NSG 100
FINAL
2026
CONTAINS:
✓ Post-operative pain management and opioid safety
✓ Priority nursing assessments after IV morphine administration
✓ Respiratory depression monitoring (ABCs priority)
✓ Nasogastric tube placement verification (x-ray confirmation)
✓ Pneumonia care and pressure injury risk factors
✓ Skin integrity, nutrition, moisture, mobility, and aging risks
✓ IV potassium administration safety and renal function assessment
✓ Dehydration management and electrolyte considerations
✓ Incentive spirometer teaching and post-operative respiratory care
✓ Cardiac arrest response and ACLS priorities (ventricular fibrillation,
defibrillation)
✓ Blood transfusion reactions (acute hemolytic reaction recognition)
✓ Restraint use regulations (Joint Commission standards)
✓ Mental health nursing: therapeutic communication with hallucinations
✓ Client safety with command hallucinations and schizophrenia
✓ Digoxin (Lanoxin) administration and electrolyte-related toxicity
✓ Hypokalemia and its impact on cardiac glycoside therapy
✓ NCLEX-style multiple-choice and select-all-that-apply questions
✓ Detailed rationales emphasizing priority, safety, and clinical judgment
,A nurse is caring for a client who is 2 hours post-operative following a cholecystectomy. The client
reports pain as a 7 on a scale of 0 to 10. The nurse administers the prescribed intravenous morphine
sulfate. Which of the following assessments is the priority for the nurse to monitor after administering
the medication?
A) Level of consciousness
B) Blood pressure
C) Respiratory rate
D) Incisional drainage
Correct Answer: C) Respiratory rate
Explanation / Rationale:
The correct answer is C. Morphine sulfate is an opioid analgesic that acts on the central nervous
system to relieve pain but also has significant side effects, including respiratory depression.
Respiratory depression is the most life-threatening adverse effect of opioid administration. Monitoring
the respiratory rate is the priority assessment because a significant drop in respiratory rate can lead to
hypoxia, respiratory arrest, and death if not detected and managed promptly. While monitoring level
of consciousness (A), blood pressure (B), and incisional drainage (D) is important in the post-operative
period, the immediate life-threatening risk associated with opioid administration is compromised
respiratory function. Therefore, the ABCs (Airway, Breathing, Circulation) framework prioritizes
respiratory assessment above other parameters.
A nurse is preparing to insert a nasogastric tube for a client requiring gastric decompression. Which of
the following actions should the nurse take to verify correct placement of the tube prior to feeding?
A) Aspirate gastric contents and test the pH
B) Inject 10 mL of air and listen for a whooshing sound over the epigastrium
C) Place the end of the tube in a cup of water to check for bubbling
D) Obtain a portable chest x-ray
Correct Answer: D) Obtain a portable chest x-ray
,Explanation / Rationale:
The correct answer is D. While bedside methods such as checking pH of aspirate (A) are often used for
routine verification, the most reliable and definitive method to confirm placement of a nasogastric
tube, especially before initiating feeding (which carries the risk of aspiration if misplaced in the lung),
is a radiographic examination. An x-ray provides visual confirmation of the tube's position within the
stomach. Checking for a whooshing sound (B) is considered an unreliable method as air can be heard
in the esophagus or trachea. Placing the tube in water (C) is dangerous and contraindicated because if
the tube is in the trachea, the client is at risk for aspiration. While pH testing is a standard bedside
check, x-ray remains the gold standard for initial placement verification, particularly for high-risk
scenarios.
Select-All-That-Apply: A nurse is reviewing the chart of a client admitted with a diagnosis of
pneumonia. Which of the following findings should the nurse identify as risk factors for the
development of pressure injuries? (Select all that apply.)
A) Age 78 years old
B) Body Mass Index (BMI) of 32 (Obesity)
C) Moisture from incontinence
D) Low serum albumin level
E) Diagnosed with anemia
Correct Answer: A, B, C, D, E
Explanation / Rationale:
All options listed are correct. Pressure injuries (ulcers) develop due to prolonged pressure, shear, and
friction, but intrinsic and extrinsic factors significantly increase risk.
A) Age 78: Older adults have decreased skin elasticity, reduced subcutaneous fat, and diminished
blood supply, increasing susceptibility.
B) BMI of 32: Obesity increases pressure on bony prominences and makes turning and repositioning
difficult due to the weight. Conversely, very low BMI is also a risk, but obesity poses specific mobility
and skin fold challenges.
C) Moisture: Incontinence causes the skin to become macerated (softened), making it much more
vulnerable to breakdown from friction and pressure.
, D) Low serum albumin: Indicates malnutrition and poor protein intake, which impairs tissue integrity
and the body's ability to repair damaged skin.
E) Anemia: Results in reduced oxygen-carrying capacity of the blood, leading to decreased
oxygenation of tissues and impaired healing.
A nurse is caring for a client who has been admitted with dehydration. The client has a prescription
for potassium chloride 20 mEq to be added to the current IV infusion. Which of the following actions
should the nurse take prior to administering the potassium?
A) Assess the client for deep tendon reflexes
B) Check the client’s serum potassium level
C) Evaluate the client’s renal function (BUN and Creatinine)
D) Monitor the client’s cardiac rhythm on the telemetry monitor
Correct Answer: C) Evaluate the client’s renal function (BUN and Creatinine)
Explanation / Rationale:
The correct answer is C. While all assessments are relevant to a client receiving potassium, checking
renal function is the priority safety precaution before administration. The kidneys are primarily
responsible for excreting potassium. If a client has renal insufficiency or failure, they cannot excrete
potassium effectively, leading to hyperkalemia. Hyperkalemia can cause life-threatening cardiac
arrhythmias. Therefore, the nurse must ensure the kidneys are functioning adequately before adding
potassium to the IV regimen. Checking the current serum potassium (B) is also important to determine
if replacement is actually needed, but in the context of safety regarding the administration of a
prescribed dose, ensuring the ability to excrete it (renal function) is critical. Monitoring cardiac rhythm
(D) is important during and after administration but is a monitoring step rather than the prerequisite
safety check for administration.
A nurse is teaching a client about the use of a incentive spirometer. Which of the following
instructions should the nurse include in the teaching?
A) Exhale forcefully into the device to raise the ball
B) Perform the exercises once per day
C) Sit upright or in high Fowler’s position
D) Hold your breath for 5 seconds after inhaling
FINAL
2026
CONTAINS:
✓ Post-operative pain management and opioid safety
✓ Priority nursing assessments after IV morphine administration
✓ Respiratory depression monitoring (ABCs priority)
✓ Nasogastric tube placement verification (x-ray confirmation)
✓ Pneumonia care and pressure injury risk factors
✓ Skin integrity, nutrition, moisture, mobility, and aging risks
✓ IV potassium administration safety and renal function assessment
✓ Dehydration management and electrolyte considerations
✓ Incentive spirometer teaching and post-operative respiratory care
✓ Cardiac arrest response and ACLS priorities (ventricular fibrillation,
defibrillation)
✓ Blood transfusion reactions (acute hemolytic reaction recognition)
✓ Restraint use regulations (Joint Commission standards)
✓ Mental health nursing: therapeutic communication with hallucinations
✓ Client safety with command hallucinations and schizophrenia
✓ Digoxin (Lanoxin) administration and electrolyte-related toxicity
✓ Hypokalemia and its impact on cardiac glycoside therapy
✓ NCLEX-style multiple-choice and select-all-that-apply questions
✓ Detailed rationales emphasizing priority, safety, and clinical judgment
,A nurse is caring for a client who is 2 hours post-operative following a cholecystectomy. The client
reports pain as a 7 on a scale of 0 to 10. The nurse administers the prescribed intravenous morphine
sulfate. Which of the following assessments is the priority for the nurse to monitor after administering
the medication?
A) Level of consciousness
B) Blood pressure
C) Respiratory rate
D) Incisional drainage
Correct Answer: C) Respiratory rate
Explanation / Rationale:
The correct answer is C. Morphine sulfate is an opioid analgesic that acts on the central nervous
system to relieve pain but also has significant side effects, including respiratory depression.
Respiratory depression is the most life-threatening adverse effect of opioid administration. Monitoring
the respiratory rate is the priority assessment because a significant drop in respiratory rate can lead to
hypoxia, respiratory arrest, and death if not detected and managed promptly. While monitoring level
of consciousness (A), blood pressure (B), and incisional drainage (D) is important in the post-operative
period, the immediate life-threatening risk associated with opioid administration is compromised
respiratory function. Therefore, the ABCs (Airway, Breathing, Circulation) framework prioritizes
respiratory assessment above other parameters.
A nurse is preparing to insert a nasogastric tube for a client requiring gastric decompression. Which of
the following actions should the nurse take to verify correct placement of the tube prior to feeding?
A) Aspirate gastric contents and test the pH
B) Inject 10 mL of air and listen for a whooshing sound over the epigastrium
C) Place the end of the tube in a cup of water to check for bubbling
D) Obtain a portable chest x-ray
Correct Answer: D) Obtain a portable chest x-ray
,Explanation / Rationale:
The correct answer is D. While bedside methods such as checking pH of aspirate (A) are often used for
routine verification, the most reliable and definitive method to confirm placement of a nasogastric
tube, especially before initiating feeding (which carries the risk of aspiration if misplaced in the lung),
is a radiographic examination. An x-ray provides visual confirmation of the tube's position within the
stomach. Checking for a whooshing sound (B) is considered an unreliable method as air can be heard
in the esophagus or trachea. Placing the tube in water (C) is dangerous and contraindicated because if
the tube is in the trachea, the client is at risk for aspiration. While pH testing is a standard bedside
check, x-ray remains the gold standard for initial placement verification, particularly for high-risk
scenarios.
Select-All-That-Apply: A nurse is reviewing the chart of a client admitted with a diagnosis of
pneumonia. Which of the following findings should the nurse identify as risk factors for the
development of pressure injuries? (Select all that apply.)
A) Age 78 years old
B) Body Mass Index (BMI) of 32 (Obesity)
C) Moisture from incontinence
D) Low serum albumin level
E) Diagnosed with anemia
Correct Answer: A, B, C, D, E
Explanation / Rationale:
All options listed are correct. Pressure injuries (ulcers) develop due to prolonged pressure, shear, and
friction, but intrinsic and extrinsic factors significantly increase risk.
A) Age 78: Older adults have decreased skin elasticity, reduced subcutaneous fat, and diminished
blood supply, increasing susceptibility.
B) BMI of 32: Obesity increases pressure on bony prominences and makes turning and repositioning
difficult due to the weight. Conversely, very low BMI is also a risk, but obesity poses specific mobility
and skin fold challenges.
C) Moisture: Incontinence causes the skin to become macerated (softened), making it much more
vulnerable to breakdown from friction and pressure.
, D) Low serum albumin: Indicates malnutrition and poor protein intake, which impairs tissue integrity
and the body's ability to repair damaged skin.
E) Anemia: Results in reduced oxygen-carrying capacity of the blood, leading to decreased
oxygenation of tissues and impaired healing.
A nurse is caring for a client who has been admitted with dehydration. The client has a prescription
for potassium chloride 20 mEq to be added to the current IV infusion. Which of the following actions
should the nurse take prior to administering the potassium?
A) Assess the client for deep tendon reflexes
B) Check the client’s serum potassium level
C) Evaluate the client’s renal function (BUN and Creatinine)
D) Monitor the client’s cardiac rhythm on the telemetry monitor
Correct Answer: C) Evaluate the client’s renal function (BUN and Creatinine)
Explanation / Rationale:
The correct answer is C. While all assessments are relevant to a client receiving potassium, checking
renal function is the priority safety precaution before administration. The kidneys are primarily
responsible for excreting potassium. If a client has renal insufficiency or failure, they cannot excrete
potassium effectively, leading to hyperkalemia. Hyperkalemia can cause life-threatening cardiac
arrhythmias. Therefore, the nurse must ensure the kidneys are functioning adequately before adding
potassium to the IV regimen. Checking the current serum potassium (B) is also important to determine
if replacement is actually needed, but in the context of safety regarding the administration of a
prescribed dose, ensuring the ability to excrete it (renal function) is critical. Monitoring cardiac rhythm
(D) is important during and after administration but is a monitoring step rather than the prerequisite
safety check for administration.
A nurse is teaching a client about the use of a incentive spirometer. Which of the following
instructions should the nurse include in the teaching?
A) Exhale forcefully into the device to raise the ball
B) Perform the exercises once per day
C) Sit upright or in high Fowler’s position
D) Hold your breath for 5 seconds after inhaling
