Final Exam: NUR 125 Fundamentals of Nursing
Latest 2026/2027 Update
Joyce University
Section I: Safe & Effective Care Environment (Management of Care)
1. A nurse is caring for a client who is post-operative day one following
abdominal surgery. The client reports a pain level of 8 on a scale of 0 to 10. The
nurse administers morphine sulfate 4 mg IV push. What is the nurse's priority
action after administering the medication?
A. Document the medication administration.
B. Assess the client's pain level in 15-30 minutes.
C. Instruct the client to call for assistance before getting up.
D. Evaluate the client's respiratory rate.
✅ Answer: D. Evaluate the client's respiratory rate.
Rationale: Morphine sulfate, an opioid analgesic, can cause respiratory
depression as a life-threatening side effect. The nurse's priority is to assess
,respiratory rate to ensure safety. While all other options are important, airway
and breathing are always the highest priority following opioid administration.
2. A nurse is preparing to delegate tasks to an unlicensed assistive personnel
(UAP). Which task is appropriate for the nurse to delegate?
A. Assessing a client's lung sounds.
B. Creating a plan of care for a client with pneumonia.
C. Performing oral suctioning for a client with a tracheostomy.
D. Ambulating a client who is post-operative day two with a steady gait.
✅ Answer: D. Ambulating a client who is post-operative day two with a
steady gait.
Rationale: Delegation is based on the five rights. Ambulating a stable client is a
standard, routine task that falls within the UAP's scope of practice. Assessment,
planning, and skilled procedures like tracheostomy suctioning are the
responsibility of the licensed nurse.
3. A charge nurse is observing a new graduate nurse perform a sterile dressing
change. Which action by the graduate nurse requires immediate intervention?
A. The nurse opens the sterile kit away from their body.
B. The nurse sets up the sterile field on a clean, dry bedside table.
,C. The nurse reaches over the sterile field to obtain a piece of gauze.
D. The nurse dons sterile gloves before opening the final flap of the sterile kit.
✅ Answer: C. The nurse reaches over the sterile field to obtain a piece of
gauze.
Rationale: Reaching over a sterile field contaminates it, as gravity causes non-
sterile particles to fall onto the sterile surface. Sterile fields must be kept within
view and only approached from the sides. The other options describe correct
sterile technique.
4. A client is being discharged home with a new prescription for warfarin
(Coumadin). Which statement by the client indicates a need for further
teaching?
A. "I will take ibuprofen if I get a headache."
B. "I will eat my normal amount of green leafy vegetables each week."
C. "I will get my blood drawn regularly to check my INR."
D. "I will use an electric razor instead of a manual one."
✅ Answer: A. "I will take ibuprofen if I get a headache."
Rationale: Ibuprofen (an NSAID) increases the risk of gastrointestinal bleeding,
especially when taken with an anticoagulant like warfarin. The client should use
, acetaminophen for pain or headache. Consistency with vitamin K (green leafy
vegetables) is important, and INR monitoring is essential for safety.
5. A nurse is documenting client care. Which entry demonstrates appropriate
documentation practices?
A. "Client seems anxious about the procedure."
B. "Client is in a lot of pain."
C. "Client is uncooperative with staff."
D. "Client's wound dressing is dry and intact, with scant serous drainage noted."
✅ Answer: D. "Client's wound dressing is dry and intact, with scant serous
drainage noted."
Rationale: Documentation must be objective, factual, and descriptive. "Seems,"
"a lot," and "uncooperative" are subjective and judgmental terms. Objective data
is measurable and observable, as in option D.
6. A nurse is planning care for a client who is on contact precautions. Which of
the following should the nurse ensure is available in the client's room?
A. N95 respirator mask
B. Gown and gloves
Latest 2026/2027 Update
Joyce University
Section I: Safe & Effective Care Environment (Management of Care)
1. A nurse is caring for a client who is post-operative day one following
abdominal surgery. The client reports a pain level of 8 on a scale of 0 to 10. The
nurse administers morphine sulfate 4 mg IV push. What is the nurse's priority
action after administering the medication?
A. Document the medication administration.
B. Assess the client's pain level in 15-30 minutes.
C. Instruct the client to call for assistance before getting up.
D. Evaluate the client's respiratory rate.
✅ Answer: D. Evaluate the client's respiratory rate.
Rationale: Morphine sulfate, an opioid analgesic, can cause respiratory
depression as a life-threatening side effect. The nurse's priority is to assess
,respiratory rate to ensure safety. While all other options are important, airway
and breathing are always the highest priority following opioid administration.
2. A nurse is preparing to delegate tasks to an unlicensed assistive personnel
(UAP). Which task is appropriate for the nurse to delegate?
A. Assessing a client's lung sounds.
B. Creating a plan of care for a client with pneumonia.
C. Performing oral suctioning for a client with a tracheostomy.
D. Ambulating a client who is post-operative day two with a steady gait.
✅ Answer: D. Ambulating a client who is post-operative day two with a
steady gait.
Rationale: Delegation is based on the five rights. Ambulating a stable client is a
standard, routine task that falls within the UAP's scope of practice. Assessment,
planning, and skilled procedures like tracheostomy suctioning are the
responsibility of the licensed nurse.
3. A charge nurse is observing a new graduate nurse perform a sterile dressing
change. Which action by the graduate nurse requires immediate intervention?
A. The nurse opens the sterile kit away from their body.
B. The nurse sets up the sterile field on a clean, dry bedside table.
,C. The nurse reaches over the sterile field to obtain a piece of gauze.
D. The nurse dons sterile gloves before opening the final flap of the sterile kit.
✅ Answer: C. The nurse reaches over the sterile field to obtain a piece of
gauze.
Rationale: Reaching over a sterile field contaminates it, as gravity causes non-
sterile particles to fall onto the sterile surface. Sterile fields must be kept within
view and only approached from the sides. The other options describe correct
sterile technique.
4. A client is being discharged home with a new prescription for warfarin
(Coumadin). Which statement by the client indicates a need for further
teaching?
A. "I will take ibuprofen if I get a headache."
B. "I will eat my normal amount of green leafy vegetables each week."
C. "I will get my blood drawn regularly to check my INR."
D. "I will use an electric razor instead of a manual one."
✅ Answer: A. "I will take ibuprofen if I get a headache."
Rationale: Ibuprofen (an NSAID) increases the risk of gastrointestinal bleeding,
especially when taken with an anticoagulant like warfarin. The client should use
, acetaminophen for pain or headache. Consistency with vitamin K (green leafy
vegetables) is important, and INR monitoring is essential for safety.
5. A nurse is documenting client care. Which entry demonstrates appropriate
documentation practices?
A. "Client seems anxious about the procedure."
B. "Client is in a lot of pain."
C. "Client is uncooperative with staff."
D. "Client's wound dressing is dry and intact, with scant serous drainage noted."
✅ Answer: D. "Client's wound dressing is dry and intact, with scant serous
drainage noted."
Rationale: Documentation must be objective, factual, and descriptive. "Seems,"
"a lot," and "uncooperative" are subjective and judgmental terms. Objective data
is measurable and observable, as in option D.
6. A nurse is planning care for a client who is on contact precautions. Which of
the following should the nurse ensure is available in the client's room?
A. N95 respirator mask
B. Gown and gloves
