VERIFIED ANSWERS | 2026–2027 LATEST UPDATE |
GUARANTEED PASS | DETAILED RATIONALES | FULL STUDY
GUIDE | EXAM PREP | PRACTICE TEST | CERTIFICATION
PREPARATION
1. A nurse is caring for a postoperative patient. Which assessment finding requires immediate
intervention?
A. Pain score of 4/10
B. Temperature of 37.4°C (99.3°F)
C. Oxygen saturation of 88%
D. Heart rate of 92 beats/min
Correct Answer: C. Oxygen saturation of 88%
Rationale:
An oxygen saturation of 88% indicates inadequate oxygenation and requires prompt assessment and
intervention. The other findings are relatively expected and less urgent.
2. Which action best demonstrates patient advocacy?
A. Following physician orders without question
B. Respecting patient preferences during care planning
C. Completing documentation early
D. Delegating all routine tasks
Correct Answer: B. Respecting patient preferences during care planning
Rationale:
Patient advocacy involves supporting patient rights, values, and informed decision-making. The other
options do not directly represent advocacy.
3. A patient with diabetes reports dizziness and sweating. What should the nurse assess first?
A. Blood glucose level
B. Blood pressure
C. Temperature
D. Respiratory rate
Correct Answer: A. Blood glucose level
Rationale:
These symptoms commonly indicate hypoglycemia. Immediate glucose assessment helps identify and
address the cause quickly.
4. Which infection-control measure is most effective in preventing healthcare-associated
infections?
A. Wearing gloves at all times
B. Administering antibiotics prophylactically
C. Hand hygiene
D. Using sterile dressings
Correct Answer: C. Hand hygiene
Rationale:
,Hand hygiene remains the single most effective strategy for reducing transmission of pathogens in
healthcare settings.
5. A nurse is prioritizing care using the ABC framework. Which patient should be seen first?
A. Patient with a fractured wrist
B. Patient with shortness of breath
C. Patient awaiting discharge teaching
D. Patient requesting pain medication
Correct Answer: B. Patient with shortness of breath
Rationale:
Airway and breathing concerns take priority according to the ABC approach.
6. Which finding suggests fluid volume deficit?
A. Bounding pulse
B. Weight gain
C. Edema
D. Dry mucous membranes
Correct Answer: D. Dry mucous membranes
Rationale:
Dry mucous membranes are a classic sign of dehydration. The other findings are more consistent with
fluid excess.
7. A nurse is obtaining informed consent. Which responsibility belongs to the nurse?
A. Explaining all procedural risks
B. Performing the procedure
C. Witnessing the patient's signature
D. Determining competency
Correct Answer: C. Witnessing the patient's signature
Rationale:
The provider explains risks and benefits. The nurse verifies identity, witnesses the signature, and
confirms voluntary participation.
8. Which laboratory value should the nurse report immediately?
A. Sodium 139 mEq/L
B. Potassium 2.8 mEq/L
C. Hemoglobin 13 g/dL
D. WBC 8,000/mm³
Correct Answer: B. Potassium 2.8 mEq/L
Rationale:
Severe hypokalemia increases the risk of dangerous cardiac dysrhythmias and requires urgent
attention.
9. What is the primary purpose of nursing documentation?
A. Replacing verbal communication
B. Supporting continuity of care
C. Reducing staffing needs
D. Eliminating legal responsibility
Correct Answer: B. Supporting continuity of care
Rationale:
, Documentation ensures accurate communication among healthcare team members and supports
safe patient care.
10. A patient refuses prescribed medication. What should the nurse do first?
A. Force administration
B. Notify security
C. Explore the reason for refusal
D. Document noncompliance only
Correct Answer: C. Explore the reason for refusal
Rationale:
Understanding concerns allows patient education and supports informed decision-making while
respecting autonomy.
11. Which patient is at highest risk for falls?
A. Healthy 25-year-old
B. Ambulatory teenager
C. Middle-aged office worker
D. Older adult receiving sedatives
Correct Answer: D. Older adult receiving sedatives
Rationale:
Advanced age and sedative use significantly increase fall risk.
12. What is the most appropriate nursing action when receiving a verbal order?
A. Ignore the order
B. Ask another nurse to interpret it
C. Read back the order for verification
D. Wait until the next shift
Correct Answer: C. Read back the order for verification
Rationale:
Read-back verification reduces communication errors and enhances patient safety.
13. A patient develops sudden confusion. Which assessment should occur first?
A. Nutritional history
B. Blood glucose assessment
C. Family interview
D. Pain assessment
Correct Answer: B. Blood glucose assessment
Rationale:
Acute confusion may result from hypoglycemia and requires rapid evaluation.
14. Which principle is essential when delegating tasks?
A. Delegate all assessments
B. Match tasks to staff competency
C. Delegate only to registered nurses
D. Avoid follow-up
Correct Answer: B. Match tasks to staff competency
Rationale:
Safe delegation requires assigning tasks based on training, competence, and patient needs.