NU140
Nursing Fundamentals
Final Exam Prep
2025
(With Solutions)
Which of the following is the most accurate method to assess a patient's core body
temperature? a) Oral thermometer b) Tympanic membrane thermometer c) Axillary
thermometer d) Temporal artery thermometer
Answer: b) Tympanic membrane thermometer
Rationale: The tympanic membrane shares blood supply with the hypothalamus,
making it closely reflective of core temperature. Oral may be affected by recent
intake, axillary is less accurate, and temporal artery is less precise in critical cases.
2. What is the primary purpose of performing a head-to-toe assessment in nursing?
a) To identify all problems at once
b) To obtain baseline data for comparison
c) To focus on patient's complaints
d) To delegate tasks to healthcare team
Answer: b) To obtain baseline data for comparison
Rationale: A comprehensive head-to-toe assessment gives baseline information for
ongoing monitoring and helps detect changes in patient status over time.
3. Which nursing action best prevents catheter-associated urinary tract infections
(CAUTI)?
a) Changing catheter tubing every 48 hours
b) Using sterile technique during insertion and care
c) Keeping the drainage bag above bladder level
d) Irrigating the catheter daily
Answer: b) Using sterile technique during insertion and care
1
,Rationale: Sterile technique during catheter insertion and care is crucial to prevent
infection. Drainage bag should always be below bladder level, and routine irrigation
is not recommended.
4. A patient has a nasogastric tube. The nurse should confirm placement by which
method initially?
a) Measuring pH of aspirate
b) Palpating the abdomen
c) Visualizing the tube at the nostril
d) Auscultating the epigastric area during air instillation
Answer: a) Measuring pH of aspirate
Rationale: pH testing of aspirate is the most reliable bedside method to confirm NG
tube placement before feeding or medication administration; auscultation is less
reliable.
5. Which nursing intervention best reduces the risk of pressure ulcers in immobile
patients?
a) Repositioning every four hours
b) Using donut-shaped cushions at bony prominences
c) Applying moisturizing lotion once daily
d) Repositioning every two hours
Answer: d) Repositioning every two hours
Rationale: Repositioning immobile patients every two hours redistributes pressure
and reduces risk of ulcers. Donut cushions can cause ischemia, four hours is too
long between turns.
6. What is the primary rationale for providing smoke-free environment education to
new nurses?
a) To reduce hospital air pollution
b) To prevent second-hand smoke exposure in vulnerable patients
c) To comply with hospital policy
d) To reduce nurse smoking rates
Answer: b) To prevent second-hand smoke exposure in vulnerable patients
Rationale: Smoke-free policies are critical to protect patients, many of whom have
2
,respiratory or cardiac vulnerabilities, from harmful second-hand smoke.
7. When administering intramuscular injections, the preferred site for an adult
patient is:
a) Vastus lateralis muscle
b) Deltoid muscle
c) Dorsogluteal muscle
d) Ventrogluteal muscle
Answer: d) Ventrogluteal muscle
Rationale: The ventrogluteal site is preferred due to fewer nerves and blood vessels,
offering safer administration compared to dorsogluteal, which has sciatic nerve
risk.
8. After receiving report, a nurse finds a patient has a serum potassium level of 6.5
mEq/L. The nurse's first action should be:
a) Administer potassium supplements
b) Notify the healthcare provider immediately
c) Reassess potassium level in 24 hours
d) Restrict potassium intake
Answer: b) Notify the healthcare provider immediately
Rationale: Hyperkalemia at 6.5 poses risk for cardiac arrhythmias and requires
urgent medical intervention.
9. Which of the following best describes the appropriate hand hygiene technique for
prolonged contact with a patient with Clostridium difficile infection?
a) Alcohol-based hand rub for 20 seconds
b) Hand washing with soap and water for at least 20 seconds
c) Gloves only, no handwashing needed
d) Synthetic wipes usage between glove changes
Answer: b) Hand washing with soap and water for at least 20 seconds
Rationale: Alcohol-based sanitizers are ineffective against C. difficile spores; soap
and water handwashing is necessary to physically remove spores.
10. Which physiological change should the nurse expect in an elderly patient
3
, regarding pharmacokinetics?
a) Increased renal clearance of medications
b) Slowed hepatic metabolism
c) Increased volume of distribution for water-soluble drugs
d) Faster gastric emptying time
Answer: b) Slowed hepatic metabolism
Rationale: Hepatic metabolism slows in elderly, increasing drug half-life and risk of
toxicity. Renal clearance decreases, volume of distribution for water-soluble drugs
decreases, and gastric emptying slows.
11. In assessing a patient’s neurological status using the Glasgow Coma Scale
(GCS), a score of 15 indicates:
a) Moderate brain injury
b) Severe brain injury
c) Normal neurological status
d) Comatose state
Answer: c) Normal neurological status
Rationale: A GCS score of 15 is the highest and indicates full consciousness and
responsiveness.
12. How should a nurse document a patient's allergy to penicillin after medication
administration results in hives?
a) Note as “allergic reaction to penicillin: hives” in medical record
b) Record only the medication error in the chart
c) Report allergy only if anaphylaxis occurs
d) Write allergy in chart but no need to alert pharmacist
Answer: a) Note as “allergic reaction to penicillin: hives” in medical record
Rationale: Allergies and reactions should be clearly documented to avoid future
administration and ensure safety.
13. For a patient on contact precautions with MRSA, the nurse understands that:
a) Wearing gloves and gowns when entering the room is essential
b) Surgical masks are mandatory in all situations
c) Patient sharing is allowed with same infection
4
Nursing Fundamentals
Final Exam Prep
2025
(With Solutions)
Which of the following is the most accurate method to assess a patient's core body
temperature? a) Oral thermometer b) Tympanic membrane thermometer c) Axillary
thermometer d) Temporal artery thermometer
Answer: b) Tympanic membrane thermometer
Rationale: The tympanic membrane shares blood supply with the hypothalamus,
making it closely reflective of core temperature. Oral may be affected by recent
intake, axillary is less accurate, and temporal artery is less precise in critical cases.
2. What is the primary purpose of performing a head-to-toe assessment in nursing?
a) To identify all problems at once
b) To obtain baseline data for comparison
c) To focus on patient's complaints
d) To delegate tasks to healthcare team
Answer: b) To obtain baseline data for comparison
Rationale: A comprehensive head-to-toe assessment gives baseline information for
ongoing monitoring and helps detect changes in patient status over time.
3. Which nursing action best prevents catheter-associated urinary tract infections
(CAUTI)?
a) Changing catheter tubing every 48 hours
b) Using sterile technique during insertion and care
c) Keeping the drainage bag above bladder level
d) Irrigating the catheter daily
Answer: b) Using sterile technique during insertion and care
1
,Rationale: Sterile technique during catheter insertion and care is crucial to prevent
infection. Drainage bag should always be below bladder level, and routine irrigation
is not recommended.
4. A patient has a nasogastric tube. The nurse should confirm placement by which
method initially?
a) Measuring pH of aspirate
b) Palpating the abdomen
c) Visualizing the tube at the nostril
d) Auscultating the epigastric area during air instillation
Answer: a) Measuring pH of aspirate
Rationale: pH testing of aspirate is the most reliable bedside method to confirm NG
tube placement before feeding or medication administration; auscultation is less
reliable.
5. Which nursing intervention best reduces the risk of pressure ulcers in immobile
patients?
a) Repositioning every four hours
b) Using donut-shaped cushions at bony prominences
c) Applying moisturizing lotion once daily
d) Repositioning every two hours
Answer: d) Repositioning every two hours
Rationale: Repositioning immobile patients every two hours redistributes pressure
and reduces risk of ulcers. Donut cushions can cause ischemia, four hours is too
long between turns.
6. What is the primary rationale for providing smoke-free environment education to
new nurses?
a) To reduce hospital air pollution
b) To prevent second-hand smoke exposure in vulnerable patients
c) To comply with hospital policy
d) To reduce nurse smoking rates
Answer: b) To prevent second-hand smoke exposure in vulnerable patients
Rationale: Smoke-free policies are critical to protect patients, many of whom have
2
,respiratory or cardiac vulnerabilities, from harmful second-hand smoke.
7. When administering intramuscular injections, the preferred site for an adult
patient is:
a) Vastus lateralis muscle
b) Deltoid muscle
c) Dorsogluteal muscle
d) Ventrogluteal muscle
Answer: d) Ventrogluteal muscle
Rationale: The ventrogluteal site is preferred due to fewer nerves and blood vessels,
offering safer administration compared to dorsogluteal, which has sciatic nerve
risk.
8. After receiving report, a nurse finds a patient has a serum potassium level of 6.5
mEq/L. The nurse's first action should be:
a) Administer potassium supplements
b) Notify the healthcare provider immediately
c) Reassess potassium level in 24 hours
d) Restrict potassium intake
Answer: b) Notify the healthcare provider immediately
Rationale: Hyperkalemia at 6.5 poses risk for cardiac arrhythmias and requires
urgent medical intervention.
9. Which of the following best describes the appropriate hand hygiene technique for
prolonged contact with a patient with Clostridium difficile infection?
a) Alcohol-based hand rub for 20 seconds
b) Hand washing with soap and water for at least 20 seconds
c) Gloves only, no handwashing needed
d) Synthetic wipes usage between glove changes
Answer: b) Hand washing with soap and water for at least 20 seconds
Rationale: Alcohol-based sanitizers are ineffective against C. difficile spores; soap
and water handwashing is necessary to physically remove spores.
10. Which physiological change should the nurse expect in an elderly patient
3
, regarding pharmacokinetics?
a) Increased renal clearance of medications
b) Slowed hepatic metabolism
c) Increased volume of distribution for water-soluble drugs
d) Faster gastric emptying time
Answer: b) Slowed hepatic metabolism
Rationale: Hepatic metabolism slows in elderly, increasing drug half-life and risk of
toxicity. Renal clearance decreases, volume of distribution for water-soluble drugs
decreases, and gastric emptying slows.
11. In assessing a patient’s neurological status using the Glasgow Coma Scale
(GCS), a score of 15 indicates:
a) Moderate brain injury
b) Severe brain injury
c) Normal neurological status
d) Comatose state
Answer: c) Normal neurological status
Rationale: A GCS score of 15 is the highest and indicates full consciousness and
responsiveness.
12. How should a nurse document a patient's allergy to penicillin after medication
administration results in hives?
a) Note as “allergic reaction to penicillin: hives” in medical record
b) Record only the medication error in the chart
c) Report allergy only if anaphylaxis occurs
d) Write allergy in chart but no need to alert pharmacist
Answer: a) Note as “allergic reaction to penicillin: hives” in medical record
Rationale: Allergies and reactions should be clearly documented to avoid future
administration and ensure safety.
13. For a patient on contact precautions with MRSA, the nurse understands that:
a) Wearing gloves and gowns when entering the room is essential
b) Surgical masks are mandatory in all situations
c) Patient sharing is allowed with same infection
4
