires prompt pharmacological intervention.
The nurse should administer prescribed analgesia and then reassess effectiveness.
7. A nurse is providing oral care to an unconscious patient. Which action is most
important to prevent aspiration?
A. Position the patient in a semi-Fowler's position
B. Turn the patient's head to the side
C. Use a soft toothbrush
D. Apply petroleum jelly to the lips
Answer: B
Rationale: Turning the head to the side allows fluids to drain from the mouth,
preventing aspiration into the airway.
3
, 8. The nurse is preparing to insert a Foley catheter. Which of the following is the
correct order of steps?
A. Cleanse the perineum, open the sterile kit, insert the catheter, inflate the
balloon
B. Open the sterile kit, apply sterile gloves, cleanse the perineum, insert the
catheter, inflate the balloon
C. Apply sterile gloves, open the sterile kit, cleanse the perineum, insert the
catheter, inflate the balloon
D. Open the sterile kit, cleanse the perineum, apply sterile gloves, insert the
catheter, inflate the balloon
Answer: B
Rationale: Maintaining sterility is paramount. The correct sequence is: open
sterile kit, apply sterile gloves, cleanse the perineum with sterile solution, insert
the catheter, then inflate the balloon.
9. A nurse is assessing a patient's skin. The nurse notes an area of non-blanchable
redness over the patient's coccyx. This finding is consistent with which stage of
pressure injury?
A. Stage 1 pressure injury
B. Stage 2 pressure injury
C. Stage 3 pressure injury
D. Deep tissue pressure injury
Answer: A
Rationale: Stage 1 pressure injury presents as intact skin with non-blanchable
erythema. Stage 2 involves partial-thickness skin loss. Stage 3 involves full-
thickness tissue loss.
10. The nurse is teaching a patient about fall prevention in the hospital. Which
statement by the patient indicates a need for further teaching?
A. "I will call for help when I need to get up."
B. "I can get up on my own if I feel steady."
C. "I will keep my call light within reach."
D. "I will wear my non-slip socks."
4
