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Section 1: Safe & Effective Care Environment
1. A nurse is preparing to transfer a client who has right-sided weakness from the
bed to a wheelchair. Which action by the nurse demonstrates correct body
mechanics?
A. Keep feet together and twist at the waist.
B. Position the wheelchair at a 90-degree angle to the bed.
C. Place the wheelchair on the client’s weak side.
D. Bend at the knees and keep the client close to the body.
Answer: D
Rationale: Bending at the knees and keeping the load close maintains a low center
of gravity and uses leg muscles, preventing back injury. Option C is incorrect – the
wheelchair should be on the strong side so the client can help push up.
2. A nurse is applying restraints to a confused client who is pulling at their IV line.
Which of the following actions should the nurse take first?
A. Pad the bony prominences.
B. Obtain a prescription for the restraints.
C. Tie the restraints to the side rail.
D. Ensure two fingers can fit between the restraint and the client’s wrist.
Answer: B
Rationale: Restraints must be prescribed by a provider based on face-to-face
assessment (CMS conditions of participation). The nurse should obtain the
order first unless an emergency exists. Padding and fit are important but come
after the legal requirement.
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,3. A charge nurse is observing a new graduate perform hand hygiene. Which
action requires intervention?
A. Rinsing hands with water before applying soap.
B. Using an alcohol-based rub for 15 seconds when hands are not visibly soiled.
C. Drying hands with a paper towel, then using that towel to turn off the faucet.
D. Removing jewelry including a plain wedding band before washing.
Answer: D
Rationale: A plain wedding band does not need to be removed for hand hygiene;
it can be washed with soap and water. The other options are correct techniques.
Turning off the faucet with a paper towel prevents recontamination.
Section 2: Health Promotion & Maintenance
4. A nurse is teaching a client about modifiable risk factors for coronary artery
disease. Which factor should the nurse include?
A. Age
B. Gender
C. Smoking
D. Family history
Answer: C
Rationale: Smoking is modifiable. Age, gender, and family history are
non-modifiable. Others include hypertension, hyperlipidemia, obesity, sedentary
lifestyle.
5. A nurse is providing discharge teaching to an older adult client about fall
prevention at home. Which statement by the client indicates understanding?
A. “I will wear socks instead of shoes for better grip.”
B. “I should walk barefoot to feel the floor better.”
C. “I’ll remove all throw rugs from the house.”
D. “Using a nightlight might make me trip, so I’ll keep the room dark.”
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,Answer: C
Rationale: Throw rugs are a major fall hazard. Socks and bare feet increase
slipping risk. Nightlights improve visibility and reduce falls.
Section 3: Psychosocial Integrity
6. A client with a new colostomy tells the nurse, “I’m disgusting. No one will want
to be near me.” Which is the nurse’s best response?
A. “Many people feel that way at first, but you’ll get used to it.”
B. “Would you like to talk about what is making you feel this way?”
C. “You shouldn’t feel that way – the stoma is clean and odorless.”
D. “Let me show you how to change the pouch so there is no smell.”
Answer: B
Rationale: This open-ended, therapeutic response acknowledges the client’s
feelings and encourages expression. Cliché reassurance (A, C) dismisses emotions.
Focusing on the task (D) avoids the psychosocial issue.
7. A nurse is caring for a client who is grieving the recent death of their spouse.
Which behavior indicates maladaptive grieving?
A. Crying frequently when alone.
B. Keeping the spouse’s belongings as they were.
C. Attending a grief support group.
D. Looking at old photo albums.
Answer: B
Rationale: Keeping belongings unchanged for a prolonged period can indicate
complicated grief. The other options are normal expressions of grief.
Section 4: Basic Care & Comfort
8. A nurse is repositioning a bedridden client. To prevent pressure injuries, how
often should the nurse change the client’s position?
A. Every 1 hour
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, B. Every 2 hours
C. Every 4 hours
D. Every 6 hours
Answer: B
Rationale: Standard of care is repositioning every 2 hours for clients at risk. Some
protocols allow up to 4 hours with specialized surfaces, but 2 hours is the safest
answer for the NCLEX/ATI.
9. A nurse is teaching a client with heart failure about a 2-gram sodium diet.
Which food choice by the client indicates understanding?
A. Ham sandwich with pickles
B. Canned vegetable soup
C. Grilled chicken breast with steamed rice
D. Frozen lasagna with cheese
Answer: C
Rationale: Fresh or simply prepared foods are low in sodium. Ham, pickles,
canned soups, processed frozen meals, and cheese are high in sodium.
10. A nurse is inserting an indwelling urinary catheter. After cleansing the meatus,
which hand should the nurse use to pick up the sterile catheter?
A. Dominant hand
B. Non-dominant hand
C. Gloved sterile hand
D. Clean glove hand
Answer: C
Rationale: After establishing the sterile field, the nurse dons sterile gloves. The
sterile gloved hand picks up the catheter. The other hand (non-sterile or less
sterile) is used to separate labia.
Section 5: Pharmacological & Parenteral Therapies
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