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A nurse is preparing to administer medication to a patient. Which action is part of the
“five rights” of medication administration?
A. Right diagnosis
B. Right route
C. Right insurance
D. Right physician
Answer: B
Rationale: The five rights include right patient, medication, dose, route, and time. “Right
route” ensures the medication is given via the correct method for safe absorption.
Which vital sign should the nurse assess first in a patient experiencing shortness of
breath?
A. Temperature
B. Pulse
C. Respiratory rate
D. Blood pressure
Answer: C
Rationale: Respiratory rate directly reflects breathing status and oxygenation, making it
the priority in patients with dyspnea.
A patient’s blood pressure reads 88/54 mmHg. How should the nurse interpret this?
A. Hypertension
,B. Normal
C. Hypotension
D. Orthostatic hypertension
Answer: C
Rationale: A blood pressure below 90/60 mmHg is generally considered hypotension
and may indicate inadequate perfusion.
Which position is best for administering an enema?
A. Supine
B. Prone
C. Left Sims
D. Fowler’s
Answer: C
Rationale: The left Sims position allows gravity to facilitate the flow of solution into the
colon.
A nurse is caring for a patient with a fever. Which intervention is most appropriate?
A. Provide extra blankets
B. Administer antipyretics
C. Restrict fluids
D. Decrease room ventilation
Answer: B
Rationale: Antipyretics help reduce fever. Fluids and cooling measures are also
appropriate, not restriction or overheating.
What is the normal range for adult heart rate?
A. 40–60 bpm
B. 60–100 bpm
C. 100–120 bpm
, D. 120–140 bpm
Answer: B
Rationale: A normal adult heart rate ranges from 60 to 100 beats per minute.
Which infection control measure is most effective in preventing the spread of infection?
A. Wearing gloves
B. Hand hygiene
C. Using masks
D. Sterilizing equipment
Answer: B
Rationale: Hand hygiene is the single most effective method to prevent infection
transmission.
A nurse is assessing pain. Which scale is appropriate for a child?
A. Numeric scale
B. FLACC scale
C. Glasgow scale
D. Braden scale
Answer: B
Rationale: The FLACC scale is commonly used for children or nonverbal patients.
Which electrolyte imbalance is associated with muscle weakness and arrhythmias?
A. Hypercalcemia
B. Hypokalemia
C. Hypernatremia
D. Hypomagnesemia
Answer: B
Rationale: Low potassium levels can cause muscle weakness and dangerous cardiac
arrhythmias.