**The Fundamentals & Health Assessment Final:
NGN Foundations of Nursing Practice**
1. A nurse is performing a physical assessment on a client admitted with abdominal pain. Which
technique should the nurse perform first?
A) Palpation of the abdomen
B) Percussion of the abdomen
C) Auscultation of bowel sounds
D) Inspection of the abdomen
💫RATIONALE✔️✔️: Inspection is always the first assessment technique; palpation and percussion after
auscultation prevent altering bowel sounds.
💫ANSWER✔️✔️: D) Inspection of the abdomen
---
2. A nurse is caring for a client with a nasogastric tube to low intermittent suction. Which finding
indicates the tube is properly placed?
A) The client reports a sore throat
B) Aspirate has a pH of 4
C) Bowel sounds are hypoactive
D) The tube is taped to the bed sheet
💫RATIONALE✔️✔️: Gastric aspirate pH is typically ≤4; respiratory aspirate has pH >6.
💫ANSWER✔️✔️: B) Aspirate has a pH of 4
---
3. A nurse is providing oral care for an unconscious client. Which action is correct?
A) Place the client in a supine position
B) Use a small amount of water to rinse the mouth
,C) Position the client on the side with the head lowered
D) Use a firm toothbrush to remove plaque
💫RATIONALE✔️✔️: Side-lying with head lowered prevents aspiration of fluids during oral care.
💫ANSWER✔️✔️: C) Position the client on the side with the head lowered
---
4. A nurse is calculating intake for a client with heart failure. The client drank 6 oz of coffee, 4 oz of
water, and ate 8 oz of ice chips. What is the total intake in mL?
A) 420 mL
B) 480 mL
C) 540 mL
D) 600 mL
💫RATIONALE✔️✔️: 6 oz (180 mL) + 4 oz (120 mL) + 8 oz ice chips (240 mL, half volume) = 540 mL total.
💫ANSWER✔️✔️: C) 540 mL
---
5. A nurse is assessing a client’s peripheral pulses. Which pulse requires the use of a doppler device?
A) Radial pulse 2+
B) Pedal pulse palpable but weak (1+)
C) Popliteal pulse not palpable
D) Carotid pulse 3+
💫RATIONALE✔️✔️: A non-palpable pulse requires a doppler to assess blood flow; 1+ is palpable but
weak.
💫ANSWER✔️✔️: C) Popliteal pulse not palpable
---
6. A nurse is teaching a client about a low-sodium diet. Which food choice indicates understanding?
A) Canned vegetable soup
B) Grilled chicken breast with steamed broccoli
,C) Ham and cheese sandwich
D) Frozen lasagna
💫RATIONALE✔️✔️: Fresh or grilled chicken with steamed vegetables is naturally low in sodium;
processed foods are high in sodium.
💫ANSWER✔️✔️: B) Grilled chicken breast with steamed broccoli
---
7. A nurse is preparing to insert an indwelling urinary catheter. Which technique is correct?
A) Inflate the balloon before insertion to check integrity
B) Insert the catheter until urine flows, then advance 2-3 cm more
C) Use sterile gloves for the procedure but clean gloves are optional
D) Apply lubricant to the catheter tip and the meatus
💫RATIONALE✔️✔️: Advance the catheter 2-3 cm after urine flow to ensure balloon is in the bladder.
💫ANSWER✔️✔️: B) Insert the catheter until urine flows, then advance 2-3 cm more
---
8. A client with a new colostomy asks about odor control. Which instruction is correct?
A) "Place a slice of fresh onion in the pouch"
B) "Empty the pouch when it is one-third full"
C) "Use soap and water to clean the stoma daily"
D) "Avoid all high-fiber foods permanently"
💫RATIONALE✔️✔️: Emptying the pouch at one-third full prevents leakage and reduces odor; deodorants
can be added to pouch.
💫ANSWER✔️✔️: B) "Empty the pouch when it is one-third full"
---
9. A nurse is assessing a client’s respiratory status. Which finding is abnormal?
A) Respiratory rate of 16 breaths/min
B) Symmetrical chest expansion
, C) Bronchial breath sounds over the peripheral lung fields
D) Clear breath sounds in all lobes
💫RATIONALE✔️✔️: Bronchial breath sounds are normal only over the trachea; vesicular sounds are
normal over peripheral lung fields.
💫ANSWER✔️✔️: C) Bronchial breath sounds over the peripheral lung fields
---
10. A nurse is preparing to administer an enema. Which position is most appropriate?
A) Prone
B) Supine with legs elevated
C) Left lateral Sims' position
D) Trendelenburg
💫RATIONALE✔️✔️: Left lateral Sims' position follows the natural curve of the sigmoid colon and
improves enema retention.
💫ANSWER✔️✔️: C) Left lateral Sims' position
---
11. A nurse is caring for a client with a fever. Which finding indicates that an antipyretic medication is
effective?
A) Heart rate 110 bpm
B) Respiratory rate 24 breaths/min
C) Temperature decreases from 102.2°F to 99.8°F
D) Skin is warm and dry
💫RATIONALE✔️✔️: A decrease in temperature indicates antipyretic effectiveness; defervescence may
take 60-90 minutes.
💫ANSWER✔️✔️: C) Temperature decreases from 102.2°F to 99.8°F
---
12. A nurse is assessing a client’s cranial nerve XII (hypoglossal). Which action should the nurse ask the
client to perform?
NGN Foundations of Nursing Practice**
1. A nurse is performing a physical assessment on a client admitted with abdominal pain. Which
technique should the nurse perform first?
A) Palpation of the abdomen
B) Percussion of the abdomen
C) Auscultation of bowel sounds
D) Inspection of the abdomen
💫RATIONALE✔️✔️: Inspection is always the first assessment technique; palpation and percussion after
auscultation prevent altering bowel sounds.
💫ANSWER✔️✔️: D) Inspection of the abdomen
---
2. A nurse is caring for a client with a nasogastric tube to low intermittent suction. Which finding
indicates the tube is properly placed?
A) The client reports a sore throat
B) Aspirate has a pH of 4
C) Bowel sounds are hypoactive
D) The tube is taped to the bed sheet
💫RATIONALE✔️✔️: Gastric aspirate pH is typically ≤4; respiratory aspirate has pH >6.
💫ANSWER✔️✔️: B) Aspirate has a pH of 4
---
3. A nurse is providing oral care for an unconscious client. Which action is correct?
A) Place the client in a supine position
B) Use a small amount of water to rinse the mouth
,C) Position the client on the side with the head lowered
D) Use a firm toothbrush to remove plaque
💫RATIONALE✔️✔️: Side-lying with head lowered prevents aspiration of fluids during oral care.
💫ANSWER✔️✔️: C) Position the client on the side with the head lowered
---
4. A nurse is calculating intake for a client with heart failure. The client drank 6 oz of coffee, 4 oz of
water, and ate 8 oz of ice chips. What is the total intake in mL?
A) 420 mL
B) 480 mL
C) 540 mL
D) 600 mL
💫RATIONALE✔️✔️: 6 oz (180 mL) + 4 oz (120 mL) + 8 oz ice chips (240 mL, half volume) = 540 mL total.
💫ANSWER✔️✔️: C) 540 mL
---
5. A nurse is assessing a client’s peripheral pulses. Which pulse requires the use of a doppler device?
A) Radial pulse 2+
B) Pedal pulse palpable but weak (1+)
C) Popliteal pulse not palpable
D) Carotid pulse 3+
💫RATIONALE✔️✔️: A non-palpable pulse requires a doppler to assess blood flow; 1+ is palpable but
weak.
💫ANSWER✔️✔️: C) Popliteal pulse not palpable
---
6. A nurse is teaching a client about a low-sodium diet. Which food choice indicates understanding?
A) Canned vegetable soup
B) Grilled chicken breast with steamed broccoli
,C) Ham and cheese sandwich
D) Frozen lasagna
💫RATIONALE✔️✔️: Fresh or grilled chicken with steamed vegetables is naturally low in sodium;
processed foods are high in sodium.
💫ANSWER✔️✔️: B) Grilled chicken breast with steamed broccoli
---
7. A nurse is preparing to insert an indwelling urinary catheter. Which technique is correct?
A) Inflate the balloon before insertion to check integrity
B) Insert the catheter until urine flows, then advance 2-3 cm more
C) Use sterile gloves for the procedure but clean gloves are optional
D) Apply lubricant to the catheter tip and the meatus
💫RATIONALE✔️✔️: Advance the catheter 2-3 cm after urine flow to ensure balloon is in the bladder.
💫ANSWER✔️✔️: B) Insert the catheter until urine flows, then advance 2-3 cm more
---
8. A client with a new colostomy asks about odor control. Which instruction is correct?
A) "Place a slice of fresh onion in the pouch"
B) "Empty the pouch when it is one-third full"
C) "Use soap and water to clean the stoma daily"
D) "Avoid all high-fiber foods permanently"
💫RATIONALE✔️✔️: Emptying the pouch at one-third full prevents leakage and reduces odor; deodorants
can be added to pouch.
💫ANSWER✔️✔️: B) "Empty the pouch when it is one-third full"
---
9. A nurse is assessing a client’s respiratory status. Which finding is abnormal?
A) Respiratory rate of 16 breaths/min
B) Symmetrical chest expansion
, C) Bronchial breath sounds over the peripheral lung fields
D) Clear breath sounds in all lobes
💫RATIONALE✔️✔️: Bronchial breath sounds are normal only over the trachea; vesicular sounds are
normal over peripheral lung fields.
💫ANSWER✔️✔️: C) Bronchial breath sounds over the peripheral lung fields
---
10. A nurse is preparing to administer an enema. Which position is most appropriate?
A) Prone
B) Supine with legs elevated
C) Left lateral Sims' position
D) Trendelenburg
💫RATIONALE✔️✔️: Left lateral Sims' position follows the natural curve of the sigmoid colon and
improves enema retention.
💫ANSWER✔️✔️: C) Left lateral Sims' position
---
11. A nurse is caring for a client with a fever. Which finding indicates that an antipyretic medication is
effective?
A) Heart rate 110 bpm
B) Respiratory rate 24 breaths/min
C) Temperature decreases from 102.2°F to 99.8°F
D) Skin is warm and dry
💫RATIONALE✔️✔️: A decrease in temperature indicates antipyretic effectiveness; defervescence may
take 60-90 minutes.
💫ANSWER✔️✔️: C) Temperature decreases from 102.2°F to 99.8°F
---
12. A nurse is assessing a client’s cranial nerve XII (hypoglossal). Which action should the nurse ask the
client to perform?
