NSG 300 Final Exam V3 | NSG 300 Foundations of
Nursing | Actual Q&A with Rationale (NSG300 Final
Exam) | Grand Canyon University
1. A nurse is implementing fall precautions for an older adult patient who was recently
admitted to the medical-surgical unit. Which of the following interventions should be
included in the plan of care? (Select all that apply)
A. Place the bed in the lowest position.
B. Ensure the call light is within the patient’s reach.
C. Keep all four side rails in the upright position.
D. Provide non-skid footwear for ambulation.
E. Keep the environment free of clutter and obstacles.
Correct Answer: A, B, D, E
Explanation: Placing the bed in the lowest position reduces the distance of a potential fall,
while keeping the call light within reach ensures the patient can request assistance easily.
Non-skid footwear provides better traction during movement, and removing clutter
minimizes tripping hazards. Raising all four side rails is considered a restraint and should
not be used as a standard fall precaution.
2. A nurse is preparing to measure a patient’s blood pressure. Which action by the nurse
would result in an incorrectly high blood pressure reading?
A. Using a cuff that is too wide for the arm.
,B. Positioning the arm above the level of the heart.
C. Deflating the cuff at a rate of 2 to 3 mmHg per second.
D. Wrapping the cuff too loosely around the arm.
Correct Answer: D
Explanation: A loosely wrapped cuff results in an erroneously high blood pressure reading
because the bladder must inflate more to compress the artery. Conversely, a cuff that is too
wide or an arm positioned above the heart level typically results in a false-low reading. The
deflation rate of 2 to 3 mmHg per second is the standard procedure for an accurate
assessment.
3. The nurse is caring for a patient who refuses a scheduled blood transfusion for religious
reasons. Which ethical principle is the nurse upholding by respecting the patient’s decision?
A. Justice
B. Autonomy
C. Beneficence
D. Non-maleficence
Correct Answer: B
Explanation: Autonomy refers to the patient’s right to make their own decisions regarding
their healthcare, even if those decisions conflict with the medical team’s recommendations.
,By respecting the refusal, the nurse honors the patient’s self-determination and personal
values. This principle is a cornerstone of patient-centered care and legal informed consent.
4. During the assessment phase of the nursing process, the nurse collects which of the
following as objective data?
A. The patient’s report of a headache.
B. The patient’s rating of pain as a 7 on a scale of 0 to 10.
C. The patient’s description of feeling anxious about surgery.
D. The patient’s respiratory rate of 22 breaths per minute.
Correct Answer: D
Explanation: Objective data are observable and measurable signs that can be verified by
the nurse, such as vital signs, physical exam findings, or laboratory results. Subjective data,
such as pain ratings, feelings, and reported symptoms, are provided by the patient and
cannot be directly measured by the observer. Respiratory rate is a clear example of
measurable objective data obtained through observation.
5. A nurse is documenting a patient’s response to pain medication. Which of the following
entries is the most accurate and professional?
A. Patient seems much better after receiving the medication.
B. Administered Morphine; patient is now sleeping soundly.
C. Patient reports pain level decreased from 8/10 to 3/10 thirty minutes after Morphine
administration.
, D. The medication was effective as the patient stopped complaining about their back.
Correct Answer: C
Explanation: Professional documentation must be factual, accurate, and use specific
measurements rather than vague descriptions. Using the patient’s self-reported pain scale
before and after intervention provides clear evidence of the medication’s efficacy. Phrases
like ‘seems better’ or ‘stopped complaining’ are subjective and do not meet clinical
documentation standards.
6. A patient is placed on airborne precautions for suspected tuberculosis. Which of the
following personal protective equipment (PPE) and room requirements are necessary? (Select
all that apply)
A. A private room with negative-pressure airflow.
B. Use of an N95 respirator mask by healthcare workers.
C. Surgical mask for the patient during transport.
D. Goggles or face shield for all patient contact.
E. Disposable gowns for every entry into the room.
Correct Answer: A, B, C
Explanation: Airborne precautions require a private, negative-pressure room to prevent
the spread of infectious particles through the air. Healthcare workers must wear an N95
respirator to filter out small droplets, and the patient must wear a surgical mask when
Nursing | Actual Q&A with Rationale (NSG300 Final
Exam) | Grand Canyon University
1. A nurse is implementing fall precautions for an older adult patient who was recently
admitted to the medical-surgical unit. Which of the following interventions should be
included in the plan of care? (Select all that apply)
A. Place the bed in the lowest position.
B. Ensure the call light is within the patient’s reach.
C. Keep all four side rails in the upright position.
D. Provide non-skid footwear for ambulation.
E. Keep the environment free of clutter and obstacles.
Correct Answer: A, B, D, E
Explanation: Placing the bed in the lowest position reduces the distance of a potential fall,
while keeping the call light within reach ensures the patient can request assistance easily.
Non-skid footwear provides better traction during movement, and removing clutter
minimizes tripping hazards. Raising all four side rails is considered a restraint and should
not be used as a standard fall precaution.
2. A nurse is preparing to measure a patient’s blood pressure. Which action by the nurse
would result in an incorrectly high blood pressure reading?
A. Using a cuff that is too wide for the arm.
,B. Positioning the arm above the level of the heart.
C. Deflating the cuff at a rate of 2 to 3 mmHg per second.
D. Wrapping the cuff too loosely around the arm.
Correct Answer: D
Explanation: A loosely wrapped cuff results in an erroneously high blood pressure reading
because the bladder must inflate more to compress the artery. Conversely, a cuff that is too
wide or an arm positioned above the heart level typically results in a false-low reading. The
deflation rate of 2 to 3 mmHg per second is the standard procedure for an accurate
assessment.
3. The nurse is caring for a patient who refuses a scheduled blood transfusion for religious
reasons. Which ethical principle is the nurse upholding by respecting the patient’s decision?
A. Justice
B. Autonomy
C. Beneficence
D. Non-maleficence
Correct Answer: B
Explanation: Autonomy refers to the patient’s right to make their own decisions regarding
their healthcare, even if those decisions conflict with the medical team’s recommendations.
,By respecting the refusal, the nurse honors the patient’s self-determination and personal
values. This principle is a cornerstone of patient-centered care and legal informed consent.
4. During the assessment phase of the nursing process, the nurse collects which of the
following as objective data?
A. The patient’s report of a headache.
B. The patient’s rating of pain as a 7 on a scale of 0 to 10.
C. The patient’s description of feeling anxious about surgery.
D. The patient’s respiratory rate of 22 breaths per minute.
Correct Answer: D
Explanation: Objective data are observable and measurable signs that can be verified by
the nurse, such as vital signs, physical exam findings, or laboratory results. Subjective data,
such as pain ratings, feelings, and reported symptoms, are provided by the patient and
cannot be directly measured by the observer. Respiratory rate is a clear example of
measurable objective data obtained through observation.
5. A nurse is documenting a patient’s response to pain medication. Which of the following
entries is the most accurate and professional?
A. Patient seems much better after receiving the medication.
B. Administered Morphine; patient is now sleeping soundly.
C. Patient reports pain level decreased from 8/10 to 3/10 thirty minutes after Morphine
administration.
, D. The medication was effective as the patient stopped complaining about their back.
Correct Answer: C
Explanation: Professional documentation must be factual, accurate, and use specific
measurements rather than vague descriptions. Using the patient’s self-reported pain scale
before and after intervention provides clear evidence of the medication’s efficacy. Phrases
like ‘seems better’ or ‘stopped complaining’ are subjective and do not meet clinical
documentation standards.
6. A patient is placed on airborne precautions for suspected tuberculosis. Which of the
following personal protective equipment (PPE) and room requirements are necessary? (Select
all that apply)
A. A private room with negative-pressure airflow.
B. Use of an N95 respirator mask by healthcare workers.
C. Surgical mask for the patient during transport.
D. Goggles or face shield for all patient contact.
E. Disposable gowns for every entry into the room.
Correct Answer: A, B, C
Explanation: Airborne precautions require a private, negative-pressure room to prevent
the spread of infectious particles through the air. Healthcare workers must wear an N95
respirator to filter out small droplets, and the patient must wear a surgical mask when
