NUR 104 MIDTERM AND FINAL EXAM EXCELSIOR COLLEGE Practice
Questions 150 QUESTIONS AND CORRECT ANSWERS WITH ATIONALES
COVERING THE MOST TESTED QUESTIONS GUARANTEE A+ GRADE
1. Which of the following is the most important first step in ensuring patient safety?
A) Administering medications promptly
B) Performing a thorough patient assessment
C) Documenting care immediately
D) Checking lab results only if ordered
Rationale: Patient assessment is the foundation of safe care because it identifies potential risks
before interventions are performed.
2. A nurse is caring for a patient with a newly placed Foley catheter. Which action is most
important to prevent infection?
A) Changing the catheter every 24 hours
B) Irrigating the catheter daily
C) Maintaining a closed drainage system
D) Using powdered gloves during insertion
Rationale: Maintaining a closed system prevents bacteria from entering the urinary tract,
reducing the risk of catheter-associated infections.
3. When performing hand hygiene, the nurse should:
A) Wash hands for at least 5 seconds
B) Rub hands with soap and water or an alcohol-based solution for at least 20 seconds
C) Use gloves instead of washing hands
D) Wash only visibly soiled areas
Rationale: Proper hand hygiene is essential to prevent the spread of infection; 20 seconds is
recommended for effectiveness.
4. The most appropriate nursing action for a patient experiencing orthostatic hypotension is
to:
A) Encourage rapid standing from bed
B) Assist the patient to rise slowly and monitor blood pressure
C) Administer antihypertensive medications immediately
D) Restrict fluid intake
Rationale: Gradual position changes reduce the risk of dizziness or falls due to orthostatic
hypotension.
,5. A patient is receiving oxygen via nasal cannula at 2 L/min. The nurse should:
A) Remove the cannula every hour
B) Keep oxygen at 6 L/min
C) Ensure the cannula fits properly and monitor for skin breakdown
D) Humidify only if the patient requests it
Rationale: Proper fit and skin monitoring are essential to maintain oxygen delivery and prevent
irritation.
6. Which of the following actions demonstrates proper use of PPE when caring for a patient
with droplet precautions?
A) Wearing a surgical mask within 3 feet of the patient
B) Using a respirator mask for all patient contact
C) Wearing gloves only when touching surfaces
D) Placing the patient in a negative-pressure room
Rationale: Droplet precautions require a surgical mask for close contact to prevent
transmission of respiratory pathogens.
7. When administering an intramuscular injection, the nurse should:
A) Use a 5 mL syringe
B) Select the appropriate needle size and injection site based on patient size
C) Inject at a 15-degree angle
D) Aspirate in all IM injections
Rationale: Correct needle size and site selection ensure safe and effective IM medication
delivery.
8. The best nursing intervention for a patient at risk for pressure ulcers is:
A) Apply a single layer of dressing to bony prominences
B) Reposition the patient every 2 hours and assess skin integrity
C) Keep the patient in one position to avoid confusion
D) Massage reddened areas vigorously
Rationale: Regular repositioning and skin assessment prevent pressure injury development.
9. Which of the following is the most reliable indicator of adequate tissue perfusion?
A) Patient’s subjective feeling of warmth
B) Capillary refill less than 3 seconds
,C) Skin temperature alone
D) Patient’s pulse strength only
Rationale: Capillary refill assesses peripheral perfusion objectively and quickly.
10. A nurse teaching a patient about a new medication should include:
A) Only the drug name
B) Side effects will not occur
C) Purpose, dosage, potential side effects, and when to seek help
D) Instructions are unnecessary if prescribed by a doctor
Rationale: Patient education ensures safe and effective medication use and promotes
adherence.
11. The primary purpose of a health assessment is to:
A) Diagnose the patient
B) Gather data to identify actual or potential health problems
C) Provide treatment independently
D) Replace physician evaluation
Rationale: Nursing assessments collect data to plan and prioritize care, not to make a medical
diagnosis.
12. A patient with diabetes reports numbness in the feet. The nurse recognizes this as:
A) Hypoglycemia
B) Peripheral neuropathy
C) Hyperthyroidism
D) Renal failure
Rationale: Peripheral neuropathy is a common complication of diabetes causing numbness and
tingling in extremities.
13. Which of the following is the most appropriate intervention for a patient with impaired
mobility?
A) Encourage only passive exercises
B) Encourage active or passive range-of-motion exercises and proper positioning
C) Restrict all movement
D) Use restraints to prevent falls
Rationale: ROM exercises maintain joint function and prevent complications of immobility.
, 14. A patient develops sudden shortness of breath and wheezing after receiving a new
medication. The nurse’s priority action is:
A) Document the reaction
B) Administer a PRN analgesic
C) Stop the medication and notify the provider immediately
D) Encourage deep breathing
Rationale: This is a potential allergic reaction or anaphylaxis; immediate intervention is
required.
15. When performing a sterile dressing change, the nurse should:
A) Touch the inside of the sterile field
B) Maintain aseptic technique and avoid contamination
C) Allow the sterile field to touch non-sterile surfaces
D) Use clean technique only
Rationale: Aseptic technique prevents infection during dressing changes.
16. A patient has an order for a low-sodium diet. The nurse should:
A) Offer regular meals and no modifications
B) Educate the patient on foods high in sodium and provide alternatives
C) Encourage canned and processed foods
D) Ignore dietary needs if patient refuses
Rationale: Patient education and dietary modifications help manage conditions such as
hypertension and heart failure.
17. Which of the following is a sign of hypoglycemia?
A) Flushed skin and increased thirst
B) Sweating, confusion, and shakiness
C) Polyuria and polydipsia
D) Constipation and fatigue
Rationale: Hypoglycemia presents with adrenergic symptoms like sweating, shakiness, and
confusion.
18. A nurse assessing a patient’s neurological status should evaluate:
A) Only reflexes
B) Blood pressure
C) Level of consciousness, motor function, and pupillary response
Questions 150 QUESTIONS AND CORRECT ANSWERS WITH ATIONALES
COVERING THE MOST TESTED QUESTIONS GUARANTEE A+ GRADE
1. Which of the following is the most important first step in ensuring patient safety?
A) Administering medications promptly
B) Performing a thorough patient assessment
C) Documenting care immediately
D) Checking lab results only if ordered
Rationale: Patient assessment is the foundation of safe care because it identifies potential risks
before interventions are performed.
2. A nurse is caring for a patient with a newly placed Foley catheter. Which action is most
important to prevent infection?
A) Changing the catheter every 24 hours
B) Irrigating the catheter daily
C) Maintaining a closed drainage system
D) Using powdered gloves during insertion
Rationale: Maintaining a closed system prevents bacteria from entering the urinary tract,
reducing the risk of catheter-associated infections.
3. When performing hand hygiene, the nurse should:
A) Wash hands for at least 5 seconds
B) Rub hands with soap and water or an alcohol-based solution for at least 20 seconds
C) Use gloves instead of washing hands
D) Wash only visibly soiled areas
Rationale: Proper hand hygiene is essential to prevent the spread of infection; 20 seconds is
recommended for effectiveness.
4. The most appropriate nursing action for a patient experiencing orthostatic hypotension is
to:
A) Encourage rapid standing from bed
B) Assist the patient to rise slowly and monitor blood pressure
C) Administer antihypertensive medications immediately
D) Restrict fluid intake
Rationale: Gradual position changes reduce the risk of dizziness or falls due to orthostatic
hypotension.
,5. A patient is receiving oxygen via nasal cannula at 2 L/min. The nurse should:
A) Remove the cannula every hour
B) Keep oxygen at 6 L/min
C) Ensure the cannula fits properly and monitor for skin breakdown
D) Humidify only if the patient requests it
Rationale: Proper fit and skin monitoring are essential to maintain oxygen delivery and prevent
irritation.
6. Which of the following actions demonstrates proper use of PPE when caring for a patient
with droplet precautions?
A) Wearing a surgical mask within 3 feet of the patient
B) Using a respirator mask for all patient contact
C) Wearing gloves only when touching surfaces
D) Placing the patient in a negative-pressure room
Rationale: Droplet precautions require a surgical mask for close contact to prevent
transmission of respiratory pathogens.
7. When administering an intramuscular injection, the nurse should:
A) Use a 5 mL syringe
B) Select the appropriate needle size and injection site based on patient size
C) Inject at a 15-degree angle
D) Aspirate in all IM injections
Rationale: Correct needle size and site selection ensure safe and effective IM medication
delivery.
8. The best nursing intervention for a patient at risk for pressure ulcers is:
A) Apply a single layer of dressing to bony prominences
B) Reposition the patient every 2 hours and assess skin integrity
C) Keep the patient in one position to avoid confusion
D) Massage reddened areas vigorously
Rationale: Regular repositioning and skin assessment prevent pressure injury development.
9. Which of the following is the most reliable indicator of adequate tissue perfusion?
A) Patient’s subjective feeling of warmth
B) Capillary refill less than 3 seconds
,C) Skin temperature alone
D) Patient’s pulse strength only
Rationale: Capillary refill assesses peripheral perfusion objectively and quickly.
10. A nurse teaching a patient about a new medication should include:
A) Only the drug name
B) Side effects will not occur
C) Purpose, dosage, potential side effects, and when to seek help
D) Instructions are unnecessary if prescribed by a doctor
Rationale: Patient education ensures safe and effective medication use and promotes
adherence.
11. The primary purpose of a health assessment is to:
A) Diagnose the patient
B) Gather data to identify actual or potential health problems
C) Provide treatment independently
D) Replace physician evaluation
Rationale: Nursing assessments collect data to plan and prioritize care, not to make a medical
diagnosis.
12. A patient with diabetes reports numbness in the feet. The nurse recognizes this as:
A) Hypoglycemia
B) Peripheral neuropathy
C) Hyperthyroidism
D) Renal failure
Rationale: Peripheral neuropathy is a common complication of diabetes causing numbness and
tingling in extremities.
13. Which of the following is the most appropriate intervention for a patient with impaired
mobility?
A) Encourage only passive exercises
B) Encourage active or passive range-of-motion exercises and proper positioning
C) Restrict all movement
D) Use restraints to prevent falls
Rationale: ROM exercises maintain joint function and prevent complications of immobility.
, 14. A patient develops sudden shortness of breath and wheezing after receiving a new
medication. The nurse’s priority action is:
A) Document the reaction
B) Administer a PRN analgesic
C) Stop the medication and notify the provider immediately
D) Encourage deep breathing
Rationale: This is a potential allergic reaction or anaphylaxis; immediate intervention is
required.
15. When performing a sterile dressing change, the nurse should:
A) Touch the inside of the sterile field
B) Maintain aseptic technique and avoid contamination
C) Allow the sterile field to touch non-sterile surfaces
D) Use clean technique only
Rationale: Aseptic technique prevents infection during dressing changes.
16. A patient has an order for a low-sodium diet. The nurse should:
A) Offer regular meals and no modifications
B) Educate the patient on foods high in sodium and provide alternatives
C) Encourage canned and processed foods
D) Ignore dietary needs if patient refuses
Rationale: Patient education and dietary modifications help manage conditions such as
hypertension and heart failure.
17. Which of the following is a sign of hypoglycemia?
A) Flushed skin and increased thirst
B) Sweating, confusion, and shakiness
C) Polyuria and polydipsia
D) Constipation and fatigue
Rationale: Hypoglycemia presents with adrenergic symptoms like sweating, shakiness, and
confusion.
18. A nurse assessing a patient’s neurological status should evaluate:
A) Only reflexes
B) Blood pressure
C) Level of consciousness, motor function, and pupillary response
