1. What is the most important initial action for a nurse to take when entering a patient's
room?
A) Introduce themselves to the patient
B) Ask the patient about their medical history
C) Perform a full assessment of the patient
D) Wash hands thoroughly
Answer: D) Wash hands thoroughly
Rationale: Hand hygiene is the most important initial action to prevent the spread of infections.
It is a fundamental nursing practice before any patient contact.
2. Which of the following is a sign of acute hypoxia?
A) Bradycardia
B) Cyanosis
C) Hypertension
D) Hyperventilation
Answer: B) Cyanosis
Rationale: Cyanosis, or a bluish color of the skin, is a classic sign of acute hypoxia, indicating
inadequate oxygen supply to tissues.
3. A nurse is providing care for a patient with a nasogastric tube. Which of the following is
the most important to monitor?
A) Fluid and electrolyte balance
B) Patient's respiratory status
C) Urine output
D) Nutritional status
Answer: A) Fluid and electrolyte balance
Rationale: A nasogastric tube can affect fluid and electrolyte balance due to potential loss of
gastric contents. Monitoring is essential to avoid imbalances.
4. A nurse is caring for a patient who has a new prescription for warfarin. What is the most
important information for the nurse to include in the teaching plan?
A) Take the medication with food to prevent stomach irritation
B) Monitor for signs of bleeding
,C) Limit fluid intake to avoid fluid overload
D) Increase vitamin K in the diet
Answer: B) Monitor for signs of bleeding
Rationale: Warfarin is an anticoagulant, and one of its major risks is bleeding. The nurse should
educate the patient on how to recognize signs of bleeding.
5. What is the primary purpose of patient advocacy in nursing?
A) To make decisions on behalf of the patient
B) To protect the patient's rights
C) To promote the nurse's professional autonomy
D) To provide financial assistance to patients
Answer: B) To protect the patient's rights
Rationale: Patient advocacy ensures that patients’ rights, preferences, and interests are
protected, especially when they are unable to advocate for themselves.
6. Which of the following is the most effective way to prevent the spread of infection in a
healthcare setting?
A) Wearing gloves at all times
B) Maintaining a clean environment
C) Practicing good hand hygiene
D) Using disinfectants frequently
Answer: C) Practicing good hand hygiene
Rationale: Hand hygiene is the single most effective way to prevent the transmission of
infections in healthcare settings.
7. The nurse is caring for a patient in the post-operative period. Which of the following
interventions would be the priority?
A) Monitoring for signs of infection
B) Encouraging deep breathing and coughing
C) Administering pain medication as prescribed
D) Assessing vital signs
, Answer: D) Assessing vital signs
Rationale: In the post-operative period, it is essential to first assess the patient’s vital signs to
monitor for complications such as shock or respiratory distress.
8. A nurse is educating a patient on the correct use of an inhaler. Which instruction should
the nurse include?
A) Exhale fully before using the inhaler
B) Use the inhaler only when experiencing shortness of breath
C) Shake the inhaler only after use
D) Inhale rapidly while using the inhaler
Answer: A) Exhale fully before using the inhaler
Rationale: To ensure effective medication delivery, the patient should exhale fully before
inhaling the medication.
9. A nurse is assessing a patient with a blood pressure of 160/95 mmHg. Which
classification of blood pressure does this fall under?
A) Normal
B) Prehypertension
C) Hypertension Stage 1
D) Hypertension Stage 2
Answer: C) Hypertension Stage 1
Rationale: A blood pressure reading of 160/95 mmHg is classified as Stage 1 hypertension
according to current guidelines.
10. When caring for a patient with an intravenous (IV) line, which of the following actions
should the nurse take first?
A) Check the IV site for signs of infiltration
B) Assess the patient’s pain level
C) Ensure the IV site is patent
D) Prepare medication for administration
Answer: C) Ensure the IV site is patent
Rationale: Ensuring that the IV site is patent (i.e., clear and free of obstruction) is essential to
safely administer fluids and medications.
room?
A) Introduce themselves to the patient
B) Ask the patient about their medical history
C) Perform a full assessment of the patient
D) Wash hands thoroughly
Answer: D) Wash hands thoroughly
Rationale: Hand hygiene is the most important initial action to prevent the spread of infections.
It is a fundamental nursing practice before any patient contact.
2. Which of the following is a sign of acute hypoxia?
A) Bradycardia
B) Cyanosis
C) Hypertension
D) Hyperventilation
Answer: B) Cyanosis
Rationale: Cyanosis, or a bluish color of the skin, is a classic sign of acute hypoxia, indicating
inadequate oxygen supply to tissues.
3. A nurse is providing care for a patient with a nasogastric tube. Which of the following is
the most important to monitor?
A) Fluid and electrolyte balance
B) Patient's respiratory status
C) Urine output
D) Nutritional status
Answer: A) Fluid and electrolyte balance
Rationale: A nasogastric tube can affect fluid and electrolyte balance due to potential loss of
gastric contents. Monitoring is essential to avoid imbalances.
4. A nurse is caring for a patient who has a new prescription for warfarin. What is the most
important information for the nurse to include in the teaching plan?
A) Take the medication with food to prevent stomach irritation
B) Monitor for signs of bleeding
,C) Limit fluid intake to avoid fluid overload
D) Increase vitamin K in the diet
Answer: B) Monitor for signs of bleeding
Rationale: Warfarin is an anticoagulant, and one of its major risks is bleeding. The nurse should
educate the patient on how to recognize signs of bleeding.
5. What is the primary purpose of patient advocacy in nursing?
A) To make decisions on behalf of the patient
B) To protect the patient's rights
C) To promote the nurse's professional autonomy
D) To provide financial assistance to patients
Answer: B) To protect the patient's rights
Rationale: Patient advocacy ensures that patients’ rights, preferences, and interests are
protected, especially when they are unable to advocate for themselves.
6. Which of the following is the most effective way to prevent the spread of infection in a
healthcare setting?
A) Wearing gloves at all times
B) Maintaining a clean environment
C) Practicing good hand hygiene
D) Using disinfectants frequently
Answer: C) Practicing good hand hygiene
Rationale: Hand hygiene is the single most effective way to prevent the transmission of
infections in healthcare settings.
7. The nurse is caring for a patient in the post-operative period. Which of the following
interventions would be the priority?
A) Monitoring for signs of infection
B) Encouraging deep breathing and coughing
C) Administering pain medication as prescribed
D) Assessing vital signs
, Answer: D) Assessing vital signs
Rationale: In the post-operative period, it is essential to first assess the patient’s vital signs to
monitor for complications such as shock or respiratory distress.
8. A nurse is educating a patient on the correct use of an inhaler. Which instruction should
the nurse include?
A) Exhale fully before using the inhaler
B) Use the inhaler only when experiencing shortness of breath
C) Shake the inhaler only after use
D) Inhale rapidly while using the inhaler
Answer: A) Exhale fully before using the inhaler
Rationale: To ensure effective medication delivery, the patient should exhale fully before
inhaling the medication.
9. A nurse is assessing a patient with a blood pressure of 160/95 mmHg. Which
classification of blood pressure does this fall under?
A) Normal
B) Prehypertension
C) Hypertension Stage 1
D) Hypertension Stage 2
Answer: C) Hypertension Stage 1
Rationale: A blood pressure reading of 160/95 mmHg is classified as Stage 1 hypertension
according to current guidelines.
10. When caring for a patient with an intravenous (IV) line, which of the following actions
should the nurse take first?
A) Check the IV site for signs of infiltration
B) Assess the patient’s pain level
C) Ensure the IV site is patent
D) Prepare medication for administration
Answer: C) Ensure the IV site is patent
Rationale: Ensuring that the IV site is patent (i.e., clear and free of obstruction) is essential to
safely administer fluids and medications.
