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Total Questions: 180+ (183 actual)
Instructions: Select the best answer. Correct answers are highlighted in bold with
a rationale.
Section 1: Fundamentals of Nursing (Questions 1-25)
1. A nurse is caring for a client who is postoperative day 1 following
abdominal surgery. Which of the following findings should the nurse report to
the provider immediately?
A. Heart rate 88/min
B. Respiratory rate 28/min
C. Temperature 37.2°C (99.0°F)
D. Blood pressure 118/76 mm Hg
Rationale: Tachypnea (RR >20) post-abdominal surgery may indicate atelectasis,
pneumonia, or pulmonary embolism. This requires immediate intervention.
2. A client tells the nurse, "I don't want my blood transfusion because I'm
afraid of getting AIDS." Which of the following responses by the nurse is most
appropriate?
A. "Don't worry, the blood supply is very safe now."
B. "I will notify your provider that you are refusing the transfusion."
, C. "Tell me more about your concerns regarding the blood transfusion."
D. "You need this transfusion to survive your illness."
Rationale: The nurse should first explore the client's concerns to provide
education and address fears before notifying the provider.
3. A nurse is preparing to insert an indwelling urinary catheter for a female
client. Which of the following techniques should the nurse use?
A. Open sterile glove package after applying sterile drape.
B. Cleanse each labial fold with a separate cotton ball using forceps.
C. Insert catheter 2.5 cm (1 inch) into urethra until urine flows.
D. Inflate balloon before taping catheter to thigh.
Rationale: Each labial fold should be cleansed with a separate sterile cotton ball
from top to bottom to prevent contamination.
4. A nurse is providing discharge teaching about wound care to a client. Which
of the following statements indicates a need for further teaching?
A. "I will wash my hands before and after changing my dressing."
B. "I should report any green drainage from my wound."
C. "I will apply alcohol to the healed edges of my wound each day."
D. "I will dispose of soiled dressings in a plastic bag."
Rationale: Alcohol is cytotoxic and delays wound healing; only mild soap and
water or normal saline should be used on healed edges.
5. A client is on fall precautions. Which of the following actions by the nurse is
most important?
A. Place the call light within reach.
B. Keep the bed in the lowest position.
C. Assist the client with ambulation every 2 hours.
D. Lock the bed wheels.
Rationale: Direct supervision and assistance with ambulation is the most effective
fall prevention strategy for a client at risk.
*(Continued for 25 questions - sample pattern)*
6. A nurse is assessing a client’s peripheral IV site. Which finding indicates
phlebitis?
A. Cool skin around the site
B. Redness and warmth along the vein
C. Infiltration of fluid into surrounding tissue
D. Absence of blood return