1. A nurse is caring for a client who is recovering from surgery and
reports feeling very cold. What should the nurse do first?
• A) Apply a warm blanket.
• B) Assess the client's temperature.
• C) Offer the client hot tea.
• D) Turn up the room's thermostat.
Answer: B) Assess the client's temperature.
Rationale: The first action the nurse should take is to assess the client's
temperature to determine if the client is hypothermic, febrile, or
experiencing chills. Interventions like applying a warm blanket or
offering hot tea can be done after the assessment if indicated.
2. A nurse is preparing to administer a medication to a client. Which of
the following is the priority action before giving the medication?
• A) Check the client's vital signs.
• B) Verify the client's identity.
• C) Explain the medication to the client.
• D) Review the client's medical history.
Answer: B) Verify the client's identity.
Rationale: The priority action is to verify the client's identity using two
identifiers (such as name and birth date) to prevent medication errors.
This is a key step in ensuring patient safety.
,3. A nurse is caring for a client who is at risk for falls. Which of the
following actions should the nurse take to prevent injury?
• A) Place a bed alarm on the client.
• B) Keep the client's bed in a low position.
• C) Provide the client with a non-slip robe.
• D) Encourage the client to walk unassisted.
Answer: B) Keep the client's bed in a low position.
Rationale: Keeping the bed in a low position reduces the risk of injury if
the client attempts to get out of bed independently. While bed alarms
and non-slip clothing may be helpful, ensuring the bed is low is a critical
preventive measure for falls.
4. A nurse is assessing a client with a wound infection. Which of the
following findings is the best indicator of systemic infection?
• A) Redness around the wound.
• B) Purulent drainage from the wound.
• C) Elevated white blood cell count.
• D) Pain at the wound site.
Answer: C) Elevated white blood cell count.
Rationale: An elevated white blood cell count is a key indicator of a
systemic infection. While redness, purulent drainage, and pain may
indicate local infection, an elevated WBC count suggests the infection
may be spreading.
, 5. A nurse is caring for a client who is receiving a blood transfusion.
The client begins to have chills and shortness of breath. What should
the nurse do first?
• A) Administer acetaminophen for fever.
• B) Stop the transfusion immediately.
• C) Notify the provider about the reaction.
• D) Take the client’s vital signs.
Answer: B) Stop the transfusion immediately.
Rationale: If a client shows signs of a transfusion reaction, the nurse
should stop the transfusion immediately to prevent further
complications, such as hemolysis or shock. Vital signs and notifying the
provider are important next steps.
6. A nurse is teaching a client about a new prescription for an
anticoagulant medication. Which of the following instructions should
the nurse include?
• A) "Avoid eating foods rich in vitamin K."
• B) "You can skip a dose if you miss one."
• C) "Take the medication with a large meal."
• D) "You will need regular blood tests to monitor your medication
levels."
Answer: A) "Avoid eating foods rich in vitamin K."
Rationale: Vitamin K can interfere with the action of anticoagulant
medications like warfarin. Clients should be instructed to maintain a
reports feeling very cold. What should the nurse do first?
• A) Apply a warm blanket.
• B) Assess the client's temperature.
• C) Offer the client hot tea.
• D) Turn up the room's thermostat.
Answer: B) Assess the client's temperature.
Rationale: The first action the nurse should take is to assess the client's
temperature to determine if the client is hypothermic, febrile, or
experiencing chills. Interventions like applying a warm blanket or
offering hot tea can be done after the assessment if indicated.
2. A nurse is preparing to administer a medication to a client. Which of
the following is the priority action before giving the medication?
• A) Check the client's vital signs.
• B) Verify the client's identity.
• C) Explain the medication to the client.
• D) Review the client's medical history.
Answer: B) Verify the client's identity.
Rationale: The priority action is to verify the client's identity using two
identifiers (such as name and birth date) to prevent medication errors.
This is a key step in ensuring patient safety.
,3. A nurse is caring for a client who is at risk for falls. Which of the
following actions should the nurse take to prevent injury?
• A) Place a bed alarm on the client.
• B) Keep the client's bed in a low position.
• C) Provide the client with a non-slip robe.
• D) Encourage the client to walk unassisted.
Answer: B) Keep the client's bed in a low position.
Rationale: Keeping the bed in a low position reduces the risk of injury if
the client attempts to get out of bed independently. While bed alarms
and non-slip clothing may be helpful, ensuring the bed is low is a critical
preventive measure for falls.
4. A nurse is assessing a client with a wound infection. Which of the
following findings is the best indicator of systemic infection?
• A) Redness around the wound.
• B) Purulent drainage from the wound.
• C) Elevated white blood cell count.
• D) Pain at the wound site.
Answer: C) Elevated white blood cell count.
Rationale: An elevated white blood cell count is a key indicator of a
systemic infection. While redness, purulent drainage, and pain may
indicate local infection, an elevated WBC count suggests the infection
may be spreading.
, 5. A nurse is caring for a client who is receiving a blood transfusion.
The client begins to have chills and shortness of breath. What should
the nurse do first?
• A) Administer acetaminophen for fever.
• B) Stop the transfusion immediately.
• C) Notify the provider about the reaction.
• D) Take the client’s vital signs.
Answer: B) Stop the transfusion immediately.
Rationale: If a client shows signs of a transfusion reaction, the nurse
should stop the transfusion immediately to prevent further
complications, such as hemolysis or shock. Vital signs and notifying the
provider are important next steps.
6. A nurse is teaching a client about a new prescription for an
anticoagulant medication. Which of the following instructions should
the nurse include?
• A) "Avoid eating foods rich in vitamin K."
• B) "You can skip a dose if you miss one."
• C) "Take the medication with a large meal."
• D) "You will need regular blood tests to monitor your medication
levels."
Answer: A) "Avoid eating foods rich in vitamin K."
Rationale: Vitamin K can interfere with the action of anticoagulant
medications like warfarin. Clients should be instructed to maintain a
