PN COMPREHENSIVE ONLINE PRACTICE FORM B | ALL 150 QUESTIONS AND
CORRECT DETAILED ANSWERS PLUS RATIONALES | LATEST UPDATE (2026) |
ALREADY GRADED A+
Question 1
A nurse is collecting data from a client who reports recent methamphetamine use. Which of the
following manifestations should the nurse expect?
A) Pinpoint pupils
B) Dilated pupils
C) Bradycardia
D) Increased appetite
E) Somnolence
Correct Answer: B) Dilated pupils
Rationale: Methamphetamine is a central nervous system stimulant that triggers the
sympathetic "fight or flight" response. This leads to mydriasis (dilated pupils),
tachycardia, hypertension, and hyper-alertness. Pinpoint pupils are associated with opioid
use.
Question 2
A nurse is contributing to the plan of care for a client who has a continent urinary diversion.
Which of the following interventions should the nurse plan to implement to facilitate urinary
elimination?
A) Apply a permanent external collection bag.
B) Use intermittent urinary catheterization at regular intervals.
C) Encourage the client to use the Valsalva maneuver to void.
D) Maintain the client on continuous bed rest.
E) Irrigate the stoma with 100 mL of sterile water hourly.
Correct Answer: B) Use intermittent urinary catheterization for the client at regular
intervals.
Rationale: A continent urinary diversion (like a Kock pouch) creates an internal reservoir
from the intestine. Because there is no sphincter, the client must use a catheter to manually
drain the urine at regular intervals to prevent overdistension and reflux.
Question 3
A nurse is reviewing the procedure for endotracheal suctioning with a newly licensed nurse.
Which of the following statements by the newly licensed nurse indicates an understanding of the
teaching?
A) "I should suction for 30 seconds at a time."
B) "I should apply suction while inserting the catheter."
C) "I should apply sterile saline to lubricate the suction catheter."
D) "I should use clean technique during the procedure."
E) "I should rotate the catheter only upon insertion."
, 2
Correct Answer: C) "I should apply sterile saline to lubricate the suction catheter."
Rationale: Sterile saline or water-soluble lubricant is used to facilitate the passage of the
catheter and minimize trauma to the tracheal mucosa. Suction should only be applied
intermittently while withdrawing the catheter, and the duration should not exceed 10-15
seconds to prevent hypoxia.
Question 4
A nurse is reinforcing teaching about strategies to promote eating with a client who has COPD.
Which of the following instructions should the nurse include in the teaching?
A) Drink plenty of water immediately before meals.
B) Eat three large meals a day.
C) Drink high-protein and high-calorie nutritional supplements.
D) Perform vigorous exercise just before eating to increase appetite.
E) Choose high-carbohydrate foods to provide quick energy.
Correct Answer: C) Drink high-protein and high-calorie nutritional supplements.
Rationale: Clients with COPD often experience fatigue while eating and have high energy
expenditures due to the work of breathing. Supplements provide concentrated nutrients.
High-carbohydrate diets are avoided because they increase carbon dioxide production.
Question 5
A nurse is receiving change-of-shift report for four clients. Which of the following clients should
the nurse see first?
A) A client who has a temperature of 37.9° C (100.2° F).
B) A client who reports a pain level of 4 on a scale of 0 to 10.
C) A client whose urinary output was 100 mL for the past 12 hr.
D) A client who is requesting a dressing change.
E) A client who needs assistance with a scheduled walk.
Correct Answer: C) A client whose urinary output was 100 mL for the past 12 hr.
Rationale: Normal urinary output should be at least 30 mL/hr. An output of 100 mL over 12
hours (approx. 8.3 mL/hr) indicates oliguria, which may signal acute kidney injury or
severe dehydration and requires immediate intervention.
Question 6
A nurse is assisting in the care of an adolescent who sustained a leg fracture. Which of the
following findings is the most critical to report to the provider as a sign of potential compartment
syndrome?
A) Ecchymosis around the fracture site.
B) Presence of a strong pedal pulse.
C) Capillary refill of 4 seconds.
D) Reporting the pain as a 3 on a scale of 0 to 10.
E) Ability to wiggle the toes.
, 3
Correct Answer: C) capillary refill
Rationale: Delayed capillary refill (greater than 3 seconds), along with changes in skin
temperature, diminished pulses, and intense pain, are early indicators of neurovascular
compromise and compartment syndrome.
Question 7
A nurse is assisting with the care of an adolescent returning from surgery for a fractured limb.
Which action is appropriate to prevent complications?
A) Keep the limb in a dependent position.
B) Elevate the affected limb at chest level.
C) Apply a tight heat wrap to the surgical site.
D) Restrict fluids for the first 48 hours.
E) Monitor neurovascular status every 8 hours.
Correct Answer: B) elevating the adolescent's affected limb at chest level.
Rationale: Elevating the limb at or slightly above the level of the heart promotes venous
return and reduces swelling, which is critical in preventing compartment syndrome post-
surgery.
Question 8
A nurse is caring for a client with a suspected musculoskeletal complication. The nurse identifies
that the client is at risk for compartment syndrome. What is the priority data to monitor?
A) Daily weight
B) Pain level
C) Urinary specific gravity
D) Breath sounds
E) Bowel sounds
Correct Answer: B) pain level
Rationale: Pain that is out of proportion to the injury and is not relieved by analgesics is the
hallmark sign of developing compartment syndrome.
Question 9
A nurse is caring for an adolescent with a limb injury. Which of the following actions is
contraindicated if compartment syndrome is suspected?
A) Removing the splint or cast.
B) Preparing the client for a fasciotomy.
C) Elevating the leg above heart level.
D) Monitoring peripheral pulses.
E) Administering prescribed IV analgesics.
Correct Answer: C) Elevate the right leg above heart level.
Rationale: While elevation at the heart level is standard for swelling, elevating an
, 4
extremity above heart level in suspected compartment syndrome is contraindicated because
it can further decrease arterial perfusion to the already stressed tissues.
Question 10
A nurse is assisting with preparing an adolescent for an emergency fasciotomy. Which of the
following findings is most important to report to the provider?
A) The client had a small breakfast 2 hours ago.
B) The client’s parents have concerns regarding the surgery.
C) The client’s heart rate is 105/min.
D) The client’s white blood cell count is 9,000/mm³.
E) The client reports being thirsty.
Correct Answer: B) The adolescent's parents have concerns regarding the surgery.
Rationale: Informed consent is necessary for surgery. If the legal guardians have concerns
or lack understanding of the procedure, it must be addressed by the provider before the
surgery proceeds, unless it is a life-threatening emergency.
Question 11
A nurse is collecting data from an adolescent 4 hours following a fasciotomy. Which finding
indicates an improvement in the client's condition?
A) Capillary refill of 5 seconds.
B) Extremity pulse +3.
C) Client reports "pins and needles" sensation.
D) Skin is cool to the touch.
E) Pain reported as 9 on a scale of 0 to 10.
Correct Answer: B) Extremity pulse +3.
Rationale: A strong (+3) peripheral pulse, warm skin, 2-second capillary refill, and
decreased pain/numbness indicate that blood flow has been successfully restored to the
limb following the surgical release of pressure.
Question 12
A community health nurse is reinforcing teaching about Hepatitis A with staff at a childcare
facility. Which of the following is an external factor that can impede learning?
A) The participants' high level of anxiety.
B) Poor lighting in the learning setting.
C) Lack of prior knowledge about the virus.
D) The participants' cultural beliefs.
E) A high level of motivation among the staff.
Correct Answer: B) Poor lighting in the learning setting.
Rationale: External factors refer to environmental conditions. Poor lighting, noise, or an
uncomfortable temperature are external barriers, whereas anxiety or lack of knowledge
are internal factors.
CORRECT DETAILED ANSWERS PLUS RATIONALES | LATEST UPDATE (2026) |
ALREADY GRADED A+
Question 1
A nurse is collecting data from a client who reports recent methamphetamine use. Which of the
following manifestations should the nurse expect?
A) Pinpoint pupils
B) Dilated pupils
C) Bradycardia
D) Increased appetite
E) Somnolence
Correct Answer: B) Dilated pupils
Rationale: Methamphetamine is a central nervous system stimulant that triggers the
sympathetic "fight or flight" response. This leads to mydriasis (dilated pupils),
tachycardia, hypertension, and hyper-alertness. Pinpoint pupils are associated with opioid
use.
Question 2
A nurse is contributing to the plan of care for a client who has a continent urinary diversion.
Which of the following interventions should the nurse plan to implement to facilitate urinary
elimination?
A) Apply a permanent external collection bag.
B) Use intermittent urinary catheterization at regular intervals.
C) Encourage the client to use the Valsalva maneuver to void.
D) Maintain the client on continuous bed rest.
E) Irrigate the stoma with 100 mL of sterile water hourly.
Correct Answer: B) Use intermittent urinary catheterization for the client at regular
intervals.
Rationale: A continent urinary diversion (like a Kock pouch) creates an internal reservoir
from the intestine. Because there is no sphincter, the client must use a catheter to manually
drain the urine at regular intervals to prevent overdistension and reflux.
Question 3
A nurse is reviewing the procedure for endotracheal suctioning with a newly licensed nurse.
Which of the following statements by the newly licensed nurse indicates an understanding of the
teaching?
A) "I should suction for 30 seconds at a time."
B) "I should apply suction while inserting the catheter."
C) "I should apply sterile saline to lubricate the suction catheter."
D) "I should use clean technique during the procedure."
E) "I should rotate the catheter only upon insertion."
, 2
Correct Answer: C) "I should apply sterile saline to lubricate the suction catheter."
Rationale: Sterile saline or water-soluble lubricant is used to facilitate the passage of the
catheter and minimize trauma to the tracheal mucosa. Suction should only be applied
intermittently while withdrawing the catheter, and the duration should not exceed 10-15
seconds to prevent hypoxia.
Question 4
A nurse is reinforcing teaching about strategies to promote eating with a client who has COPD.
Which of the following instructions should the nurse include in the teaching?
A) Drink plenty of water immediately before meals.
B) Eat three large meals a day.
C) Drink high-protein and high-calorie nutritional supplements.
D) Perform vigorous exercise just before eating to increase appetite.
E) Choose high-carbohydrate foods to provide quick energy.
Correct Answer: C) Drink high-protein and high-calorie nutritional supplements.
Rationale: Clients with COPD often experience fatigue while eating and have high energy
expenditures due to the work of breathing. Supplements provide concentrated nutrients.
High-carbohydrate diets are avoided because they increase carbon dioxide production.
Question 5
A nurse is receiving change-of-shift report for four clients. Which of the following clients should
the nurse see first?
A) A client who has a temperature of 37.9° C (100.2° F).
B) A client who reports a pain level of 4 on a scale of 0 to 10.
C) A client whose urinary output was 100 mL for the past 12 hr.
D) A client who is requesting a dressing change.
E) A client who needs assistance with a scheduled walk.
Correct Answer: C) A client whose urinary output was 100 mL for the past 12 hr.
Rationale: Normal urinary output should be at least 30 mL/hr. An output of 100 mL over 12
hours (approx. 8.3 mL/hr) indicates oliguria, which may signal acute kidney injury or
severe dehydration and requires immediate intervention.
Question 6
A nurse is assisting in the care of an adolescent who sustained a leg fracture. Which of the
following findings is the most critical to report to the provider as a sign of potential compartment
syndrome?
A) Ecchymosis around the fracture site.
B) Presence of a strong pedal pulse.
C) Capillary refill of 4 seconds.
D) Reporting the pain as a 3 on a scale of 0 to 10.
E) Ability to wiggle the toes.
, 3
Correct Answer: C) capillary refill
Rationale: Delayed capillary refill (greater than 3 seconds), along with changes in skin
temperature, diminished pulses, and intense pain, are early indicators of neurovascular
compromise and compartment syndrome.
Question 7
A nurse is assisting with the care of an adolescent returning from surgery for a fractured limb.
Which action is appropriate to prevent complications?
A) Keep the limb in a dependent position.
B) Elevate the affected limb at chest level.
C) Apply a tight heat wrap to the surgical site.
D) Restrict fluids for the first 48 hours.
E) Monitor neurovascular status every 8 hours.
Correct Answer: B) elevating the adolescent's affected limb at chest level.
Rationale: Elevating the limb at or slightly above the level of the heart promotes venous
return and reduces swelling, which is critical in preventing compartment syndrome post-
surgery.
Question 8
A nurse is caring for a client with a suspected musculoskeletal complication. The nurse identifies
that the client is at risk for compartment syndrome. What is the priority data to monitor?
A) Daily weight
B) Pain level
C) Urinary specific gravity
D) Breath sounds
E) Bowel sounds
Correct Answer: B) pain level
Rationale: Pain that is out of proportion to the injury and is not relieved by analgesics is the
hallmark sign of developing compartment syndrome.
Question 9
A nurse is caring for an adolescent with a limb injury. Which of the following actions is
contraindicated if compartment syndrome is suspected?
A) Removing the splint or cast.
B) Preparing the client for a fasciotomy.
C) Elevating the leg above heart level.
D) Monitoring peripheral pulses.
E) Administering prescribed IV analgesics.
Correct Answer: C) Elevate the right leg above heart level.
Rationale: While elevation at the heart level is standard for swelling, elevating an
, 4
extremity above heart level in suspected compartment syndrome is contraindicated because
it can further decrease arterial perfusion to the already stressed tissues.
Question 10
A nurse is assisting with preparing an adolescent for an emergency fasciotomy. Which of the
following findings is most important to report to the provider?
A) The client had a small breakfast 2 hours ago.
B) The client’s parents have concerns regarding the surgery.
C) The client’s heart rate is 105/min.
D) The client’s white blood cell count is 9,000/mm³.
E) The client reports being thirsty.
Correct Answer: B) The adolescent's parents have concerns regarding the surgery.
Rationale: Informed consent is necessary for surgery. If the legal guardians have concerns
or lack understanding of the procedure, it must be addressed by the provider before the
surgery proceeds, unless it is a life-threatening emergency.
Question 11
A nurse is collecting data from an adolescent 4 hours following a fasciotomy. Which finding
indicates an improvement in the client's condition?
A) Capillary refill of 5 seconds.
B) Extremity pulse +3.
C) Client reports "pins and needles" sensation.
D) Skin is cool to the touch.
E) Pain reported as 9 on a scale of 0 to 10.
Correct Answer: B) Extremity pulse +3.
Rationale: A strong (+3) peripheral pulse, warm skin, 2-second capillary refill, and
decreased pain/numbness indicate that blood flow has been successfully restored to the
limb following the surgical release of pressure.
Question 12
A community health nurse is reinforcing teaching about Hepatitis A with staff at a childcare
facility. Which of the following is an external factor that can impede learning?
A) The participants' high level of anxiety.
B) Poor lighting in the learning setting.
C) Lack of prior knowledge about the virus.
D) The participants' cultural beliefs.
E) A high level of motivation among the staff.
Correct Answer: B) Poor lighting in the learning setting.
Rationale: External factors refer to environmental conditions. Poor lighting, noise, or an
uncomfortable temperature are external barriers, whereas anxiety or lack of knowledge
are internal factors.
