NU 301 Unit 4 Exam (PDF) | (Updated) NCLEX-Style
Fundamentals of Nursing Questions — 200 Questions
Section 1: Management of Care (Questions 1-25)
1 A nurse is leading a multidisciplinary team in a community health center. The team is developing a care plan for
a patient with complex chronic conditions who frequently misses appointments. Which approach best aligns
with principles of patient-centered care coordination?
A) Assign a case manager to schedule all appointments and follow up via phone calls
B) Collaborate with the patient to identify barriers and co-create a flexible care schedule
C) Refer the patient to a social worker for transportation assistance only
D) Document missed appointments in the chart and discharge the patient after three no-shows
Answer: B
Rationale: Patient-centered care coordination requires active partnership with the patient to address individual
barriers. Option B empowers the patient and respects their autonomy, improving adherence. Option A is
prescriptive and may not address root causes; option C is too narrow; option D is punitive and violates ethical
principles.
2 A charge nurse is making assignments for a medical-surgical unit with four registered nurses (RNs), two
licensed practical nurses (LPNs), and two nursing assistants (NAs). Which assignment best demonstrates
appropriate delegation within scope of practice?
A) Assign the LPN to administer IV push antibiotics to a patient with a central line
B) Assign the NA to perform a sterile dressing change for a surgical wound
C) Assign the RN to monitor a patient receiving a blood transfusion for the first 15 minutes
D) Assign the LPN to conduct the initial admission assessment for a new patient
Answer: C
Rationale: RNs are responsible for monitoring blood transfusions due to the risk of reactions; this is within their
scope. LPNs cannot administer IV push medications in most states (option A). NAs cannot perform sterile
procedures (option B). Initial admission assessments require RN-level critical thinking (option D).
3 During a disaster drill, the hospital incident command center receives word of a mass casualty event with 50
victims. The triage officer must prioritize care using the Simple Triage and Rapid Treatment (START) system.
Which victim should be classified as 'Immediate' (red tag)?
A) A victim with a palpable radial pulse, respiratory rate 22, and able to follow commands
B) A victim with no spontaneous respirations after airway repositioning
C) A victim with respiratory rate 40 and capillary refill less than 2 seconds
D) A victim with a respiratory rate of 8 and no radial pulse
Answer: C
Rationale: In START, respiratory rate >30 is a criterion for immediate (red) category. Option C has RR 40, meeting
that threshold. Option A is delayed (green). Option B is deceased (black). Option D has no radial pulse, indicating
critical but not necessarily immediate based on RR; however, RR<10 and no pulse would likely be expectant or
deceased, but per START, RR>30 is immediate.
,4 A nurse manager is implementing a new evidence-based protocol to reduce catheter-associated urinary tract
infections (CAUTIs). The unit has a culture of resistance to change. Which strategy is most effective for
achieving sustained adherence?
A) Mandate compliance through written warnings for non-adherence
B) Provide a single educational session on the protocol's benefits
C) Engage frontline staff as champions and provide real-time feedback on compliance
D) Post the protocol on the unit bulletin board and send a memo
Answer: C
Rationale: Sustained practice change requires active engagement of staff, peer influence, and feedback. Champions
and real-time feedback address resistance and promote ownership. Mandates (A) create resentment; single
education (B) is insufficient; passive posting (D) has low impact.
5 A nurse is caring for four patients. Which patient should the nurse assess first?
A) A patient with a newly placed chest tube who reports pain at the insertion site
B) A patient with diabetes who has a blood glucose of 180 mg/dL and is asymptomatic
C) A patient who had a hip replacement 2 days ago and has a temperature of 37.8°C (100°F)
D) A patient receiving a blood transfusion who reports chills and lower back pain
Answer: D
Rationale: Chills and lower back pain are signs of a hemolytic transfusion reaction, which is life-threatening and
requires immediate intervention. The other patients are stable: chest tube pain (A) can be addressed after, glucose
180 (B) is not urgent, and low-grade fever post-op (C) may be normal.
6 A nurse is preparing to delegate tasks to an unlicensed assistive personnel (UAP). Which task should the nurse
delegate?
A) Feeding a patient with dysphagia who requires a pureed diet
B) Ambulating a patient who has a history of falls and uses a walker
C) Taking vital signs on a patient who is 1 hour post-cardiac catheterization
D) Emptying a urinary drainage bag and recording output for a stable patient
Answer: D
Rationale: Emptying a urinary drainage bag is a routine, non-invasive task that can be delegated to a UAP. Feeding a
patient with dysphagia (A) requires assessment of swallowing ability, ambulating a fall-risk patient (B) requires
judgment, and vital signs post-cath (C) require monitoring for complications.
7 A nurse is reviewing the plan of care for a patient with a new diagnosis of heart failure. The patient is prescribed
furosemide 40 mg IV push. The nurse notes that the patient's potassium level is 3.2 mEq/L. What is the nurse's
priority action?
A) Administer the furosemide as prescribed and monitor potassium levels
B) Hold the furosemide and notify the healthcare provider of the low potassium
C) Administer the furosemide and give a potassium supplement as needed
D) Double the dose of furosemide to promote potassium excretion
Answer: B
Rationale: Furosemide is a loop diuretic that causes potassium loss. Administering it when potassium is low (3.2)
could precipitate dangerous hypokalemia. The nurse must hold the medication and notify the provider for potential
potassium replacement or alternative therapy. Option A is unsafe; C requires a prescription; D is incorrect.
8 A nurse is evaluating the effectiveness of discharge teaching for a patient with a new colostomy. Which patient
statement indicates a need for further teaching?
,A) I will clean the stoma with mild soap and water during pouch changes
B) I will change the pouch every 3 days or when it leaks
C) I will use a hair dryer on the cool setting to dry the skin around the stoma
D) I will notify my provider if the stoma becomes purple or black
Answer: C
Rationale: Using a hair dryer, even on cool setting, can cause thermal injury or drying of peristomal skin; it is not
recommended. Options A, B, and D are correct: mild soap and water is appropriate, changing pouch every 3 days
or when leaking is standard, and reporting discoloration is essential.
9 A nurse is preparing to administer a blood transfusion. Which action is most important to prevent a transfusion
reaction?
A) Verify the patient's identity with two identifiers and check the blood product with another nurse
B) Prime the blood tubing with normal saline and ensure the patient has signed consent
C) Monitor vital signs every 15 minutes during the first hour of the transfusion
D) Use a blood warmer for all transfusions to prevent hypothermia
Answer: A
Rationale: The most critical step to prevent a transfusion reaction is proper identification and verification of the
blood product with the patient. Mismatched blood can cause fatal hemolytic reactions. While B, C, and D are
important, they do not prevent the most common cause of reactions: human error in identification.
10 A nurse is caring for a patient who is post-operative day 1 after abdominal surgery. The patient has a
nasogastric (NG) tube to low intermittent suction. Which finding requires immediate action?
A) The NG tube is draining 200 mL of greenish fluid over 8 hours
B) The patient reports nausea and has a distended abdomen
C) The NG tube is secured to the patient's gown with tape
D) The suction pressure is set at 80 mm Hg
Answer: B
Rationale: Nausea and abdominal distention may indicate that the NG tube is not functioning properly, possibly
blocked or misplaced, and could lead to vomiting and aspiration. Option A is normal output; C is acceptable if
secure; D is within typical range (low intermittent suction 80-100 mm Hg).
11 A charge nurse is reviewing the assignment of a licensed practical nurse (LPN) and a registered nurse (RN) on
a medical-surgical unit. Which client should the charge nurse assign to the LPN?
A) A client with diabetes mellitus who requires insulin adjustment based on sliding scale and blood glucose
monitoring every 4 hours.
B) A client with pneumonia who has a history of chronic obstructive pulmonary disease and is receiving oxygen
at 2 L/min via nasal cannula.
C) A client with a new colostomy who is learning to perform self-care and requires reinforcement of teaching.
D) A client with heart failure who has new-onset atrial fibrillation and is receiving a continuous heparin infusion.
Answer: C
Rationale: LPNs can provide care for stable clients with predictable outcomes and reinforce teaching. The client
with a new colostomy is stable and requires reinforcement of teaching, which is within LPN scope. Option A
involves complex insulin adjustments (RN responsibility), B requires monitoring of a chronic condition (stable but
LPN can provide care, but the RN typically manages complex respiratory clients; however, C is more clearly
appropriate), and D involves a continuous heparin infusion and new dysrhythmia, requiring RN assessment and
titration.
, 12 A nurse is delegating tasks to an assistive personnel (AP). Which task is within the AP's scope of practice and
appropriate to delegate?
A) Performing a sterile wound dressing change for a client with a surgical incision.
B) Obtaining a blood glucose reading via fingerstick for a client with diabetes.
C) Assessing the lung sounds of a client who is post-operative day 1.
D) Administering a scheduled oral medication to a client with hypertension.
Answer: B
Rationale: APs can perform non-invasive, routine tasks such as obtaining blood glucose readings via fingerstick,
which is a delegated task in many facilities. Sterile wound care requires sterile technique and is typically performed
by licensed personnel. Assessment (lung sounds) and medication administration are beyond AP scope and require a
licensed nurse.
13 A nurse is caring for a client who requires a blood transfusion. The client has a history of multiple transfusions
and is at risk for a transfusion reaction. Which action by the nurse demonstrates appropriate management of
care?
A) Initiating the transfusion at a slow rate and increasing after 15 minutes if no reaction occurs.
B) Obtaining informed consent from the client for the transfusion.
C) Administering the blood with lactated Ringer's solution to prevent clotting.
D) Checking the client's vital signs every hour during the transfusion.
Answer: A
Rationale: For clients at risk for transfusion reaction, initiating the transfusion slowly (e.g., 20-25 mL/hour for the
first 15 minutes) allows early detection of adverse reactions. Informed consent is obtained by the provider, not the
nurse (though the nurse may witness). Blood should be administered with normal saline, not lactated Ringer's (can
cause clotting or hemolysis). Vital signs are checked more frequently, typically every 15 minutes initially.
14 A nurse is planning care for a group of clients on a medical-surgical unit. Which client should the nurse assess
first?
A) A client with a history of type 2 diabetes who has a blood glucose level of 180 mg/dL and is complaining of
thirst.
B) A client with a newly placed chest tube who has continuous bubbling in the water seal chamber.
C) A client with a urinary tract infection who has a temperature of 38.6°C (101.5°F) and is receiving intravenous
antibiotics.
D) A client who is post-operative day 1 following abdominal surgery and has a heart rate of 100 beats per
minute.
Answer: B
Rationale: Continuous bubbling in the water seal chamber indicates an air leak, which can compromise the chest
tube's function and lead to tension pneumothorax. This is a potential emergency requiring immediate assessment.
The other clients are stable: elevated blood glucose (A) is non-urgent, temperature with antibiotics (C) is expected,
and mild tachycardia post-op (D) is common.
15 A charge nurse is evaluating the performance of a newly licensed nurse who is providing discharge teaching to
a client with a new diagnosis of heart failure. Which action by the newly licensed nurse requires intervention?
A) Providing written instructions about a low-sodium diet.
B) Asking the client to demonstrate how to weigh themselves daily.
C) Teaching the client to take their pulse before taking digoxin.
D) Instructing the client to notify the provider if their weight increases by 1 kg (2.2 lb) in a week.
Fundamentals of Nursing Questions — 200 Questions
Section 1: Management of Care (Questions 1-25)
1 A nurse is leading a multidisciplinary team in a community health center. The team is developing a care plan for
a patient with complex chronic conditions who frequently misses appointments. Which approach best aligns
with principles of patient-centered care coordination?
A) Assign a case manager to schedule all appointments and follow up via phone calls
B) Collaborate with the patient to identify barriers and co-create a flexible care schedule
C) Refer the patient to a social worker for transportation assistance only
D) Document missed appointments in the chart and discharge the patient after three no-shows
Answer: B
Rationale: Patient-centered care coordination requires active partnership with the patient to address individual
barriers. Option B empowers the patient and respects their autonomy, improving adherence. Option A is
prescriptive and may not address root causes; option C is too narrow; option D is punitive and violates ethical
principles.
2 A charge nurse is making assignments for a medical-surgical unit with four registered nurses (RNs), two
licensed practical nurses (LPNs), and two nursing assistants (NAs). Which assignment best demonstrates
appropriate delegation within scope of practice?
A) Assign the LPN to administer IV push antibiotics to a patient with a central line
B) Assign the NA to perform a sterile dressing change for a surgical wound
C) Assign the RN to monitor a patient receiving a blood transfusion for the first 15 minutes
D) Assign the LPN to conduct the initial admission assessment for a new patient
Answer: C
Rationale: RNs are responsible for monitoring blood transfusions due to the risk of reactions; this is within their
scope. LPNs cannot administer IV push medications in most states (option A). NAs cannot perform sterile
procedures (option B). Initial admission assessments require RN-level critical thinking (option D).
3 During a disaster drill, the hospital incident command center receives word of a mass casualty event with 50
victims. The triage officer must prioritize care using the Simple Triage and Rapid Treatment (START) system.
Which victim should be classified as 'Immediate' (red tag)?
A) A victim with a palpable radial pulse, respiratory rate 22, and able to follow commands
B) A victim with no spontaneous respirations after airway repositioning
C) A victim with respiratory rate 40 and capillary refill less than 2 seconds
D) A victim with a respiratory rate of 8 and no radial pulse
Answer: C
Rationale: In START, respiratory rate >30 is a criterion for immediate (red) category. Option C has RR 40, meeting
that threshold. Option A is delayed (green). Option B is deceased (black). Option D has no radial pulse, indicating
critical but not necessarily immediate based on RR; however, RR<10 and no pulse would likely be expectant or
deceased, but per START, RR>30 is immediate.
,4 A nurse manager is implementing a new evidence-based protocol to reduce catheter-associated urinary tract
infections (CAUTIs). The unit has a culture of resistance to change. Which strategy is most effective for
achieving sustained adherence?
A) Mandate compliance through written warnings for non-adherence
B) Provide a single educational session on the protocol's benefits
C) Engage frontline staff as champions and provide real-time feedback on compliance
D) Post the protocol on the unit bulletin board and send a memo
Answer: C
Rationale: Sustained practice change requires active engagement of staff, peer influence, and feedback. Champions
and real-time feedback address resistance and promote ownership. Mandates (A) create resentment; single
education (B) is insufficient; passive posting (D) has low impact.
5 A nurse is caring for four patients. Which patient should the nurse assess first?
A) A patient with a newly placed chest tube who reports pain at the insertion site
B) A patient with diabetes who has a blood glucose of 180 mg/dL and is asymptomatic
C) A patient who had a hip replacement 2 days ago and has a temperature of 37.8°C (100°F)
D) A patient receiving a blood transfusion who reports chills and lower back pain
Answer: D
Rationale: Chills and lower back pain are signs of a hemolytic transfusion reaction, which is life-threatening and
requires immediate intervention. The other patients are stable: chest tube pain (A) can be addressed after, glucose
180 (B) is not urgent, and low-grade fever post-op (C) may be normal.
6 A nurse is preparing to delegate tasks to an unlicensed assistive personnel (UAP). Which task should the nurse
delegate?
A) Feeding a patient with dysphagia who requires a pureed diet
B) Ambulating a patient who has a history of falls and uses a walker
C) Taking vital signs on a patient who is 1 hour post-cardiac catheterization
D) Emptying a urinary drainage bag and recording output for a stable patient
Answer: D
Rationale: Emptying a urinary drainage bag is a routine, non-invasive task that can be delegated to a UAP. Feeding a
patient with dysphagia (A) requires assessment of swallowing ability, ambulating a fall-risk patient (B) requires
judgment, and vital signs post-cath (C) require monitoring for complications.
7 A nurse is reviewing the plan of care for a patient with a new diagnosis of heart failure. The patient is prescribed
furosemide 40 mg IV push. The nurse notes that the patient's potassium level is 3.2 mEq/L. What is the nurse's
priority action?
A) Administer the furosemide as prescribed and monitor potassium levels
B) Hold the furosemide and notify the healthcare provider of the low potassium
C) Administer the furosemide and give a potassium supplement as needed
D) Double the dose of furosemide to promote potassium excretion
Answer: B
Rationale: Furosemide is a loop diuretic that causes potassium loss. Administering it when potassium is low (3.2)
could precipitate dangerous hypokalemia. The nurse must hold the medication and notify the provider for potential
potassium replacement or alternative therapy. Option A is unsafe; C requires a prescription; D is incorrect.
8 A nurse is evaluating the effectiveness of discharge teaching for a patient with a new colostomy. Which patient
statement indicates a need for further teaching?
,A) I will clean the stoma with mild soap and water during pouch changes
B) I will change the pouch every 3 days or when it leaks
C) I will use a hair dryer on the cool setting to dry the skin around the stoma
D) I will notify my provider if the stoma becomes purple or black
Answer: C
Rationale: Using a hair dryer, even on cool setting, can cause thermal injury or drying of peristomal skin; it is not
recommended. Options A, B, and D are correct: mild soap and water is appropriate, changing pouch every 3 days
or when leaking is standard, and reporting discoloration is essential.
9 A nurse is preparing to administer a blood transfusion. Which action is most important to prevent a transfusion
reaction?
A) Verify the patient's identity with two identifiers and check the blood product with another nurse
B) Prime the blood tubing with normal saline and ensure the patient has signed consent
C) Monitor vital signs every 15 minutes during the first hour of the transfusion
D) Use a blood warmer for all transfusions to prevent hypothermia
Answer: A
Rationale: The most critical step to prevent a transfusion reaction is proper identification and verification of the
blood product with the patient. Mismatched blood can cause fatal hemolytic reactions. While B, C, and D are
important, they do not prevent the most common cause of reactions: human error in identification.
10 A nurse is caring for a patient who is post-operative day 1 after abdominal surgery. The patient has a
nasogastric (NG) tube to low intermittent suction. Which finding requires immediate action?
A) The NG tube is draining 200 mL of greenish fluid over 8 hours
B) The patient reports nausea and has a distended abdomen
C) The NG tube is secured to the patient's gown with tape
D) The suction pressure is set at 80 mm Hg
Answer: B
Rationale: Nausea and abdominal distention may indicate that the NG tube is not functioning properly, possibly
blocked or misplaced, and could lead to vomiting and aspiration. Option A is normal output; C is acceptable if
secure; D is within typical range (low intermittent suction 80-100 mm Hg).
11 A charge nurse is reviewing the assignment of a licensed practical nurse (LPN) and a registered nurse (RN) on
a medical-surgical unit. Which client should the charge nurse assign to the LPN?
A) A client with diabetes mellitus who requires insulin adjustment based on sliding scale and blood glucose
monitoring every 4 hours.
B) A client with pneumonia who has a history of chronic obstructive pulmonary disease and is receiving oxygen
at 2 L/min via nasal cannula.
C) A client with a new colostomy who is learning to perform self-care and requires reinforcement of teaching.
D) A client with heart failure who has new-onset atrial fibrillation and is receiving a continuous heparin infusion.
Answer: C
Rationale: LPNs can provide care for stable clients with predictable outcomes and reinforce teaching. The client
with a new colostomy is stable and requires reinforcement of teaching, which is within LPN scope. Option A
involves complex insulin adjustments (RN responsibility), B requires monitoring of a chronic condition (stable but
LPN can provide care, but the RN typically manages complex respiratory clients; however, C is more clearly
appropriate), and D involves a continuous heparin infusion and new dysrhythmia, requiring RN assessment and
titration.
, 12 A nurse is delegating tasks to an assistive personnel (AP). Which task is within the AP's scope of practice and
appropriate to delegate?
A) Performing a sterile wound dressing change for a client with a surgical incision.
B) Obtaining a blood glucose reading via fingerstick for a client with diabetes.
C) Assessing the lung sounds of a client who is post-operative day 1.
D) Administering a scheduled oral medication to a client with hypertension.
Answer: B
Rationale: APs can perform non-invasive, routine tasks such as obtaining blood glucose readings via fingerstick,
which is a delegated task in many facilities. Sterile wound care requires sterile technique and is typically performed
by licensed personnel. Assessment (lung sounds) and medication administration are beyond AP scope and require a
licensed nurse.
13 A nurse is caring for a client who requires a blood transfusion. The client has a history of multiple transfusions
and is at risk for a transfusion reaction. Which action by the nurse demonstrates appropriate management of
care?
A) Initiating the transfusion at a slow rate and increasing after 15 minutes if no reaction occurs.
B) Obtaining informed consent from the client for the transfusion.
C) Administering the blood with lactated Ringer's solution to prevent clotting.
D) Checking the client's vital signs every hour during the transfusion.
Answer: A
Rationale: For clients at risk for transfusion reaction, initiating the transfusion slowly (e.g., 20-25 mL/hour for the
first 15 minutes) allows early detection of adverse reactions. Informed consent is obtained by the provider, not the
nurse (though the nurse may witness). Blood should be administered with normal saline, not lactated Ringer's (can
cause clotting or hemolysis). Vital signs are checked more frequently, typically every 15 minutes initially.
14 A nurse is planning care for a group of clients on a medical-surgical unit. Which client should the nurse assess
first?
A) A client with a history of type 2 diabetes who has a blood glucose level of 180 mg/dL and is complaining of
thirst.
B) A client with a newly placed chest tube who has continuous bubbling in the water seal chamber.
C) A client with a urinary tract infection who has a temperature of 38.6°C (101.5°F) and is receiving intravenous
antibiotics.
D) A client who is post-operative day 1 following abdominal surgery and has a heart rate of 100 beats per
minute.
Answer: B
Rationale: Continuous bubbling in the water seal chamber indicates an air leak, which can compromise the chest
tube's function and lead to tension pneumothorax. This is a potential emergency requiring immediate assessment.
The other clients are stable: elevated blood glucose (A) is non-urgent, temperature with antibiotics (C) is expected,
and mild tachycardia post-op (D) is common.
15 A charge nurse is evaluating the performance of a newly licensed nurse who is providing discharge teaching to
a client with a new diagnosis of heart failure. Which action by the newly licensed nurse requires intervention?
A) Providing written instructions about a low-sodium diet.
B) Asking the client to demonstrate how to weigh themselves daily.
C) Teaching the client to take their pulse before taking digoxin.
D) Instructing the client to notify the provider if their weight increases by 1 kg (2.2 lb) in a week.
