NURSING 104 FINAL (EXAM 2 SECTION) –
ULL STUDY GUIDE Comprehensive Review
and Key Concepts, Multiple Choice Questions
with Answers and Rationales
1. A nurse is caring for a patient who is postoperative day 1 following
abdominal surgery. Which assessment finding requires IMMEDIATE
notification of the healthcare provider?
A. Temperature of 99.2°F (37.3°C)
B. Heart rate of 88 beats/minute
C. Respiratory rate of 24 breaths/minute
D. Blood pressure of 88/52 mmHg
Answer: D. Blood pressure of 88/52 mmHg
Rationale: A blood pressure of 88/52 mmHg indicates hypotension, which could
be a sign of internal bleeding, hypovolemia, or shock. This finding requires
immediate notification of the healthcare provider. Slight temperature elevation,
mild tachycardia, and slightly increased respiratory rate are expected findings
postoperatively.
2. A nurse is preparing to administer a medication to a patient. Which action
is essential to ensure patient safety?
A. Reading the medication label once
B. Performing the three checks of medication administration
C. Administering the medication without verifying the patient's identity
D. Documenting the medication administration after the shift ends
Answer: B. Performing the three checks of medication administration
Rationale: The three checks (checking the medication label when removing from
storage, when preparing, and before administering) are essential for medication
safety. Reading the label only once is insufficient; patient identity must be verified
using two identifiers; documentation should occur immediately after
administration.
,3. A patient is receiving oxygen via nasal cannula at 2 L/min. The nurse
should perform which intervention to prevent complications?
A. Apply petroleum jelly to the nares
B. Assess the nares for skin breakdown and dryness
C. Place the patient in a supine position
D. Turn the oxygen off during meals
Answer: B. Assess the nares for skin breakdown and dryness
Rationale: Oxygen therapy can cause drying of mucous membranes and skin
breakdown. The nurse should assess the nares regularly and use water-soluble
lubricant if needed (not petroleum jelly, which is flammable). Supine positioning is
not specifically indicated, and oxygen should not be turned off during meals.
4. A patient is on fall precautions. Which nursing action is MOST
appropriate?
A. Keep the bed in the highest position
B. Place the call light within the patient's reach
C. Keep the side rails down to allow free movement
D. Leave the patient unattended in the bathroom
Answer: B. Place the call light within the patient's reach
Rationale: For fall precautions, the call light should be within reach and the bed
should be in the lowest position. Side rails should be up as appropriate; the patient
should not be left unattended in the bathroom.
5. A nurse is performing hand hygiene. Which statement is correct regarding
hand hygiene?
A. Hand hygiene is not necessary if gloves are worn
B. Alcohol-based hand rub is effective against most pathogens
C. Handwashing should last at least 5 seconds
D. Soap and water are not effective against any pathogens
Answer: B. Alcohol-based hand rub is effective against most pathogens
,Rationale: Alcohol-based hand rub is effective against most pathogens and is the
preferred method for routine hand hygiene unless hands are visibly soiled. Hand
hygiene is still required with glove use; handwashing should last 20-30 seconds;
soap and water are effective.
6. A patient has a nasogastric (NG) tube for gastric decompression. Which
assessment finding should the nurse report immediately?
A. Drainage of 100 mL of green fluid
B. Tube dislodgement with respiratory distress
C. Mild discomfort at the nares
D. Slight drainage from the tube insertion site
Answer: B. Tube dislodgement with respiratory distress
Rationale: Tube dislodgement with respiratory distress indicates possible tube
misplacement into the airway, which is a life-threatening emergency requiring
immediate reporting. Expected findings include drainage of gastric contents, mild
nares discomfort, and slight drainage.
7. A patient is NPO (nothing by mouth) before surgery. Which statement by
the patient indicates understanding?
A. "I can have water until midnight."
B. "I understand that I cannot eat or drink anything before surgery."
C. "It's okay to have a small snack."
D. "I can chew gum to help with my dry mouth."
Answer: B. "I understand that I cannot eat or drink anything before
surgery."
Rationale: NPO means nothing by mouth, including water, food, gum, and candy.
Patients should not have any oral intake for the specified time before surgery to
reduce aspiration risk.
8. A nurse is documenting patient care. Which documentation practice is
MOST appropriate?
, A. Using vague terms like "patient appears comfortable"
B. Recording objective, factual information
C. Writing in the chart after the shift is complete
D. Using correction fluid to fix errors
Answer: B. Recording objective, factual information
Rationale: Documentation should be objective, factual, and timely. Subjective
terms should be avoided; documentation should occur in real-time; correction fluid
should never be used (draw a single line through errors and initial).
9. A patient with a history of falls is at risk for which complication?
A. Hyperglycemia
B. Hip fracture
C. Myocardial infarction
D. Stroke
Answer: B. Hip fracture
Rationale: Falls in older adults can lead to fractures, particularly hip fractures,
which are associated with significant morbidity and mortality. Hyperglycemia, MI,
and stroke are not directly caused by falls.
10. A patient is receiving IV fluids. Which finding indicates fluid overload?
A. Decreased blood pressure
B. Crackles in the lung bases
C. Decreased urine output
D. Thready pulse
Answer: B. Crackles in the lung bases
Rationale: Crackles in the lung bases indicate pulmonary edema from fluid
overload. Decreased blood pressure, decreased urine output, and thready pulse
indicate hypovolemia.
SECTION 2: VITAL SIGNS AND ASSESSMENT
ULL STUDY GUIDE Comprehensive Review
and Key Concepts, Multiple Choice Questions
with Answers and Rationales
1. A nurse is caring for a patient who is postoperative day 1 following
abdominal surgery. Which assessment finding requires IMMEDIATE
notification of the healthcare provider?
A. Temperature of 99.2°F (37.3°C)
B. Heart rate of 88 beats/minute
C. Respiratory rate of 24 breaths/minute
D. Blood pressure of 88/52 mmHg
Answer: D. Blood pressure of 88/52 mmHg
Rationale: A blood pressure of 88/52 mmHg indicates hypotension, which could
be a sign of internal bleeding, hypovolemia, or shock. This finding requires
immediate notification of the healthcare provider. Slight temperature elevation,
mild tachycardia, and slightly increased respiratory rate are expected findings
postoperatively.
2. A nurse is preparing to administer a medication to a patient. Which action
is essential to ensure patient safety?
A. Reading the medication label once
B. Performing the three checks of medication administration
C. Administering the medication without verifying the patient's identity
D. Documenting the medication administration after the shift ends
Answer: B. Performing the three checks of medication administration
Rationale: The three checks (checking the medication label when removing from
storage, when preparing, and before administering) are essential for medication
safety. Reading the label only once is insufficient; patient identity must be verified
using two identifiers; documentation should occur immediately after
administration.
,3. A patient is receiving oxygen via nasal cannula at 2 L/min. The nurse
should perform which intervention to prevent complications?
A. Apply petroleum jelly to the nares
B. Assess the nares for skin breakdown and dryness
C. Place the patient in a supine position
D. Turn the oxygen off during meals
Answer: B. Assess the nares for skin breakdown and dryness
Rationale: Oxygen therapy can cause drying of mucous membranes and skin
breakdown. The nurse should assess the nares regularly and use water-soluble
lubricant if needed (not petroleum jelly, which is flammable). Supine positioning is
not specifically indicated, and oxygen should not be turned off during meals.
4. A patient is on fall precautions. Which nursing action is MOST
appropriate?
A. Keep the bed in the highest position
B. Place the call light within the patient's reach
C. Keep the side rails down to allow free movement
D. Leave the patient unattended in the bathroom
Answer: B. Place the call light within the patient's reach
Rationale: For fall precautions, the call light should be within reach and the bed
should be in the lowest position. Side rails should be up as appropriate; the patient
should not be left unattended in the bathroom.
5. A nurse is performing hand hygiene. Which statement is correct regarding
hand hygiene?
A. Hand hygiene is not necessary if gloves are worn
B. Alcohol-based hand rub is effective against most pathogens
C. Handwashing should last at least 5 seconds
D. Soap and water are not effective against any pathogens
Answer: B. Alcohol-based hand rub is effective against most pathogens
,Rationale: Alcohol-based hand rub is effective against most pathogens and is the
preferred method for routine hand hygiene unless hands are visibly soiled. Hand
hygiene is still required with glove use; handwashing should last 20-30 seconds;
soap and water are effective.
6. A patient has a nasogastric (NG) tube for gastric decompression. Which
assessment finding should the nurse report immediately?
A. Drainage of 100 mL of green fluid
B. Tube dislodgement with respiratory distress
C. Mild discomfort at the nares
D. Slight drainage from the tube insertion site
Answer: B. Tube dislodgement with respiratory distress
Rationale: Tube dislodgement with respiratory distress indicates possible tube
misplacement into the airway, which is a life-threatening emergency requiring
immediate reporting. Expected findings include drainage of gastric contents, mild
nares discomfort, and slight drainage.
7. A patient is NPO (nothing by mouth) before surgery. Which statement by
the patient indicates understanding?
A. "I can have water until midnight."
B. "I understand that I cannot eat or drink anything before surgery."
C. "It's okay to have a small snack."
D. "I can chew gum to help with my dry mouth."
Answer: B. "I understand that I cannot eat or drink anything before
surgery."
Rationale: NPO means nothing by mouth, including water, food, gum, and candy.
Patients should not have any oral intake for the specified time before surgery to
reduce aspiration risk.
8. A nurse is documenting patient care. Which documentation practice is
MOST appropriate?
, A. Using vague terms like "patient appears comfortable"
B. Recording objective, factual information
C. Writing in the chart after the shift is complete
D. Using correction fluid to fix errors
Answer: B. Recording objective, factual information
Rationale: Documentation should be objective, factual, and timely. Subjective
terms should be avoided; documentation should occur in real-time; correction fluid
should never be used (draw a single line through errors and initial).
9. A patient with a history of falls is at risk for which complication?
A. Hyperglycemia
B. Hip fracture
C. Myocardial infarction
D. Stroke
Answer: B. Hip fracture
Rationale: Falls in older adults can lead to fractures, particularly hip fractures,
which are associated with significant morbidity and mortality. Hyperglycemia, MI,
and stroke are not directly caused by falls.
10. A patient is receiving IV fluids. Which finding indicates fluid overload?
A. Decreased blood pressure
B. Crackles in the lung bases
C. Decreased urine output
D. Thready pulse
Answer: B. Crackles in the lung bases
Rationale: Crackles in the lung bases indicate pulmonary edema from fluid
overload. Decreased blood pressure, decreased urine output, and thready pulse
indicate hypovolemia.
SECTION 2: VITAL SIGNS AND ASSESSMENT
