Question 1: A nurse is caring for a client who has been prescribed bed rest.
Which action should the nurse take to prevent complications?
A) Keep the client in a supine position at all times
B) Encourage the client to perform range-of-motion exercises
C) Limit fluid intake to prevent incontinence
D) Restrict visitors to promote rest
ANSWER : B
Rationale: Range-of-motion exercises help prevent complications of
immobility including muscle atrophy, contractures, and venous stasis. Clients
should be repositioned every 2 hours, fluids should be encouraged unless
contraindicated, and social interaction is beneficial for psychological well-
being.
Question 2: A nurse is preparing to administer medication through a
nasogastric (NG) tube. What should the nurse do first?
A) Flush the tube with 30 mL of water
B) Verify tube placement
C) Crush all medications together
D) Clamp the tube for 30 minutes after administration
ANSWER : B
Rationale: The nurse must verify NG tube placement before administering
anything through the tube to prevent aspiration. This can be done by checking
pH of aspirate or obtaining an X-ray confirmation.
Pharmacology
Question 3: A client is receiving warfarin (Coumadin). Which laboratory value
should the nurse monitor?
,A) Activated partial thromboplastin time (aPTT)
B) International normalized ratio (INR)
C) Platelet count
D) Hemoglobin and hematocrit
ANSWER : B
Rationale: INR is used to monitor warfarin therapy. The therapeutic range is
typically 2-3 for most conditions. aPTT is used to monitor heparin therapy.
Question 4: A nurse is teaching a client about digoxin (Lanoxin). Which
statement by the client indicates understanding?
A) "I should take this medication with my antacid."
B) "I will check my pulse before taking this medication."
C) "I can stop taking this when I feel better."
D) "I should take extra doses if I miss one."
ANSWER : B
Rationale: Clients should check their apical pulse for one full minute before
taking digoxin. If the pulse is below 60 bpm in adults, they should hold the
medication and contact their healthcare provider. Digoxin has a narrow
therapeutic range and toxicity is a serious concern.
Medical-Surgical Nursing
Question 5: A client with chronic obstructive pulmonary disease (COPD) is
receiving oxygen at 2 L/min via nasal cannula. The client's oxygen saturation is
88%. What should the nurse do?
A) Increase oxygen to 6 L/min immediately
B) Continue current oxygen therapy and monitor the client
C) Notify the healthcare provider
D) Encourage deep breathing and coughing
ANSWER : C
Rationale: The nurse should notify the healthcare provider. For clients with
COPD, oxygen should be administered cautiously at low flow rates (usually 1-3
L/min) because their respiratory drive is stimulated by hypoxemia. Any changes
in oxygen therapy should be prescribed by the provider.
, Question 6: A nurse is caring for a client 24 hours post-thyroidectomy. Which
finding requires immediate intervention?
A) Hoarseness when speaking
B) Pain at the incision site
C) Numbness and tingling around the mouth
D) Difficulty swallowing
ANSWER : C
Rationale: Numbness and tingling around the mouth (Chvostek's sign)
indicates hypocalcemia, which can occur if the parathyroid glands were
accidentally removed or damaged during thyroid surgery. This is a medical
emergency that can lead to tetany and requires immediate calcium replacement.
Maternal-Child Health
Question 7: A nurse is assessing a newborn immediately after birth. The infant
has a heart rate of 110 bpm, slow irregular respirations, some flexion of
extremities, grimaces with stimulation, and a pink body with blue extremities.
What is the Apgar score?
A) 5
B) 6
C) 7
D) 8
ANSWER : C
Rationale: Heart rate >100 (2 points), slow irregular respirations (1 point),
some flexion (1 point), grimace (1 point), acrocyanosis (1 point) = 6 points
total. Wait - let me recalculate: HR=2, Resp=1, Muscle tone=1, Reflex=1,
Color=1 = 6 points. The ANSWER should be B (6).
Corrected ANSWER : B (6 points)
Question 8: A pregnant client at 32 weeks gestation reports sudden, severe
abdominal pain and vaginal bleeding. The abdomen is rigid and tender. What
condition should the nurse suspect?
A) Placenta previa
B) Abruptio placentae
C) Ruptured ectopic pregnancy
D) Preterm labor
Which action should the nurse take to prevent complications?
A) Keep the client in a supine position at all times
B) Encourage the client to perform range-of-motion exercises
C) Limit fluid intake to prevent incontinence
D) Restrict visitors to promote rest
ANSWER : B
Rationale: Range-of-motion exercises help prevent complications of
immobility including muscle atrophy, contractures, and venous stasis. Clients
should be repositioned every 2 hours, fluids should be encouraged unless
contraindicated, and social interaction is beneficial for psychological well-
being.
Question 2: A nurse is preparing to administer medication through a
nasogastric (NG) tube. What should the nurse do first?
A) Flush the tube with 30 mL of water
B) Verify tube placement
C) Crush all medications together
D) Clamp the tube for 30 minutes after administration
ANSWER : B
Rationale: The nurse must verify NG tube placement before administering
anything through the tube to prevent aspiration. This can be done by checking
pH of aspirate or obtaining an X-ray confirmation.
Pharmacology
Question 3: A client is receiving warfarin (Coumadin). Which laboratory value
should the nurse monitor?
,A) Activated partial thromboplastin time (aPTT)
B) International normalized ratio (INR)
C) Platelet count
D) Hemoglobin and hematocrit
ANSWER : B
Rationale: INR is used to monitor warfarin therapy. The therapeutic range is
typically 2-3 for most conditions. aPTT is used to monitor heparin therapy.
Question 4: A nurse is teaching a client about digoxin (Lanoxin). Which
statement by the client indicates understanding?
A) "I should take this medication with my antacid."
B) "I will check my pulse before taking this medication."
C) "I can stop taking this when I feel better."
D) "I should take extra doses if I miss one."
ANSWER : B
Rationale: Clients should check their apical pulse for one full minute before
taking digoxin. If the pulse is below 60 bpm in adults, they should hold the
medication and contact their healthcare provider. Digoxin has a narrow
therapeutic range and toxicity is a serious concern.
Medical-Surgical Nursing
Question 5: A client with chronic obstructive pulmonary disease (COPD) is
receiving oxygen at 2 L/min via nasal cannula. The client's oxygen saturation is
88%. What should the nurse do?
A) Increase oxygen to 6 L/min immediately
B) Continue current oxygen therapy and monitor the client
C) Notify the healthcare provider
D) Encourage deep breathing and coughing
ANSWER : C
Rationale: The nurse should notify the healthcare provider. For clients with
COPD, oxygen should be administered cautiously at low flow rates (usually 1-3
L/min) because their respiratory drive is stimulated by hypoxemia. Any changes
in oxygen therapy should be prescribed by the provider.
, Question 6: A nurse is caring for a client 24 hours post-thyroidectomy. Which
finding requires immediate intervention?
A) Hoarseness when speaking
B) Pain at the incision site
C) Numbness and tingling around the mouth
D) Difficulty swallowing
ANSWER : C
Rationale: Numbness and tingling around the mouth (Chvostek's sign)
indicates hypocalcemia, which can occur if the parathyroid glands were
accidentally removed or damaged during thyroid surgery. This is a medical
emergency that can lead to tetany and requires immediate calcium replacement.
Maternal-Child Health
Question 7: A nurse is assessing a newborn immediately after birth. The infant
has a heart rate of 110 bpm, slow irregular respirations, some flexion of
extremities, grimaces with stimulation, and a pink body with blue extremities.
What is the Apgar score?
A) 5
B) 6
C) 7
D) 8
ANSWER : C
Rationale: Heart rate >100 (2 points), slow irregular respirations (1 point),
some flexion (1 point), grimace (1 point), acrocyanosis (1 point) = 6 points
total. Wait - let me recalculate: HR=2, Resp=1, Muscle tone=1, Reflex=1,
Color=1 = 6 points. The ANSWER should be B (6).
Corrected ANSWER : B (6 points)
Question 8: A pregnant client at 32 weeks gestation reports sudden, severe
abdominal pain and vaginal bleeding. The abdomen is rigid and tender. What
condition should the nurse suspect?
A) Placenta previa
B) Abruptio placentae
C) Ruptured ectopic pregnancy
D) Preterm labor
