NRSG 100 Exam 4 V3 | NRSG 100 Fundamentals of
Nursing | Actual Q&A with Rationale (NRSG100
Exam 4) | Ivy Tech
1. A nurse is caring for a client who is 24 hours postoperative following abdominal surgery.
The client reports pain as a 7 on a scale of 0 to 10. Which of the following actions should the
nurse take first?
A. Administer the prescribed opioid analgesic.
B. Assist the client to splint the incision while coughing.
C. Assess the client’s vital signs and the surgical site.
D. Document the client’s report of pain in the medical record.
Correct Answer: C
Explanation: The first step of the nursing process is assessment, so the nurse must gather
more data before intervening. Checking vital signs helps determine if the pain is associated
with complications like hemorrhage or infection. Once assessment is complete, the nurse
can then proceed with pharmacological or non-pharmacological interventions.
2. A nurse is preparing to administer oxygen via a nasal cannula to a client with COPD. Which
of the following flow rates is most appropriate for this client?
A. 1 to 2 L/min
B. 4 to 6 L/min
,C. 8 to 10 L/min
D. 12 to 15 L/min
Correct Answer: A
Explanation: Clients with COPD often rely on a hypoxic drive to breathe, and high levels of
supplemental oxygen can suppress this drive. A low flow rate of 1 to 2 L/min is typically
recommended to maintain adequate oxygenation without causing respiratory depression.
The nurse must monitor the client’s respiratory rate and oxygen saturation closely.
3. Which of the following is a primary responsibility of the nurse when obtaining informed
consent for a surgical procedure?
A. Explaining the risks and benefits of the surgery to the client.
B. Describing alternative treatments available to the client.
C. Witnessing the client’s signature on the consent form.
D. Obtaining the signature from the next of kin if the client is sedated.
Correct Answer: C
Explanation: The nurse’s role in informed consent is to act as a witness to the client’s
voluntary signature. It is the surgeon’s legal responsibility to explain the procedure, risks,
and alternatives. The nurse should also ensure that the client appears competent and
understands that they have the right to refuse.
, 4. A nurse is caring for a client who has a prescription for incentive spirometry every hour
while awake. Which of the following instructions should the nurse include?
A. Inhale slowly and deeply through the mouthpiece.
B. Exhale forcefully into the mouthpiece.
C. Hold your breath for at least 15 seconds after inhalation.
D. Clean the mouthpiece with alcohol after each use.
Correct Answer: A
Explanation: Incentive spirometry is designed to promote deep breathing and prevent
atelectasis by encouraging maximal inspiration. The client should be taught to inhale
slowly to keep the indicator at the target level and hold the breath for 3 to 5 seconds. This
exercise helps expand the lower lobes of the lungs and improve gas exchange.
5. A nurse is assessing a client for obstructive sleep apnea (OSA). Which of the following
findings should the nurse expect?
A. Hypotension during sleep.
B. Increased appetite and weight loss.
C. Excessive daytime sleepiness.
D. Decreased neck circumference.
Correct Answer: C
Nursing | Actual Q&A with Rationale (NRSG100
Exam 4) | Ivy Tech
1. A nurse is caring for a client who is 24 hours postoperative following abdominal surgery.
The client reports pain as a 7 on a scale of 0 to 10. Which of the following actions should the
nurse take first?
A. Administer the prescribed opioid analgesic.
B. Assist the client to splint the incision while coughing.
C. Assess the client’s vital signs and the surgical site.
D. Document the client’s report of pain in the medical record.
Correct Answer: C
Explanation: The first step of the nursing process is assessment, so the nurse must gather
more data before intervening. Checking vital signs helps determine if the pain is associated
with complications like hemorrhage or infection. Once assessment is complete, the nurse
can then proceed with pharmacological or non-pharmacological interventions.
2. A nurse is preparing to administer oxygen via a nasal cannula to a client with COPD. Which
of the following flow rates is most appropriate for this client?
A. 1 to 2 L/min
B. 4 to 6 L/min
,C. 8 to 10 L/min
D. 12 to 15 L/min
Correct Answer: A
Explanation: Clients with COPD often rely on a hypoxic drive to breathe, and high levels of
supplemental oxygen can suppress this drive. A low flow rate of 1 to 2 L/min is typically
recommended to maintain adequate oxygenation without causing respiratory depression.
The nurse must monitor the client’s respiratory rate and oxygen saturation closely.
3. Which of the following is a primary responsibility of the nurse when obtaining informed
consent for a surgical procedure?
A. Explaining the risks and benefits of the surgery to the client.
B. Describing alternative treatments available to the client.
C. Witnessing the client’s signature on the consent form.
D. Obtaining the signature from the next of kin if the client is sedated.
Correct Answer: C
Explanation: The nurse’s role in informed consent is to act as a witness to the client’s
voluntary signature. It is the surgeon’s legal responsibility to explain the procedure, risks,
and alternatives. The nurse should also ensure that the client appears competent and
understands that they have the right to refuse.
, 4. A nurse is caring for a client who has a prescription for incentive spirometry every hour
while awake. Which of the following instructions should the nurse include?
A. Inhale slowly and deeply through the mouthpiece.
B. Exhale forcefully into the mouthpiece.
C. Hold your breath for at least 15 seconds after inhalation.
D. Clean the mouthpiece with alcohol after each use.
Correct Answer: A
Explanation: Incentive spirometry is designed to promote deep breathing and prevent
atelectasis by encouraging maximal inspiration. The client should be taught to inhale
slowly to keep the indicator at the target level and hold the breath for 3 to 5 seconds. This
exercise helps expand the lower lobes of the lungs and improve gas exchange.
5. A nurse is assessing a client for obstructive sleep apnea (OSA). Which of the following
findings should the nurse expect?
A. Hypotension during sleep.
B. Increased appetite and weight loss.
C. Excessive daytime sleepiness.
D. Decreased neck circumference.
Correct Answer: C
