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Excelsior College NUR 109 NR109 Final Exam 1
Questions and Correct Answers (Verified Answers)
Plus Rationales 2025
- What is the primary purpose of nursing assessment? a) To diagnose medical conditions b) To collect data for planning care c) To administer medications d) To provide emotional support b) To collect data for planning care Nursing assessment involves gathering patient information to identify health problems and plan appropriate nursing interventions.
- Which of the following is an example of subjective data? a) Blood pressure reading b) Patient’s report of pain c) Temperature measurement d) Respiratory rate b) Patient’s report of pain Subjective data refers to information reported by the patient, such as feelings or symptoms, which cannot be directly measured.
- When washing your hands, how long should you rub them with soap and water?
a) 5 seconds b) 10 seconds c) 20 seconds d) 30 seconds c) 20 seconds The CDC recommends washing hands for at least 20 seconds to effectively remove germs.
- Which PPE is necessary when there is risk of splashing blood? a) Gloves only b) Gloves and mask c) Gloves, mask, and gown d) Gloves and goggles c) Gloves, mask, and gown To protect from blood splashes, gloves, mask, and gown are necessary to prevent contamination of skin and clothing.
- What is the normal adult respiratory rate? a) 6–10 breaths per minute b) 12–20 breaths per minute c) 2 0 – 28 breaths per minute d) 30–40 breaths per minute b) 12–20 breaths per minute Normal adult respiratory rate typically ranges between 12 and 20 breaths per minute.
- What is the most important step in preventing pressure ulcers? a) Use of barrier creams b) Frequent repositioning c) Massaging bony prominences d) Applying heat packs b) Frequent repositioning Repositioning relieves pressure on vulnerable areas, preventing skin breakdown. 10.Which lab test is used to assess kidney function? a) Hemoglobin b) Blood urea nitrogen (BUN) c) Liver enzymes d) Blood glucose b) Blood urea nitrogen (BUN) BUN measures nitrogen waste in the blood, indicating kidney function. 11.What does the acronym SOAP stand for in documentation? a) Subjective, Objective, Assessment, Plan b) Symptoms, Observation, Analysis, Procedure c) Standard, Objective, Assessment, Plan d) Subjective, Observation, Action, Plan a) Subjective, Objective, Assessment, Plan SOAP is a format used in nursing and medical documentation to organize patient information. 12.What is the first action when a patient starts to fall?
a) Call for help b) Try to catch the patient c) Assist patient to the floor safely d) Pull the patient back up immediately c) Assist patient to the floor safely To prevent injury, guide the patient gently to the floor rather than trying to catch and risk falling yourself. 13.What is the normal range for adult blood pressure? a) 80/40 mmHg b) 90/60 mmHg c) 120/80 mmHg d) 140/90 mmHg c) 120/80 mmHg A normal adult blood pressure is considered around 120 systolic over 80 diastolic. 14.Which of the following indicates orthostatic hypotension? a) Increase in heart rate when standing b) Drop in blood pressure when standing c) Elevated blood pressure when sitting d) Decreased respiratory rate when lying down b) Drop in blood pressure when standing Orthostatic hypotension occurs when blood pressure drops upon standing, causing dizziness or fainting.
b) 20–22 gauge 20 – 22 gauge needles are commonly used for adult IM injections to ensure medication delivery into muscle. 18.Which of the following is a sign of hypoglycemia? a) Excessive thirst b) Sweating and shakiness c) Slow pulse d) Increased urination b) Sweating and shakiness Hypoglycemia causes sympathetic nervous system activation, resulting in sweating and tremors. 19.What is the recommended angle for subcutaneous injections? a) 15 degrees b) 45 degrees c) 90 degrees d) 60 degrees b) 45 degrees Subcutaneous injections are generally given at a 45-degree angle to avoid injecting into muscle. 20.When documenting a medication administration, what must be included? a) Time and dose b) Medication name
c) Route of administration d) All of the above d) All of the above Complete documentation includes medication name, dose, route, time, and any patient response. 21.Which of the following is a symptom of fluid overload? a) Dry mucous membranes b) Edema and crackles in lungs c) Hypotension d) Decreased urine output b) Edema and crackles in lungs Fluid overload causes edema and pulmonary congestion, leading to crackles heard on auscultation. 22.What does the Glasgow Coma Scale measure? a) Muscle strength b) Level of consciousness c) Reflex response d) Sensory perception b) Level of consciousness The Glasgow Coma Scale assesses eye, verbal, and motor responses to determine neurological status. 23.Which of the following is an example of a primary prevention strategy?
a) 1 mL b) 2 mL c) 3 mL d) 5 mL c) 3 mL Up to 3 mL of medication can be safely given IM in most adult muscle sites. 27.Which electrolyte imbalance causes muscle weakness and irregular pulse? a) Hyperkalemia b) Hypokalemia c) Hypernatremia d) Hyponatremia a) Hyperkalemia High potassium levels cause muscle weakness and cardiac arrhythmias. 28.When is it appropriate to use the recovery position? a) When a patient is vomiting and unconscious b) When a patient is fully alert c) When a patient is complaining of chest pain d) When a patient is having a seizure a) When a patient is vomiting and unconscious The recovery position helps keep the airway clear and prevents aspiration. 29.What is the priority nursing intervention for a patient with shortness of breath?
a) Administer oxygen b) Start an IV c) Check vital signs d) Call family a) Administer oxygen Oxygen administration improves tissue oxygenation and relieves respiratory distress. 30.How should you respond to a patient who refuses medication? a) Force the medication b) Document refusal and notify the provider c) Ignore the refusal d) Tell the patient medication is mandatory b) Document refusal and notify the provider Respect patient autonomy, document refusal, and inform the healthcare team. 31.What is the first sign of infection? a) Redness and swelling b) Fever c) Pain d) Elevated white blood cell count a) Redness and swelling Local infection usually first presents with inflammation signs like redness and swelling. 32.How often should vital signs be taken in a stable patient?
35.Which is a sign of dehydration? a) Moist mucous membranes b) Tenting skin turgor c) Clear urine d) Edema b) Tenting skin turgor Poor skin turgor (tenting) indicates dehydration. 36.Which route of medication administration has the fastest onset? a) Oral b) Subcutaneous c) Intramuscular d) Intravenous d) Intravenous IV administration delivers medication directly into the bloodstream for rapid effect. 37.What is the recommended fluid intake per day for an adult? a) 500 mL b) 1 liter c) 2–3 liters d) 4–5 liters c) 2–3 liters Average adult fluid requirement is approximately 2 to 3 liters per day. 38.When measuring intake and output, which is considered output?
a) Oral fluids b) Vomit c) Ice chips d) Intravenous fluids b) Vomit Output includes bodily fluids expelled such as urine, vomit, and diarrhea. 39.What is the primary goal of pain management? a) Eliminate pain completely b) Reduce pain to a tolerable level c) Sedate the patient d) Avoid all medication b) Reduce pain to a tolerable level Pain management aims to improve comfort and function, not necessarily total elimination. 40.Which sign indicates hypoxia? a) Cyanosis b) Bradycardia c) Hypotension d) Hyperthermia a) Cyanosis Bluish discoloration of skin or mucous membranes indicates insufficient oxygenation. 41.What is the correct sequence when donning PPE?
a) Deliver oxygen b) Provide nutrition or remove gastric contents c) Measure blood pressure d) Administer medications intravenously b) Provide nutrition or remove gastric contents NG tubes are used for feeding or suctioning stomach contents. 45.What is a common sign of infection in older adults? a) High fever b) Confusion or delirium c) Rash d) Chest pain b) Confusion or delirium Older adults may present infection with atypical symptoms like confusion. 46.Which action is part of standard precautions? a) Wearing gloves only for blood b) Hand hygiene before and after patient contact c) Isolating all patients d) Using sterile gloves for all procedures b) Hand hygiene before and after patient contact Standard precautions emphasize hand hygiene for all patient care activities. 47.What is the best site for intradermal injection? a) Abdomen b) Inner forearm
c) Thigh d) Upper arm deltoid b) Inner forearm Intradermal injections are usually given in the inner forearm for easy observation. 48.What is the normal range for adult heart rate? a) 40–60 beats per minute b) 60–100 beats per minute c) 100–120 beats per minute d) 120–140 beats per minute b) 60–100 beats per minute A normal adult heart rate ranges between 60 and 100 beats per minute. 49.What should be done if a medication error occurs? a) Inform the patient and provider immediately b) Hide the error c) Wait and see if any reaction occurs d) Document the error only if asked a) Inform the patient and provider immediately Prompt reporting ensures patient safety and appropriate corrective measures. 50.What is the priority action when a patient is experiencing chest pain? a) Administer pain medication b) Assess vital signs and notify the provider
a) Clear lung sounds b) Frequent coughing with sputum c) Oxygen saturation at 98% d) Pink, moist mucous membranes b) Frequent coughing with sputum Frequent coughing and sputum production suggest the patient is trying to clear airway secretions. 54.What should a nurse do first when a patient experiences a seizure? a) Insert a tongue blade b) Restrain the patient c) Protect the patient from injury d) Call for emergency drugs c) Protect the patient from injury Ensuring patient safety by preventing injury during a seizure is the priority. 55.Which of the following is an expected finding in a patient with dehydration? a) Bounding pulse b) Elevated blood pressure c) Dry mucous membranes d) Peripheral edema c) Dry mucous membranes Dehydration causes dryness of mucous membranes due to fluid loss. 56.Which type of isolation precaution is required for a patient with tuberculosis?
a) Contact precautions b) Droplet precautions c) Airborne precautions d) Standard precautions c) Airborne precautions Tuberculosis is spread via airborne particles, requiring specialized precautions. 57.What is the primary purpose of a Foley catheter? a) Measure bladder volume b) Administer medications c) Drain urine continuously d) Provide fluids c) Drain urine continuously Foley catheters are used for continuous drainage of urine from the bladder. 58.What is the best indicator of adequate tissue perfusion? a) Capillary refill less than 3 seconds b) Blood pressure above 100/60 mmHg c) Heart rate above 90 bpm d) Urine output less than 20 mL/hr a) Capillary refill less than 3 seconds Capillary refill time is a quick assessment of peripheral perfusion. 59.What is a normal finding when assessing a surgical wound? a) Purulent drainage b) Redness confined to wound edges
