NSG 54 FINAL EXAM PREP QUESTIONS WITH VERIFIED SOLUTIONS LATEST UPDATE 2026
Fall risk factors in elderly patients - Answers Advanced age, previous falls, weakness/impaired
mobility, dizziness, sedating medications, confusion, orthostatic hypotension, urgency/frequency
Standard fall precautions - Answers Bed low, call light within reach, non-skid socks, bed alarm,
frequent rounding, adequate lighting, clear pathways
Tasks that can be delegated to a CNA - Answers Vital signs, I&O, daily weights, hygiene/toileting,
ambulation assistance, positioning, reporting abnormal findings
Tasks that cannot be delegated to a CNA - Answers Assessment, nursing judgment, patient teaching,
medication administration, sterile procedures, care planning
PPE required for Contact Precautions - Answers Gloves, gown, hand hygiene before and after care,
dedicated equipment if possible
Common organism requiring Contact Precautions - Answers MRSA
Principles of sterile technique - Answers Maintain sterile field above waist, do not reach over field,
sterile touches sterile only, if in doubt consider contaminated, open packages away from body first
Four main drainage types - Answers Serous = clear, Sanguineous = bloody, Serosanguineous =
pink/light red, Purulent = thick/yellow-green
Signs of wound infection - Answers Redness, warmth, swelling, purulent drainage, fever, increased
pain
Common opioid side effects - Answers Respiratory depression, sedation, constipation, nausea, fall
risk
Assessments before giving pain medication - Answers Pain level, respiratory status, LOC, blood
pressure, swallowing ability
Non-pharmacological constipation treatments - Answers Increase fluids, increase fiber, encourage
ambulation, warm fluids/prune juice, scheduled toileting
Position for enema administration - Answers Left Sims' position
Complications of enema administration - Answers Bowel perforation, cramping, bradycardia from
vagal stimulation, electrolyte imbalance, falls due to urgency
Common symptoms of decompensated heart failure - Answers Dyspnea, orthopnea, crackles,
peripheral edema, weight gain, fatigue, JVD
Best position for CHF patient - Answers High Fowler's or Semi-Fowler's position
Important CHF labs and assessments - Answers BNP, potassium, lung sounds, daily weights, I&O,
oxygen saturation
Common diet ordered for CHF patients - Answers Low sodium diet, fluid restriction, daily weights
Therapeutic effect of Lasix - Answers Removes excess fluid and reduces edema/pulmonary
congestion
Important side effects of Lasix - Answers Hypokalemia, hypotension, dehydration, dizziness, frequent
urination
Common stroke symptoms - Answers Weakness, facial droop, confusion, speech changes, dysphagia,
vision changes
Swallowing precautions - Answers High Fowler's during meals, small bites/sips, slow eating, upright
after meals, monitor for choking/coughing
Signs of aspiration - Answers Coughing, choking, wet voice, drooling, decreased oxygen saturation
Pureed diet - Answers Smooth, pudding-like foods requiring little chewing
Types of thickened liquids - Answers Nectar-thick, honey-thick, pudding-thick
Rules for restraint use - Answers Last resort, provider order required, least restrictive method,
frequent reassessment, documentation required
Alternatives to restraints - Answers Bed alarms, frequent rounding, reorientation, family presence,
low bed, diversional activities
Which side should a cane be held on? - Answers The strong side
Correct walking sequence with a cane - Answers Cane, weak leg, strong leg
Stair rule for cane teaching - Answers Up with the good, down with the bad
Hip precautions - Answers No crossing legs, no bending >90 degrees, no internal rotation, use
abduction pillow
Common postoperative complications - Answers Atelectasis, pneumonia, DVT/PE, infection, bleeding,
delirium
Frequency of incentive spirometer use - Answers 10 breaths every hour while awake
Fall risk factors in elderly patients - Answers Advanced age, previous falls, weakness/impaired
mobility, dizziness, sedating medications, confusion, orthostatic hypotension, urgency/frequency
Standard fall precautions - Answers Bed low, call light within reach, non-skid socks, bed alarm,
frequent rounding, adequate lighting, clear pathways
Tasks that can be delegated to a CNA - Answers Vital signs, I&O, daily weights, hygiene/toileting,
ambulation assistance, positioning, reporting abnormal findings
Tasks that cannot be delegated to a CNA - Answers Assessment, nursing judgment, patient teaching,
medication administration, sterile procedures, care planning
PPE required for Contact Precautions - Answers Gloves, gown, hand hygiene before and after care,
dedicated equipment if possible
Common organism requiring Contact Precautions - Answers MRSA
Principles of sterile technique - Answers Maintain sterile field above waist, do not reach over field,
sterile touches sterile only, if in doubt consider contaminated, open packages away from body first
Four main drainage types - Answers Serous = clear, Sanguineous = bloody, Serosanguineous =
pink/light red, Purulent = thick/yellow-green
Signs of wound infection - Answers Redness, warmth, swelling, purulent drainage, fever, increased
pain
Common opioid side effects - Answers Respiratory depression, sedation, constipation, nausea, fall
risk
Assessments before giving pain medication - Answers Pain level, respiratory status, LOC, blood
pressure, swallowing ability
Non-pharmacological constipation treatments - Answers Increase fluids, increase fiber, encourage
ambulation, warm fluids/prune juice, scheduled toileting
Position for enema administration - Answers Left Sims' position
Complications of enema administration - Answers Bowel perforation, cramping, bradycardia from
vagal stimulation, electrolyte imbalance, falls due to urgency
Common symptoms of decompensated heart failure - Answers Dyspnea, orthopnea, crackles,
peripheral edema, weight gain, fatigue, JVD
Best position for CHF patient - Answers High Fowler's or Semi-Fowler's position
Important CHF labs and assessments - Answers BNP, potassium, lung sounds, daily weights, I&O,
oxygen saturation
Common diet ordered for CHF patients - Answers Low sodium diet, fluid restriction, daily weights
Therapeutic effect of Lasix - Answers Removes excess fluid and reduces edema/pulmonary
congestion
Important side effects of Lasix - Answers Hypokalemia, hypotension, dehydration, dizziness, frequent
urination
Common stroke symptoms - Answers Weakness, facial droop, confusion, speech changes, dysphagia,
vision changes
Swallowing precautions - Answers High Fowler's during meals, small bites/sips, slow eating, upright
after meals, monitor for choking/coughing
Signs of aspiration - Answers Coughing, choking, wet voice, drooling, decreased oxygen saturation
Pureed diet - Answers Smooth, pudding-like foods requiring little chewing
Types of thickened liquids - Answers Nectar-thick, honey-thick, pudding-thick
Rules for restraint use - Answers Last resort, provider order required, least restrictive method,
frequent reassessment, documentation required
Alternatives to restraints - Answers Bed alarms, frequent rounding, reorientation, family presence,
low bed, diversional activities
Which side should a cane be held on? - Answers The strong side
Correct walking sequence with a cane - Answers Cane, weak leg, strong leg
Stair rule for cane teaching - Answers Up with the good, down with the bad
Hip precautions - Answers No crossing legs, no bending >90 degrees, no internal rotation, use
abduction pillow
Common postoperative complications - Answers Atelectasis, pneumonia, DVT/PE, infection, bleeding,
delirium
Frequency of incentive spirometer use - Answers 10 breaths every hour while awake
