NSG 300 Exam 2 | (2026) Nursing Exam Questions
| Foundations (PDF)
1. A nurse is caring for a patient who is confused and
attempting to get out of bed. Which action should the
nurse take first?
a) Apply wrist restraints
b) Raise all four side rails
c) Assign a sitter to stay with the patient
d) Place the bed in the lowest position
Answer: d) Place the bed in the lowest position
Rationale: The least restrictive intervention is lowering the
bed to reduce injury risk from a fall. Restraints and side
rails require orders and increase risk of
entrapment/injury. A sitter is appropriate but not first.
2. Which patient is at highest risk for falls?
a) 45-year-old post-op day 2, ambulating independently
b) 80-year-old with history of stroke, taking
1
,antihypertensives
c) 30-year-old with ankle sprain using crutches
d) 60-year-old with mild arthritis
Answer: b) 80-year-old with history of stroke, taking
antihypertensives
Rationale: Advanced age + stroke (motor/cognitive
deficits) + antihypertensives (orthostatic hypotension)
create multiple fall risk factors.
3. A nurse teaches a patient to use a walker. Which gait
pattern is correct for a patient with bilateral leg
weakness?
a) Advance walker, then left foot, then right foot
b) Advance left foot, right foot, then walker
c) Advance walker, then both feet together
d) Advance right foot, walker, left foot
Answer: a) Advance walker, then left foot, then right foot
Rationale: The swing-to or swing-through gait (walker first,
2
,then weaker leg, then stronger leg) provides maximum
stability for bilateral weakness.
4. Which finding indicates proper crutch fit?
a) 2-3 finger widths between axillary rest and axilla
b) Elbows flexed 45° when holding handgrips
c) Crutches placed 24 inches in front of feet
d) Wrist rests directly on axillary bar
Answer: a) 2-3 finger widths between axillary rest and
axilla
Rationale: Prevents brachial plexus injury. Elbows should
be flexed ~30°, not 45°.
5. A patient is on a continuous IV morphine infusion. What
safety intervention is most important?
a) Assess pain every 4 hours
b) Monitor respiratory rate every 1-2 hours
3
, c) Keep naloxone at bedside
d) Check IV site every shift
Answer: b) Monitor respiratory rate every 1-2 hours
*Rationale: Opioids cause respiratory depression;
continuous infusion requires frequent monitoring (q1-2h).
Naloxone should be available but not the top priority
action.*
6. A patient uses a cane. The nurse instructs the patient to
hold the cane on which side?
a) Opposite the weak leg
b) Same side as the weak leg
c) Opposite the strong leg
d) In whichever hand is dominant
Answer: a) Opposite the weak leg
Rationale: Cane on strong side widens base of support
and reduces load on weak side.
4
| Foundations (PDF)
1. A nurse is caring for a patient who is confused and
attempting to get out of bed. Which action should the
nurse take first?
a) Apply wrist restraints
b) Raise all four side rails
c) Assign a sitter to stay with the patient
d) Place the bed in the lowest position
Answer: d) Place the bed in the lowest position
Rationale: The least restrictive intervention is lowering the
bed to reduce injury risk from a fall. Restraints and side
rails require orders and increase risk of
entrapment/injury. A sitter is appropriate but not first.
2. Which patient is at highest risk for falls?
a) 45-year-old post-op day 2, ambulating independently
b) 80-year-old with history of stroke, taking
1
,antihypertensives
c) 30-year-old with ankle sprain using crutches
d) 60-year-old with mild arthritis
Answer: b) 80-year-old with history of stroke, taking
antihypertensives
Rationale: Advanced age + stroke (motor/cognitive
deficits) + antihypertensives (orthostatic hypotension)
create multiple fall risk factors.
3. A nurse teaches a patient to use a walker. Which gait
pattern is correct for a patient with bilateral leg
weakness?
a) Advance walker, then left foot, then right foot
b) Advance left foot, right foot, then walker
c) Advance walker, then both feet together
d) Advance right foot, walker, left foot
Answer: a) Advance walker, then left foot, then right foot
Rationale: The swing-to or swing-through gait (walker first,
2
,then weaker leg, then stronger leg) provides maximum
stability for bilateral weakness.
4. Which finding indicates proper crutch fit?
a) 2-3 finger widths between axillary rest and axilla
b) Elbows flexed 45° when holding handgrips
c) Crutches placed 24 inches in front of feet
d) Wrist rests directly on axillary bar
Answer: a) 2-3 finger widths between axillary rest and
axilla
Rationale: Prevents brachial plexus injury. Elbows should
be flexed ~30°, not 45°.
5. A patient is on a continuous IV morphine infusion. What
safety intervention is most important?
a) Assess pain every 4 hours
b) Monitor respiratory rate every 1-2 hours
3
, c) Keep naloxone at bedside
d) Check IV site every shift
Answer: b) Monitor respiratory rate every 1-2 hours
*Rationale: Opioids cause respiratory depression;
continuous infusion requires frequent monitoring (q1-2h).
Naloxone should be available but not the top priority
action.*
6. A patient uses a cane. The nurse instructs the patient to
hold the cane on which side?
a) Opposite the weak leg
b) Same side as the weak leg
c) Opposite the strong leg
d) In whichever hand is dominant
Answer: a) Opposite the weak leg
Rationale: Cane on strong side widens base of support
and reduces load on weak side.
4
