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Excelsior College NUR 109 NR109 Final Exam 2
Questions and Correct Answers (Verified Answers)
Plus Rationales 2025
- Which of the following best describes the primary purpose of the nursing process? a) To perform physician orders b) To provide a framework for individualized patient care c) To document patient care accurately d) To administer medications safely b) To provide a framework for individualized patient care The nursing process is a systematic, patient-centered approach used to assess, diagnose, plan, implement, and evaluate care tailored to each patient's needs.
- When performing hand hygiene, which action is most effective in reducing the spread of infection? a) Using hand sanitizer after touching a patient b) Washing hands with soap and water for at least 20 seconds c) Wearing gloves at all times d) Rinsing hands under cold water b) Washing hands with soap and water for at least 20 seconds Proper handwashing with soap and water for at least 20 seconds is the
most effective way to remove pathogens and prevent infection transmission.
- What is the correct order of steps in the nursing process? a) Planning, assessment, implementation, evaluation, diagnosis b) Assessment, diagnosis, planning, implementation, evaluation c) Diagnosis, assessment, planning, implementation, evaluation d) Assessment, planning, implementation, diagnosis, evaluation b) Assessment, diagnosis, planning, implementation, evaluation The nursing process follows this order to ensure systematic care: first assess, then diagnose, plan care, implement it, and finally evaluate outcomes.
- Which vital sign typically increases with pain or anxiety? a) Blood pressure b) Temperature c) Respiratory rate d) Oxygen saturation c) Respiratory rate Pain and anxiety stimulate sympathetic nervous system responses, increasing respiratory rate along with heart rate and blood pressure.
- The nurse is preparing to administer a medication. Which is the best practice to ensure patient safety? a) Administer medication as soon as it arrives b) Check the medication label three times before administration c) Ask the patient if they want the medication
b) Infection c) Circulation d) Sensory function a) Hydration status Skin turgor assesses skin elasticity, which decreases with dehydration.
- The nurse instructs a patient on the importance of deep breathing and coughing exercises postoperatively to: a) Prevent atelectasis b) Improve muscle strength c) Decrease pain d) Promote wound healing a) Prevent atelectasis Deep breathing and coughing help expand the lungs and clear secretions, preventing lung collapse (atelectasis). 10.Which electrolyte imbalance is commonly seen with dehydration? a) Hyperkalemia b) Hypokalemia c) Hypernatremia d) Hyponatremia c) Hypernatremia Dehydration often causes loss of water greater than sodium, leading to elevated sodium levels (hypernatremia). 11.What is the most appropriate site for assessing an infant’s pulse? a) Radial artery
b) Brachial artery c) Carotid artery d) Femoral artery b) Brachial artery The brachial artery is the preferred site to assess pulse in infants due to accessibility and reliability. 12.A patient receiving oxygen therapy develops nasal dryness and irritation. What intervention should the nurse implement? a) Increase oxygen flow rate b) Use a humidifier with oxygen delivery c) Discontinue oxygen therapy d) Apply petroleum jelly inside the nostrils b) Use a humidifier with oxygen delivery Humidifying oxygen helps prevent dryness and irritation of mucous membranes. 13.Which assessment finding requires immediate intervention? a) Oxygen saturation 95% on room air b) Respiratory rate 28 breaths/min c) Blood pressure 90/40 mm Hg d) Pulse 88 beats/min c) Blood pressure 90/40 mm Hg Hypotension (low blood pressure) may indicate inadequate perfusion and requires prompt assessment and intervention.
To maintain sterility, only the inside (glove lining) should be touched when donning gloves. 17.Which of the following assessments is most important for a patient receiving IV fluids? a) Lung sounds b) Bowel sounds c) Pupillary response d) Peripheral pulses a) Lung sounds Monitoring lung sounds helps detect fluid overload, a common risk with IV therapy. 18.When should the nurse document care provided? a) Immediately after care is given b) At the end of the shift c) When requested by the physician d) Within 24 hours of care a) Immediately after care is given Timely documentation ensures accuracy and continuity of care. 19.What is the priority action when a patient develops anaphylaxis? a) Administer epinephrine b) Monitor vital signs c) Apply ice packs d) Give oral antihistamines a) Administer epinephrine
Epinephrine is the first-line treatment for anaphylaxis to reverse airway constriction and hypotension. 20.Which of the following is a common side effect of opioid analgesics? a) Diarrhea b) Respiratory depression c) Hypertension d) Increased appetite b) Respiratory depression Opioids can suppress the respiratory center in the brain, causing slow, shallow breathing. 21.What is the first step in wound care after removing the old dressing? a) Apply new dressing b) Cleanse the wound c) Assess the wound for signs of infection d) Administer pain medication c) Assess the wound for signs of infection Assessment guides appropriate care; always inspect before cleaning or dressing. 22.The nurse should assess for which symptom as an early sign of hypoxia? a) Bradycardia b) Cyanosis c) Restlessness d) Hypotension c) Restlessness
a) Call for help and begin CPR Immediate CPR is critical to restore circulation and oxygenation. 26.What is the correct angle to insert an intramuscular (IM) injection? a) 15 degrees b) 45 degrees c) 90 degrees d) 30 degrees c) 90 degrees IM injections are given at a 90-degree angle to ensure delivery into muscle tissue. 27.Which of the following patients is most at risk for developing pressure ulcers? a) A patient who is ambulatory and eats well b) A patient confined to bed with limited sensation c) A patient who exercises regularly d) A patient with normal skin turgor b) A patient confined to bed with limited sensation Immobility and reduced sensation increase pressure ulcer risk due to unrelieved pressure. 28.What does the acronym "SBAR" stand for in communication? a) Situation, Background, Assessment, Recommendation b) Symptoms, Behavior, Action, Response c) Safety, Balance, Alertness, Rest d) Standard, Behavior, Action, Reporting
a) Situation, Background, Assessment, Recommendation SBAR is a standardized communication tool used to convey critical information clearly. 29.When should the nurse perform a pain assessment? a) Only when the patient requests medication b) Before and after interventions c) Once per shift d) Only during admission b) Before and after interventions Assessing pain before and after treatment helps evaluate effectiveness. 30.Which statement best describes informed consent? a) Permission granted after full explanation of risks and benefits b) A signed form from the physician c) Consent assumed in emergency situations d) A verbal agreement without documentation a) Permission granted after full explanation of risks and benefits Informed consent requires that the patient fully understands the procedure and voluntarily agrees. 31.The nurse is caring for a patient with a nasogastric (NG) tube. Which intervention prevents aspiration? a) Positioning patient flat in bed b) Maintaining the head of the bed elevated at least 30 degrees c) Feeding quickly to reduce discomfort d) Removing the tube frequently
a) Document the refusal and notify the healthcare provider Patient autonomy must be respected; refusals should be documented and communicated. 35.Which part of the nursing diagnosis identifies the cause of the patient’s problem? a) Defining characteristics b) Related factors c) Risk factors d) Goals b) Related factors Related factors explain the etiology or cause of the nursing diagnosis. 36.Which action best demonstrates patient advocacy? a) Speaking up when care is compromised b) Following all physician orders without question c) Ignoring patient complaints to avoid conflict d) Administering medications as quickly as possible a) Speaking up when care is compromised Advocacy involves protecting patient rights and ensuring safe, ethical care. 37.What is the primary goal of discharge planning? a) Prevent readmission by ensuring continuity of care b) Teach patients about medications only c) Schedule follow-up appointments only d) Prepare paperwork for insurance
a) Prevent readmission by ensuring continuity of care Discharge planning focuses on coordinating resources to support patient safety after leaving the hospital. 38.Which patient position is best for a patient with suspected spinal injury? a) Trendelenburg b) Supine with head elevated c) Lateral with neck immobilized d) Prone c) Lateral with neck immobilized Spinal precautions include immobilization and positioning to prevent further injury. 39.A patient has thick, green sputum and fever. What does this indicate? a) Viral infection b) Bacterial infection c) Allergic reaction d) Normal condition b) Bacterial infection Green sputum and fever commonly indicate bacterial respiratory infection. 40.Which of the following nursing actions promotes effective communication with a hearing-impaired patient? a) Speaking loudly without facing the patient b) Using written communication and maintaining eye contact c) Avoiding gestures to reduce confusion
c) Poor skin turgor d) Low blood pressure b) Distended neck veins Jugular vein distention is a classic sign of fluid overload and heart failure. 44.The nurse assesses a patient’s Glasgow Coma Scale score as 8. What does this indicate? a) Mild brain injury b) Moderate brain injury c) Severe brain injury d) Normal neurological status c) Severe brain injury A score of 8 or less indicates severe brain injury and often requires airway protection. 45.What is the best method to prevent medication errors? a) Administer medications quickly to avoid delays b) Double-check medication orders and patient identity c) Rely on memory to recall dosages d) Use abbreviations freely in documentation b) Double-check medication orders and patient identity Verifying orders and patient identity are critical safety steps to prevent errors. 46.What is the normal adult respiratory rate? a) 8-12 breaths per minute b) 12-20 breaths per minute
c) 20-30 breaths per minute d) 30-40 breaths per minute b) 12-20 breaths per minute The normal adult respiratory rate is 12-20 breaths per minute. 47.When should a nurse perform a pain assessment? a) Only when the patient complains b) Before and after analgesic administration c) Once per day d) Only during morning rounds b) Before and after analgesic administration Pain assessment before and after medication evaluates effectiveness and guides further care. 48.Which of the following actions is appropriate for infection control? a) Wearing gloves for all patient contact b) Using alcohol-based hand sanitizer after removing gloves c) Reusing disposable gowns if not visibly soiled d) Cleaning stethoscope weekly b) Using alcohol-based hand sanitizer after removing gloves Hand hygiene after glove removal is essential to prevent cross- contamination. 49.What is the primary goal of patient education? a) To inform patients about their condition and promote self-care b) To reduce nursing workload c) To complete documentation requirements
b) Droplet precautions c) Airborne precautions d) Standard precautions c) Airborne precautions Tuberculosis is transmitted via airborne particles; patients require negative pressure rooms and N95 masks. 53.When auscultating bowel sounds, the nurse should listen for how long before determining they are absent? a) 15 seconds b) 1 minute c) 3-5 minutes d) 10 minutes c) 3-5 minutes Bowel sounds must be absent after listening for at least 3-5 minutes before concluding they are absent. 54.What is the first sign of a developing pressure ulcer? a) Open wound b) Redness that does not blanch c) Skin cracking d) Swelling b) Redness that does not blanch Non-blanchable erythema indicates early tissue ischemia, a sign of pressure ulcer formation.
55.Which position is best to promote drainage of the left lung? a) Left lateral b) Right lateral c) Supine d) Prone b) Right lateral Positioning the right side down allows drainage of the left lung by gravity. 56.How often should a nurse reposition a bedridden patient to prevent pressure ulcers? a) Every 2 hours b) Every 4 hours c) Every 6 hours d) Once per shift a) Every 2 hours Frequent repositioning relieves pressure and promotes circulation to prevent ulcers. 57.The nurse notes a patient’s pulse is irregularly irregular. Which condition is most likely? a) Sinus bradycardia b) Atrial fibrillation c) Ventricular tachycardia d) Normal sinus rhythm b) Atrial fibrillation Atrial fibrillation causes an irregularly irregular pulse due to disorganized atrial electrical activity.
