NURSING 101 FINAL EXAM PRACTICE QUESTIONS WITH VERIFIED
CORRECT ANSWERS 2027 EDITION
1. A postoperative client is moving from the bed to a chair when blood drips from the dressing. The
nurse assesses the incision and notes evisceration. What does the nurse do first? Call the health care
provider Cover the protruding organ with sterile dressings moistened with sterile saline Have the
client lay on the back with the head elevated Instruct the client to remain quiet
Have the client lay on the back with the head elevated R: A wound evisceration occurs when the wound
completely separates, and the internal organs protrude. If disruption of a wound occurs, the client is
placed in the low Fowler's position and instructed to lie quietly. These actions minimize the protrusion of
body tissues. The protruding coils of the intestine are covered with sterile dressings moistened with sterile
saline solution, and the surgeon is notified at once.
2. A client who is deaf without bilateral hearing aids has them removed in preparation for a surgical
procedure. Which action(s) will the nurse take to communicate with this client? Select all that apply.
Provide written information. Speak slowly so the client can lip read. Plan for a sign language
interpreter. Use hand gestures to communicate. Talk loudly into one of the client's ears.
Provide written information. Provide written information. Speak slowly so the client can lip read. Plan for a
sign language interpreter. R: Special considerations for clients with physical disabilities include the need
for appropriate assistive devices, modifications in preoperative education, and additional assistance with
communication. If the client is deaf when bilateral hearing aids are removed, an alternative form of
communication needs to be planned such as providing written information, using gestures, speaking
slowly so the client can lip read, and planning for an interpreter to provide sign language. Talking loudly
into one ear will not be effective because the client is deaf when the hearing aids are removed.
3. A perioperative nurse is participating in an interdisciplinary audit of infection control practices in
the surgical department. Which action is a basic guideline for maintaining surgical asepsis? Select all
that apply. Sterile surfaces or articles may touch other sterile surfaces. The outer lip of a sterile
solution is considered sterile. Only the top surface of a draped table is considered sterile. Sterile
supplies can be used on another client if the packages are intact. The scrub nurse may pour a sterile
solution from a nonsterile bottle.
Sterile surfaces or articles may touch other sterile surfaces. Only the top surface of a draped table is
considered sterile. R: Basic guidelines for maintaining sterile technique include that sterile surfaces or
articles may touch other sterile surfaces only and only the top surface of a draped table is considered
sterile. The other options each constitute a break in sterile technique.
4. The nurse, in collaboration with the client's family, is determining priorities related to the care of
the client. The nurse explains that it is important to consider the urgency of specific problems when
setting priorities. What should the nurse adopt as the best framework for prioritizing client problems?
Family member statements The nurse's skill set Maslow hierarchy of needs Availability of hospital
resources
Maslow hierarchy of needs R: The Maslow hierarchy of needs provides a useful framework for prioritizing
problems, with the first level given to meeting physical needs of the client. Availability of hospital
resources, family member statements, and nursing skill do not provide a framework for prioritization of
client problems, although each may be considered.
1
,5. A client was admitted to the hospital unit after 2 days of vomiting and diarrhea. The client's spouse
became alarmed when the client demonstrated confusion and elevated temperature, and reported
"dry mouth." The nurse suspects the client is experiencing which condition? hyperkalemia
hypercalcemia dehydration hypervolemia
dehydration R: Dehydration results when the volume of body fluid is significantly reduced in both
extracellular and intracellular compartments. In dehydration, all fluid compartments have decreased
volumes; in hypovolemia, only blood volume is low. The most common fluid imbalance in older adults is
dehydration. Hypervolemia is caused by fluid intake that exceeds fluid loss, such as from excessive oral
intake or rapid IV infusion of fluid. Early signs of hypervolemia are weight gain, elevated BP, and increased
breathing effort. Hypercalcemia occurs when the serum calcium level is higher than normal. Some of its
signs include tingling in the extremities and the area around the mouth (circumoral paresthesia) and
muscle and abdominal cramps. Hyperkalemia is an excess of potassium in the blood. Symptoms include
diarrhea, nausea, muscle weakness, paresthesias, and cardiac dysrhythmias.
6. The nurse is taking the client into the operating room (OR) when the client informs the nurse that
the client's grandparent spiked a very high temperature in the OR and nearly died 15 years ago. What
relevance does this information have regarding the client? The client may be experiencing presurgical
anxiety. The grandparent's surgery has minimal relevance to the client's surgery. The client may be at
risk for a sudden onset of postsurgical infection. The client may be at risk for malignant hyperthermia.
The client may be at risk for malignant hyperthermia. R: Malignant hyperthermia is an inherited muscle
disorder chemically induced by anesthetic agents. Identifying clients at risk is imperative because the
mortality rate is 50%. The client's anxiety is not relevant, the grandparent's surgery is very relevant, and all
clients are at risk for surgical infections.
7. While making an initial shift assessment the nurse notes that the client's peripheral IV site appears
edematous around the insertion site. How should the existence of this complication be documented
by the nurse? Infiltration Phlebitis Fluid overload Air emboli
Infiltration R: Infiltration is the administration of nonvesicant solution or medication into the surrounding
tissue. This can occur when the IV cannula dislodges or perforates the wall of the vein. Infiltration is
characterized by edema around the insertion site, leakage of IV fluid from the insertion site, discomfort
and coolness in the area of infiltration, and a significant decrease in the flow rate. Air emboli, phlebitis, and
fluid overload are not indications of infiltration.
8. An 80-year-old client is being admitted for dehydration and syncope. The client is found to be
hypotensive, and intravenous fluids are ordered. What are some teaching strategies that the nurse
should review with this client? Before ambulation the client should rise slowly and take mini breaks
between lying, sitting, and standing. The client must use a rolling walker and call for assistance with
any change in position. The temperature in the room should stay very hot, and bathing in hot water is
appropriate. Increase consumption of meals to three times a day, with the largest meal being at
breakfast.
Before ambulation the client should rise slowly and take mini breaks between lying, sitting, and standing.
R: A client experiencing hypotension should rise slowly. The client should consider having five or six small
meals a day to minimize hypotension that can occur after a large meal. Extremes in temperature,
especially hot showers, should be avoided. Hot temperatures can cause an increase in blood flow and
cause dizziness. Every client does not need a rolling walker. Changes in position, especially in bed, should
be done independently and often to prevent pressure ulcers.
2
, 9. A 54-year-old male client is admitted to the hospital with a case of severe dehydration. The nurse
reviews the client's laboratory results. Which of the following results are consistent with the
diagnosis? Select all that apply. Serum osmolality of 310 mOsm/kg Hematocrit level of 48% Blood urea
nitrogen (BUN) of 23 mg/dL Serum glucose of 90 mg/dL Serum sodium of 148 mEq/L Urine specific
gravity of 1.03
Blood urea nitrogen (BUN) of 23 mg/dL Serum osmolality of 310 mOsm/kg Serum sodium of 148 mEq/L
Urine specific gravity of 1.03 R: Severe dehydration is associated with an increased BUN (N = 10 to 20
mg/dL), serum osmolality (N = 275 to 300 mOsm/kg), serum sodium (N = 135 to 145 mEq/L) and urine
specific gravity (N = 1.01 to 1.025). Glucose and hematocrit levels would also be elevated but are within
normal range for this question.
10. During a mumps outbreak at a school, a teacher is exposed. Because of a previous immunization
for mumps, what type of immunity does the teacher possess? Humoral immunity. Phagocytic
immunity. Natural immunity. Acquired immunity.
Acquired immunity. R: Acquired immunity usually develops as a result of prior exposure to an antigen,
often through immunization. When the body is attacked by bacteria, viruses, or other pathogens, it has
three means of defense. The first line of defense, the phagocytic immune response, involves the white
blood cells (WBCs) that have the ability to ingest foreign particles. A second protective response is the
humoral immune response, which begins when the B lymphocytes transform themselves into plasma cells
that manufacture antibodies. The natural immune response system is rapid, nonspecific immunity present
at birth.
11. A nurse is providing preoperative teaching to a client preparing for cardiac bypass. The nurse has
a teaching plan including exercises of the extremities. Which is the purpose of leg exercises prior to
surgery? Select all that apply. Prevent pressure sores to the sacrum and heels. Increase the muscle
mass postoperatively. Reduce the risk of pneumonia. Improve circulation and prevent venous
thrombosis. Increase the level of consciousness after surgery.
Improve circulation and prevent venous thrombosis. Reduce the risk of pneumonia. R: Exercise of the
extremities includes extension and flexion of the knee and hip joints (similar to bicycle riding while lying on
the side) unless contraindicated by type of surgical procedure (e.g., hip replacement). When the client does
leg exercises postoperatively, circulation is increased, which helps to prevent blood clots from forming.
This helps strengthen respiratory function and therefore decrease the risk of the development of
pneumonia. Leg exercises do not prevent pressure sores to the sacrum or increase the client's level of
consciousness. Leg exercises have the potential to increase strength and mobility but are unlikely to make
a change to muscle mass in the short term.
12. The nurse is evaluating the plan of care for a client who had a total hip replacement. Which
action(s) will the nurse perform during this step of the nursing process? Select all that apply.
Determine whether priorirites need to be reordered. Add additional nursing diagnoses to address new
problems. Change expected outcomes if they are not realistic. Check that pain assessments are being
performed with vital signs. Discontinue nursing interventions that are no longer needed.
Add additional nursing diagnoses to address new problems. Change expected outcomes if they are not
realistic. Determine whether priorirites need to be reordered. Discontinue nursing interventions that are
no longer needed. R: During the evaluation step of the nursing process, the nurse determines whether
new actual or potential health problems have developed that need to be added to the plan of care. The
nurse also checks the outcomes to determine whether they have been resolved, need modification, or
whether new outcomes need to be developed. The nurse evaluates the priorities for care to see whether
they need to be reordered. As the client's health conditions change, nursing interventions may also need
to be added or discontinued. A chart audit to determine whether pain assessments have been completed
is not part of the nursing process.
3
CORRECT ANSWERS 2027 EDITION
1. A postoperative client is moving from the bed to a chair when blood drips from the dressing. The
nurse assesses the incision and notes evisceration. What does the nurse do first? Call the health care
provider Cover the protruding organ with sterile dressings moistened with sterile saline Have the
client lay on the back with the head elevated Instruct the client to remain quiet
Have the client lay on the back with the head elevated R: A wound evisceration occurs when the wound
completely separates, and the internal organs protrude. If disruption of a wound occurs, the client is
placed in the low Fowler's position and instructed to lie quietly. These actions minimize the protrusion of
body tissues. The protruding coils of the intestine are covered with sterile dressings moistened with sterile
saline solution, and the surgeon is notified at once.
2. A client who is deaf without bilateral hearing aids has them removed in preparation for a surgical
procedure. Which action(s) will the nurse take to communicate with this client? Select all that apply.
Provide written information. Speak slowly so the client can lip read. Plan for a sign language
interpreter. Use hand gestures to communicate. Talk loudly into one of the client's ears.
Provide written information. Provide written information. Speak slowly so the client can lip read. Plan for a
sign language interpreter. R: Special considerations for clients with physical disabilities include the need
for appropriate assistive devices, modifications in preoperative education, and additional assistance with
communication. If the client is deaf when bilateral hearing aids are removed, an alternative form of
communication needs to be planned such as providing written information, using gestures, speaking
slowly so the client can lip read, and planning for an interpreter to provide sign language. Talking loudly
into one ear will not be effective because the client is deaf when the hearing aids are removed.
3. A perioperative nurse is participating in an interdisciplinary audit of infection control practices in
the surgical department. Which action is a basic guideline for maintaining surgical asepsis? Select all
that apply. Sterile surfaces or articles may touch other sterile surfaces. The outer lip of a sterile
solution is considered sterile. Only the top surface of a draped table is considered sterile. Sterile
supplies can be used on another client if the packages are intact. The scrub nurse may pour a sterile
solution from a nonsterile bottle.
Sterile surfaces or articles may touch other sterile surfaces. Only the top surface of a draped table is
considered sterile. R: Basic guidelines for maintaining sterile technique include that sterile surfaces or
articles may touch other sterile surfaces only and only the top surface of a draped table is considered
sterile. The other options each constitute a break in sterile technique.
4. The nurse, in collaboration with the client's family, is determining priorities related to the care of
the client. The nurse explains that it is important to consider the urgency of specific problems when
setting priorities. What should the nurse adopt as the best framework for prioritizing client problems?
Family member statements The nurse's skill set Maslow hierarchy of needs Availability of hospital
resources
Maslow hierarchy of needs R: The Maslow hierarchy of needs provides a useful framework for prioritizing
problems, with the first level given to meeting physical needs of the client. Availability of hospital
resources, family member statements, and nursing skill do not provide a framework for prioritization of
client problems, although each may be considered.
1
,5. A client was admitted to the hospital unit after 2 days of vomiting and diarrhea. The client's spouse
became alarmed when the client demonstrated confusion and elevated temperature, and reported
"dry mouth." The nurse suspects the client is experiencing which condition? hyperkalemia
hypercalcemia dehydration hypervolemia
dehydration R: Dehydration results when the volume of body fluid is significantly reduced in both
extracellular and intracellular compartments. In dehydration, all fluid compartments have decreased
volumes; in hypovolemia, only blood volume is low. The most common fluid imbalance in older adults is
dehydration. Hypervolemia is caused by fluid intake that exceeds fluid loss, such as from excessive oral
intake or rapid IV infusion of fluid. Early signs of hypervolemia are weight gain, elevated BP, and increased
breathing effort. Hypercalcemia occurs when the serum calcium level is higher than normal. Some of its
signs include tingling in the extremities and the area around the mouth (circumoral paresthesia) and
muscle and abdominal cramps. Hyperkalemia is an excess of potassium in the blood. Symptoms include
diarrhea, nausea, muscle weakness, paresthesias, and cardiac dysrhythmias.
6. The nurse is taking the client into the operating room (OR) when the client informs the nurse that
the client's grandparent spiked a very high temperature in the OR and nearly died 15 years ago. What
relevance does this information have regarding the client? The client may be experiencing presurgical
anxiety. The grandparent's surgery has minimal relevance to the client's surgery. The client may be at
risk for a sudden onset of postsurgical infection. The client may be at risk for malignant hyperthermia.
The client may be at risk for malignant hyperthermia. R: Malignant hyperthermia is an inherited muscle
disorder chemically induced by anesthetic agents. Identifying clients at risk is imperative because the
mortality rate is 50%. The client's anxiety is not relevant, the grandparent's surgery is very relevant, and all
clients are at risk for surgical infections.
7. While making an initial shift assessment the nurse notes that the client's peripheral IV site appears
edematous around the insertion site. How should the existence of this complication be documented
by the nurse? Infiltration Phlebitis Fluid overload Air emboli
Infiltration R: Infiltration is the administration of nonvesicant solution or medication into the surrounding
tissue. This can occur when the IV cannula dislodges or perforates the wall of the vein. Infiltration is
characterized by edema around the insertion site, leakage of IV fluid from the insertion site, discomfort
and coolness in the area of infiltration, and a significant decrease in the flow rate. Air emboli, phlebitis, and
fluid overload are not indications of infiltration.
8. An 80-year-old client is being admitted for dehydration and syncope. The client is found to be
hypotensive, and intravenous fluids are ordered. What are some teaching strategies that the nurse
should review with this client? Before ambulation the client should rise slowly and take mini breaks
between lying, sitting, and standing. The client must use a rolling walker and call for assistance with
any change in position. The temperature in the room should stay very hot, and bathing in hot water is
appropriate. Increase consumption of meals to three times a day, with the largest meal being at
breakfast.
Before ambulation the client should rise slowly and take mini breaks between lying, sitting, and standing.
R: A client experiencing hypotension should rise slowly. The client should consider having five or six small
meals a day to minimize hypotension that can occur after a large meal. Extremes in temperature,
especially hot showers, should be avoided. Hot temperatures can cause an increase in blood flow and
cause dizziness. Every client does not need a rolling walker. Changes in position, especially in bed, should
be done independently and often to prevent pressure ulcers.
2
, 9. A 54-year-old male client is admitted to the hospital with a case of severe dehydration. The nurse
reviews the client's laboratory results. Which of the following results are consistent with the
diagnosis? Select all that apply. Serum osmolality of 310 mOsm/kg Hematocrit level of 48% Blood urea
nitrogen (BUN) of 23 mg/dL Serum glucose of 90 mg/dL Serum sodium of 148 mEq/L Urine specific
gravity of 1.03
Blood urea nitrogen (BUN) of 23 mg/dL Serum osmolality of 310 mOsm/kg Serum sodium of 148 mEq/L
Urine specific gravity of 1.03 R: Severe dehydration is associated with an increased BUN (N = 10 to 20
mg/dL), serum osmolality (N = 275 to 300 mOsm/kg), serum sodium (N = 135 to 145 mEq/L) and urine
specific gravity (N = 1.01 to 1.025). Glucose and hematocrit levels would also be elevated but are within
normal range for this question.
10. During a mumps outbreak at a school, a teacher is exposed. Because of a previous immunization
for mumps, what type of immunity does the teacher possess? Humoral immunity. Phagocytic
immunity. Natural immunity. Acquired immunity.
Acquired immunity. R: Acquired immunity usually develops as a result of prior exposure to an antigen,
often through immunization. When the body is attacked by bacteria, viruses, or other pathogens, it has
three means of defense. The first line of defense, the phagocytic immune response, involves the white
blood cells (WBCs) that have the ability to ingest foreign particles. A second protective response is the
humoral immune response, which begins when the B lymphocytes transform themselves into plasma cells
that manufacture antibodies. The natural immune response system is rapid, nonspecific immunity present
at birth.
11. A nurse is providing preoperative teaching to a client preparing for cardiac bypass. The nurse has
a teaching plan including exercises of the extremities. Which is the purpose of leg exercises prior to
surgery? Select all that apply. Prevent pressure sores to the sacrum and heels. Increase the muscle
mass postoperatively. Reduce the risk of pneumonia. Improve circulation and prevent venous
thrombosis. Increase the level of consciousness after surgery.
Improve circulation and prevent venous thrombosis. Reduce the risk of pneumonia. R: Exercise of the
extremities includes extension and flexion of the knee and hip joints (similar to bicycle riding while lying on
the side) unless contraindicated by type of surgical procedure (e.g., hip replacement). When the client does
leg exercises postoperatively, circulation is increased, which helps to prevent blood clots from forming.
This helps strengthen respiratory function and therefore decrease the risk of the development of
pneumonia. Leg exercises do not prevent pressure sores to the sacrum or increase the client's level of
consciousness. Leg exercises have the potential to increase strength and mobility but are unlikely to make
a change to muscle mass in the short term.
12. The nurse is evaluating the plan of care for a client who had a total hip replacement. Which
action(s) will the nurse perform during this step of the nursing process? Select all that apply.
Determine whether priorirites need to be reordered. Add additional nursing diagnoses to address new
problems. Change expected outcomes if they are not realistic. Check that pain assessments are being
performed with vital signs. Discontinue nursing interventions that are no longer needed.
Add additional nursing diagnoses to address new problems. Change expected outcomes if they are not
realistic. Determine whether priorirites need to be reordered. Discontinue nursing interventions that are
no longer needed. R: During the evaluation step of the nursing process, the nurse determines whether
new actual or potential health problems have developed that need to be added to the plan of care. The
nurse also checks the outcomes to determine whether they have been resolved, need modification, or
whether new outcomes need to be developed. The nurse evaluates the priorities for care to see whether
they need to be reordered. As the client's health conditions change, nursing interventions may also need
to be added or discontinued. A chart audit to determine whether pain assessments have been completed
is not part of the nursing process.
3
